Tang Choong-Leong, Seow-Choen Francis, Fook-Chong Stephanie, Eu Kong-Weng
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
Dis Colon Rectum. 2003 Sep;46(9):1200-7. doi: 10.1007/s10350-004-6716-9.
A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis from an anastomotic dehiscence after a coloanal or low colorectal anastomosis. Such a stoma is usually closed after 6 to 12 weeks when the intestinal edema is reduced and the peristomal adhesions are less dense. This period is three to four times longer than necessary for assurance of anastomotic healing, which is usually achieved by the second week after surgery. With the use of a bioresorbable membrane to minimize the formation of peristomal adhesions, earlier closure is hypothetically possible at three weeks.
Patients undergoing creation of a defunctioning ileostomy were randomized in Phase I either to have an adhesion barrier membrane wrapped around the limbs of the ileostomy, with closure at three weeks, or to the control group, with no barrier membrane and closure after more than six weeks. In the subsequent Phase II, the efficacy of the barrier membrane was compared in a similar manner with a control group at ileostomy reversal after three weeks. Peristomal adhesions at the time of stomal mobilization were scored in a blinded manner.
In Phase I, no statistically significant differences were noted in the mean adhesion scores between the two groups (7.42 vs. 7.28). However, in Phase II, when peristomal adhesions at closure were compared at three weeks for both groups, with and without adhesion barrier placement, there was a significant reduction in the overall mean adhesion scores (5.81 vs. 7.82, respectively). The number of patients with dense adhesions was also reduced in the adhesion barrier group. There was no significant difference in the time taken and the difficulty encountered during ileostomy closure in the two groups. A tendency to easier closure, as evidenced by a lower incidence of perioperative complications, was noted in the adhesion barrier group.
An adhesion barrier membrane placed around the limbs of a defunctioning loop ileostomy reduces peristomal adhesion and facilitates early closure at three weeks with minimal complications.
结肠肛管或低位结直肠吻合术后，常通过建立临时回肠造口术来减轻吻合口裂开所致腹膜感染的影响。当肠水肿减轻且造口周围粘连不那么紧密时，这种造口通常在6至12周后关闭。这一时期比确保吻合口愈合所需的时间长三到四倍，而吻合口愈合通常在术后第二周即可实现。使用生物可吸收膜可尽量减少造口周围粘连的形成，理论上在三周时就可以更早关闭造口。
在第一阶段，接受去功能化回肠造口术的患者被随机分为两组，一组在回肠造口的肠袢周围包裹粘连屏障膜，并在三周时关闭造口，另一组为对照组，不使用屏障膜，六周以上后关闭造口。在随后的第二阶段，以类似方式将屏障膜的疗效与三周后回肠造口还纳时的对照组进行比较。在造口松解时，以盲法对造口周围粘连进行评分。
在第一阶段，两组的平均粘连评分无统计学显著差异（分别为7.42和7.28）。然而，在第二阶段，当比较两组在三周时关闭造口时有无粘连屏障放置情况下的造口周围粘连情况时，总体平均粘连评分有显著降低（分别为5.81和7.82）。粘连屏障组中粘连致密的患者数量也有所减少。两组在回肠造口关闭过程中所用时间和遇到的困难无显著差异。粘连屏障组出现围手术期并发症的发生率较低，显示出关闭造口更容易的趋势。
在去功能化袢式回肠造口的肠袢周围放置粘连屏障膜可减少造口周围粘连，并有助于在三周时早期关闭造口，且并发症最少。
