張茂聲

Hartmann術(shù)式和支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻臨床對(duì)比研究

張茂聲

目的 探討Hartmann術(shù)式和支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻的臨床療效差異。方法 150例左半結(jié)腸癌并腸梗阻患者隨機(jī)分為對(duì)照組和觀察組, 各75例, 分別采用Hartmann術(shù)式和支架植入手術(shù)切除一期吻合術(shù)式治療, 比較兩組患者臨床受益評(píng)分, 術(shù)后肛門排氣時(shí)間、住院時(shí)間、術(shù)后并發(fā)癥發(fā)生情況、術(shù)后轉(zhuǎn)移率及5年生存率等。結(jié)果 觀察組患者臨床受益評(píng)分顯著高于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)；觀察組患者住院時(shí)間顯著短于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)；兩組患者術(shù)后肛門排氣時(shí)間、并發(fā)癥發(fā)生率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)；觀察組患者術(shù)后轉(zhuǎn)移率顯著低于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)；兩組患者5年生存率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。結(jié)論 支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻可有效提高臨床受益評(píng)分,加快術(shù)后康復(fù)進(jìn)程, 并降低術(shù)后轉(zhuǎn)移風(fēng)險(xiǎn), 療效優(yōu)于Hartmann術(shù)式。

Hartmann術(shù)式；支架植入；一期吻合；左半結(jié)腸癌；腸梗阻

結(jié)腸癌患者好發(fā)于中老年人, 早期癥狀隱匿且易被其他疾病掩蓋, 如不及時(shí)治療可進(jìn)展出現(xiàn)腸梗阻癥狀［1,2］。目前臨床治療左半結(jié)腸癌并腸梗阻首選外科手術(shù)治療［3］。本次研究選取左半結(jié)腸癌并腸梗阻患者150例, 分別采用Hartmann術(shù)式和支架植入手術(shù)切除一期吻合術(shù)式治療, 比較兩組患者臨床受益評(píng)分, 術(shù)后肛門排氣時(shí)間、住院時(shí)間、術(shù)后并發(fā)癥發(fā)生情況、術(shù)后轉(zhuǎn)移率及5年生存率等, 探討兩種術(shù)式治療左半結(jié)腸癌并腸梗阻的臨床療效差異。現(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料 選取本院2007年7月～2009年7月收治的左半結(jié)腸癌并腸梗阻患者150例, 均經(jīng)病理活檢確診中低分化腺癌, 且影像學(xué)檢查未見遠(yuǎn)處轉(zhuǎn)移。入選患者采用隨機(jī)數(shù)字表法分為對(duì)照組和觀察組, 各75例；對(duì)照組中男32例, 女43例, 年齡50～69歲, 平均年齡(57.30±4.89)歲；觀察組患者中男30例, 女45例, 年齡52～70歲, 平均年齡(57.44±4.93)歲。兩組患者一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05), 具有可比性。

1.2 治療方法 對(duì)照組患者采用常規(guī)Hartmann術(shù)式治療；觀察組患者采用支架植入手術(shù)切除一期吻合術(shù)式治療, 首先在X線引導(dǎo)下確定狹窄位置、大小及長(zhǎng)度, 放入支架進(jìn)行腸道減壓, 并及時(shí)調(diào)整開放程度；支架放入后嚴(yán)密監(jiān)視有無(wú)惡心嘔吐、腹痛腹脹及便血等癥狀出現(xiàn)；術(shù)后第2天復(fù)查支架放入效果, 保守治療6～8 d后再行腫瘤切除, 并采用一期吻合術(shù)式。

1.3 觀察指標(biāo) ①采用Burris制定臨床受益評(píng)分標(biāo)準(zhǔn)進(jìn)行臨床受益評(píng)價(jià), 包括視覺模擬評(píng)分(VAS), 鎮(zhèn)痛藥物用量, 卡氏評(píng)分及體重等指標(biāo)；②記錄患者術(shù)后肛門排氣時(shí)間和住院時(shí)間；③記錄患者術(shù)后并發(fā)癥發(fā)生例數(shù), 包括切口感染、腹腔出血及腸瘺等；④記錄患者術(shù)后轉(zhuǎn)移和5年生存例數(shù)。

1.4 統(tǒng)計(jì)學(xué)方法 本次研究數(shù)據(jù)錄入分析軟件采用Epidata3.05和SPSS13.0；計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差( x-±s)表示, 采用t檢驗(yàn)；計(jì)數(shù)資料以率(%)表示, 采用χ2檢驗(yàn)。P＜0.05為差異具有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組患者臨床受益評(píng)分比較 對(duì)照組和觀察組患者臨床受益評(píng)分分別為(5.27±1.15)分、(9.50±1.76)分；觀察組患者臨床受益評(píng)分顯著高于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。

2.2 兩組患者術(shù)后肛門排氣時(shí)間和住院時(shí)間比較 對(duì)照組患者術(shù)后肛門排氣時(shí)間和住院時(shí)間分別為(61.74±5.14)h、(23.61± 4.08)d；觀察組患者術(shù)后肛門排氣時(shí)間和住院時(shí)間分別為(59.40± 4.38)h、(16.45±2.72)d；兩組患者術(shù)后肛門排氣時(shí)間比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)；觀察組患者住院時(shí)間顯著短于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。見表1。

2.3 兩組患者術(shù)后并發(fā)癥發(fā)生情況比較 對(duì)照組和觀察組患者術(shù)后并發(fā)癥發(fā)生率分別為6.67%(5/75)、10.67%(8/75)；兩組患者術(shù)后并發(fā)癥發(fā)生率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。見表2。

表1 兩組患者術(shù)后肛門排氣時(shí)間和住院時(shí)間比較( x-±s)

表2 兩組患者術(shù)后并發(fā)癥發(fā)生情況比較(n, %)

2.4 兩組患者術(shù)后轉(zhuǎn)移率和5年生存率比較 對(duì)照組患者術(shù)后轉(zhuǎn)移率和5年生存率分別為29.33%(22/75)、62.67%(47/75)；觀察組患者術(shù)后轉(zhuǎn)移率和5年生存率分別為10.67%(8/75)、60.00%(45/75)；觀察組患者術(shù)后轉(zhuǎn)移率顯著低于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)；兩組患者5年生存率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。

3 討論

本次研究結(jié)果中, 觀察組患者臨床受益評(píng)分顯著高于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05), 提示應(yīng)用支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻有助于緩解術(shù)后疼痛, 提高生活質(zhì)量；這可能與行Hartmann術(shù)式治療左半結(jié)腸癌并腸梗阻患者術(shù)后需要進(jìn)行人工肛門護(hù)理, 由此帶來的不適、潰瘍及出血可嚴(yán)重降低生活質(zhì)量有關(guān)［3］。觀察組患者住院時(shí)間和術(shù)后轉(zhuǎn)移率顯著優(yōu)于對(duì)照組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05), 說明, 支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻在促進(jìn)術(shù)后病情康復(fù)和降低術(shù)后轉(zhuǎn)移風(fēng)險(xiǎn)方面優(yōu)勢(shì)明顯；其中轉(zhuǎn)移率方面與以往研究不一致, 作者認(rèn)為臨床醫(yī)師腸道支架放入技術(shù)熟練程度差別可能是主要原因之一, 如進(jìn)行支架位置多次調(diào)整可能擠壓腫瘤細(xì)胞向遠(yuǎn)處轉(zhuǎn)移。但在支架植入手術(shù)切除一期吻合術(shù)式治療過程中應(yīng)注意支架放入并發(fā)癥出現(xiàn), 一旦發(fā)現(xiàn)腫瘤穿孔及腹腔出血癥狀, 應(yīng)立行手術(shù)治療。

綜上所述, 支架植入手術(shù)切除一期吻合術(shù)式治療左半結(jié)腸癌并腸梗阻可有效提高臨床受益評(píng)分, 加快術(shù)后康復(fù)進(jìn)程,并降低術(shù)后轉(zhuǎn)移風(fēng)險(xiǎn), 療效優(yōu)于Hartmann術(shù)式。

［1］ 查勇, 寸英麗, 黃云超, 等.內(nèi)鏡治療結(jié)直腸癌合并腸梗阻28例的體會(huì).中國(guó)內(nèi)鏡雜志, 2010, 16(2):192-194.

［2］ 蔡開琳, 燕普, 王繼亮, 等.結(jié)直腸癌合并腸梗阻的腸鏡與腹腔鏡聯(lián)合微創(chuàng)手術(shù)(附14例報(bào)告).中國(guó)內(nèi)鏡雜志, 2011, 17(12):1271-1277.

［3］ 劉護(hù)民.左半結(jié)直腸癌并急性腸梗阻一期切除吻合28例臨床分析.中國(guó)醫(yī)療前沿, 2010, 5(16):58.

Clinical comparative research between Hartmann operation and stent implantation excision primary anastomosis operation in the treatment of left hemicolon carcinoma complicated with intestinal obstruction

ZHANG Mao-sheng.
Shandong Longkou City Hospital of Traditional Chinese Medicine, Longkou 265701, China

Objective To investigate clinical effect differences between Hartmann operation and stent implantation excision primary anastomosis operation in the treatment of left hemicolon carcinoma complicated with intestinal obstruction.Methods A total of 150 patients with left hemicolon carcinoma complicated with intestinal obstruction were randomly divided into control group and observation group, with 75 cases in each group.Hartmann operation and stent implantation excision primary anastomosis operation were applied respectively in the two groups, and comparisons were made on clinical benefit scores, postoperative anal exhaust times, hospital stays, postoperative complications, postoperative metastasis rate, and survival rate in 5 years.Results The observation group had higher clinical benefit scores than the control group, and the difference had statistical significance (P＜0.05).The observation group had shorter hospital stays than the control group, and the difference had statistical significance (P＜0.05).There was no statistically significant difference of incidence of postoperative anal exhaust times and complications between the two groups (P＞0.05).The postoperative metastasis rate was obviously lower in the observation group than in the control group, and the difference was statistically significant (P＜0.05).The difference of survival rate in 5 years between the two groups had no statistical significance (P＞0.05).Conclusion Application of stent implantation excision primary anastomosis operation in treating left hemicolon carcinoma complicated with intestinal obstruction can effectively improve clinical benefit scores, enhance postoperative rehabilitation process, and reduce risk of postoperative metastasis.It has better curative effect than Hartmann operation

Hartmann operation; Stent implantation; Primary anastomosis; Left hemicolon carcinoma; Intestinal obstruction

10.14163/j.cnki.11-5547/r.2015.04.012

2014-09-22］

265701 山東省龍口市中醫(yī)醫(yī)院