Penalver M A, Barreau G, Sevin B U, Averette H E
Division of Gynecologic Oncology, University of Miami, Jackson Memorial Medical Center, FL 33136, USA.
J Natl Cancer Inst Monogr. 1996(21):117-22.
Total pelvic exenteration is a salvage procedure done in the effort to eliminate completely pelvic cancer. Low colorectal anastomosis and continent urinary diversion are two new procedures that allow complete pelvic evisceration without the need for external appliances. From 1984 through 1994, 67 patients have undergone rectosigmoid colectomy and low-colorectal anastomosis. Sixteen patients underwent surgery as part of a total pelvic exenteration for recurrent cervical cancer, and 51 patients underwent surgery for either primary or recurrent ovarian carcinoma as part of an optimal debulking procedure. Between 1988 and 1995, 55 patients have received continent urinary diversion with the Miami Pouch. Fifty-two patients underwent surgery for recurrent cervical cancer, two patients for advanced vulvar cancer, and one patient for a vesico-vaginal fistula. All of the patients with recurrent cervical cancer had previously received radiation therapy for gynecologic cancer.
Of the 16 patients with recurrent cervical cancer who had a low colorectal anastomosis, 14 had a temporary colostomy. Of these 14 patients, eight had a colostomy takedown and have maintained fecal continence. Of the 51 patients with ovarian cancer who had a low colorectal anastomosis, all achieved fecal continence. With the Miami Pouch, a urinary continence rate of 86% was obtained. Twenty-four (44%) patients had early complications, including ureteral obstruction, ureterocolonic anastomotic leak, reservoir cutaneous fistula, small bowel obstruction, and pyelonephritis. Nineteen (35%) patients had late complications, including ureteral reflux, urinary incontinence, difficult catheterizations, and reservoir stones. There was a perioperative mortality rate of 5%.
Low-colorectal anastomosis is an attractive alternative to permanent colostomy, allowing all patients who had the protective colostomies taken down to achieve fecal continence. Continent urinary diversion with the Miami Pouch is also a worthwhile procedure because of its high continence rate. Although survival advantage for either procedure has not been proven, the quality of life of patients undergoing such procedures has been substantially improved because of the avoidance of external appliances. This has been achieved with acceptable morbidity and mortality rates.
全盆腔脏器切除术是一种用于彻底清除盆腔癌的挽救性手术。低位结直肠吻合术和可控性尿流改道术是两种新的手术方式，可实现完全盆腔脏器清除，无需使用外部造口装置。1984年至1994年期间，67例患者接受了直肠乙状结肠切除术和低位结直肠吻合术。16例患者因复发性宫颈癌接受了全盆腔脏器切除术，51例患者因原发性或复发性卵巢癌接受了手术，作为最佳减瘤手术的一部分。1988年至1995年期间，55例患者接受了迈阿密袋可控性尿流改道术。52例患者因复发性宫颈癌接受手术，2例患者因晚期外阴癌接受手术，1例患者因膀胱阴道瘘接受手术。所有复发性宫颈癌患者此前均接受过妇科癌症放疗。
16例接受低位结直肠吻合术的复发性宫颈癌患者中，14例进行了临时结肠造口术。在这14例患者中，8例进行了结肠造口还纳术并保持了大便失禁。51例接受低位结直肠吻合术的卵巢癌患者均实现了大便失禁。采用迈阿密袋，尿失禁率为86%。24例（44%）患者出现早期并发症，包括输尿管梗阻、输尿管结肠吻合口漏、储尿囊皮肤瘘、小肠梗阻和肾盂肾炎。19例（35%）患者出现晚期并发症，包括输尿管反流、尿失禁、插管困难和储尿囊结石。围手术期死亡率为5%。
低位结直肠吻合术是永久性结肠造口术的一种有吸引力的替代方法，使所有接受保护性结肠造口还纳术的患者实现了大便失禁。迈阿密袋可控性尿流改道术也是一种值得采用的手术方式，因其尿失禁率高。尽管这两种手术方式的生存优势尚未得到证实，但由于避免了使用外部造口装置，接受此类手术患者的生活质量得到了显著改善。这是在可接受的发病率和死亡率情况下实现的。
