Cohen Z, McLeod R S, Stephen W, Stern H S, O'Connor B, Reznick R
Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.
Ann Surg. 1992 Oct;216(4):506-11; discussion 511-2. doi: 10.1097/00000658-199210000-00013.
The results of the pelvic pouch procedure were reviewed to assess the surgical complication rate and outcome of patients who had had the procedure performed with a stapled ileo-anal anastomosis with and without a defunctioning ileostomy. Between December 1982 and March 1992, 483 patients underwent a pelvic pouch (PP) procedure. Patients were divided into three groups: group I consisted of 325 patients (178 men and boys and 147 women and girls) who underwent a PP procedure with a handsewn ileoanal anastomosis (IAA) with a defunctioning loop ileostomy. In group II, there were 87 patients (47 men and boys and 40 women and girls) who had a stapled IAA with a defunctioning ileostomy. Group III patients consisted of 71 patients (43 men and boys and 28 women and girls) who had a stapled IAA with no covering ileostomy. Assessment was made of the IAA leak rate, the surgical complications, the reoperation rate, and functional outcome. Early surgical complications included 40 (12%) IAA leaks in group I patients compared with only six (7%) leaks in group II patients who had a stapled IAA (p < 0.05). In group III patients, who had a stapled IAA but no covering ileostomy, there were 13 leaks (18%). Eleven of these 13 leaks healed spontaneously with tube drainage; one patient remains with a rectal tube in place 6 weeks after operation, and only one patient has required a reoperation (defunctioning ileostomy). Functionally, all patients with a healed IAA after a leak have had an excellent result comparable to those without a leak. Patients who were male, older than age 40, on steroids, and had had a true one-stage PP procedure, had a greater risk of developing an IAA leak. In two patients, there was intraoperative difficulty, and one of these patients had an IAA leak after operation. Disease activity at the resection margin and patient weight did not affect the leak rate. Our results suggest that the IAA leak rate is significantly reduced in patients with a stapled IAA with an ileostomy compared with those with a handsewn IAA. Omission of the defunctioning ileostomy is associated with a higher IAA leak rate, but spontaneous healing occurs in almost all patients without impairment of functional results. In patients in whom the ileostomy is omitted, the IAA leak rate is greatest in male patients who have undergone a true one-stage PP procedure, are on steroids, and are older than age 40.
回顾了盆腔袋手术的结果，以评估采用吻合器进行回肠肛管吻合术且有或无暂时性回肠造口术的患者的手术并发症发生率及预后情况。1982年12月至1992年3月期间，483例患者接受了盆腔袋（PP）手术。患者被分为三组：第一组有325例患者（178例男性和男孩，147例女性和女孩），他们接受了手工缝合回肠肛管吻合术（IAA）并带有暂时性袢式回肠造口术的PP手术。第二组有87例患者（47例男性和男孩，40例女性和女孩），他们接受了吻合器IAA并带有暂时性回肠造口术。第三组患者有71例（43例男性和男孩，28例女性和女孩），他们接受了吻合器IAA且没有覆盖性回肠造口术。评估了IAA漏出率、手术并发症、再次手术率及功能预后。早期手术并发症包括：第一组患者中有40例（12%）发生IAA漏出，而接受吻合器IAA的第二组患者中仅有6例（7%）漏出（p<0.05）。第三组接受吻合器IAA但没有覆盖性回肠造口术的患者中有13例漏出（18%）。这13例漏出中有11例通过置管引流自行愈合；1例患者术后6周仍留置直肠管，仅1例患者需要再次手术（暂时性回肠造口术）。在功能方面，所有漏出后IAA愈合的患者与未发生漏出的患者结果同样良好。男性、年龄大于40岁、使用类固醇且接受真正一期PP手术的患者发生IAA漏出的风险更高。有2例患者术中出现困难，其中1例术后发生IAA漏出。切缘的疾病活动度及患者体重不影响漏出率。我们的结果表明，与手工缝合IAA的患者相比，接受吻合器IAA并带有回肠造口术的患者IAA漏出率显著降低。省略暂时性回肠造口术与较高的IAA漏出率相关，但几乎所有患者均可自行愈合，且功能结果不受影响。在省略回肠造口术的患者中，接受真正一期PP手术、使用类固醇且年龄大于40岁的男性患者IAA漏出率最高。
