Miles手术中预置腹膜前补片预防造口旁疝的效果及安全性

doi:10.3877/cma.j.issn.1674-392X.2024.03.007

目的

评估术中不同的干预方式下直肠癌腹会阴切除术后造口旁疝的发生率及相应手术风险及预后。

方法

纳入2014年1月至2018年12月在首都医科大学附属北京潞河医院普外科行直肠癌Miles术的患者共56例，经过医患双方的术前谈话共同抉择，依据手术方法的不同分为对照组（无预置补片，n=32）和试验组（预置补片，n=24）。试验组在腹直肌鞘膜下放置人工补片，对照组常规行乙状结肠造口术。随访≥6个月观察造口旁疝的发生率和手术近远期相关风险。

结果

经过5年的随访（部分病例死亡或联系脱失），试验组术后总体造口旁疝发生率为41.70%低于对照组的71.90%（P=0.045），H2型造口旁疝发生率12.50%低于对照组的43.75%（P=0.026），试验组造口旁疝术后出现的中位时间为48个月，明显晚于对照组的10个月（P<0.001）。在安全性方面，试验组的造口感染、皮下积液、造口狭窄、造口脱垂、肠梗阻、肠漏等术后并发症发生情况较对照组差异无统计学意义（P=0.798）。但长期随访观察发现预置补片组发生急症嵌顿造口旁疝（H2型）的风险增大。

结论

预防性放置补片可显著降低术后造口旁疝发生率，延缓造口旁疝的出现时间，且未增加近期手术并发症的发生率，但远期风险值得关注。

关键词: 直肠癌, 造口旁疝, 预置补片, 发病率, 手术风险

Objective

To evaluate the incidence, corresponding surgical risks, and prognosis of parastomal hernia after abdominal and perineal resection for rectal cancer under different intervention methods during surgery.

Methods

A total of 56 patients who underwent Miles surgery for rectal cancer in the Department of General Surgery, Beijing Luhe Hospital Affiliated to Capital Medical University from January 2014 to December 2018 were included. After preoperative discussions between doctors and patients, patients were divided into control group (no preset mesh, n=32) and experimental group (preset mesh, n=24) based on different surgical methods. In the experimental group, artificial mesh was placed under the sheath of the rectus abdominis, while in the control group, sigmoid colostomy was routinely performed. The incidence of parastomal hernia, short and long term surgery-related risks were observed at a follow-up of ≥6 months.

Results

After 5 years of follow-up (some cases died or lost contact), the overall incidence of parastomal hernia in the experimental group was 41.70%, which was lower than that in the control group (71.90%), (P=0.045). The incidence of H2 type parastomal hernia was 12.50% versus 43.75%, with statistical significant difference (P=0.026). The postoperative occurrence time of parastomal hernia in the experimental group was significantly later than that in the control group (48 months vs 10 months; P<0.001). In terms of safety, there was no significant difference in postoperative complications such as stoma infection, subcutaneous effusion, stoma stenosis, stoma prolapse, intestinal obstruction, and intestinal leakage between the two groups (P=0.798). But after long-term observation, we found that the preset mesh group has an increased risk of acute incarcerated parastomal hernia (H2 type).

Conclusion

Prophylactic mesh placement significantly reduces the incidence of postoperative parastomal hernia and significantly delays its appearance, and dose not increase short term surgical complications. However, the long-term risks are worth paying attention to.

Key words: Rectal cancer, Parastomal hernia, Preset mesh, Incidence, Surgical risk

图1 造口旁疝的分型注：1A　H0型（无造口旁疝）；1B　H1型（滑疝）；1C H2型（重度复杂疝）。

表1 2组患者基线资料及临床病理学特征比较

组别	例数	性别[例(%)]		年龄(岁,±s)	体重指数(kg/m²,±s)	美国癌症联合委员会TNM分期[例(%)]
组别	例数	女性	男性	年龄(岁,±s)	体重指数(kg/m²,±s)	Ⅰ期	Ⅱ期	Ⅲ期	Ⅳ期
试验组	24	6 (25)	18 (75)	65.42±12.9	24.8±2.1	6 (25)	9 (37.5)	9 (37.5)	0 (0)
对照组	32	12 (37)	20 (63)	65.53±11.8	24.8±3.3	8 (25)	8 (25)	15 (46.87)	1 (3.13)
t/χ²值		-5.000		1.052	0.078	0.582
P值		0.126		0.970	0.978	0.730

表1 2组患者基线资料及临床病理学特征比较

组别	例数	性别[例(%)]		年龄(岁,±s)	体重指数(kg/m²,±s)	美国癌症联合委员会TNM分期[例(%)]
组别	例数	女性	男性	年龄(岁,±s)	体重指数(kg/m²,±s)	Ⅰ期	Ⅱ期	Ⅲ期	Ⅳ期
试验组	24	6 (25)	18 (75)	65.42±12.9	24.8±2.1	6 (25)	9 (37.5)	9 (37.5)	0 (0)
对照组	32	12 (37)	20 (63)	65.53±11.8	24.8±3.3	8 (25)	8 (25)	15 (46.87)	1 (3.13)
t/χ²值		-5.000		1.052	0.078	0.582
P值		0.126		0.970	0.978	0.730

图2 2组患者造口旁疝发生率比较注：PSH造口旁疝；H1型为滑疝；H2型为重度复杂疝。

图3 2组患者造口旁疝相关二次手术率比较

表2 2组患者手术相关指标比较（

±s）

组别	例数	手术时间(min)	术中出血量(ml)	术后首次排气时间(h)	术后住院时间(d)
试验组	24	257.71±57.50	63.75±18.83	15.02±5.10	7.75±1.70
对照组	32	262.32±69.65	66.52±18.97	14.65±4.26	7.43±0.95
t值		0.481	-0.768	-0.017	0.447
P值		0.635	0.450	0.986	0.695

表2 2组患者手术相关指标比较（

±s）

组别	例数	手术时间(min)	术中出血量(ml)	术后首次排气时间(h)	术后住院时间(d)
试验组	24	257.71±57.50	63.75±18.83	15.02±5.10	7.75±1.70
对照组	32	262.32±69.65	66.52±18.97	14.65±4.26	7.43±0.95
t值		0.481	-0.768	-0.017	0.447
P值		0.635	0.450	0.986	0.695

表3 2组患者术后安全性指标比较[例（%）]

组别	例数	造口感染	造口皮下积液	造口狭窄	造口脱垂	肠梗阻	肠漏	总体并发症
试验组	24	1	2	2	1	1	0	7(29.17)
对照组	32	2	1	1	2	2	0	8(25.00)

表3 2组患者术后安全性指标比较[例（%）]

组别	例数	造口感染	造口皮下积液	造口狭窄	造口脱垂	肠梗阻	肠漏	总体并发症
试验组	24	1	2	2	1	1	0	7(29.17)
对照组	32	2	1	1	2	2	0	8(25.00)

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Effect and safety of preset preperitoneal mesh during Miles surgery for rectal cancer to prevent parastomal hernia

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Effect and safety of preset preperitoneal mesh during Miles surgery for rectal cancer to prevent parastomal hernia