肠系膜下动脉高位结扎后顽固性便秘21例临床分析

目的分析进展期乙状结肠癌或直肠上段癌行根治性切除术后顽固性便秘的致病因素,并总结其治疗经验。方法对江汉大学附属医院胃肠外科2004年1月至2014年12月收治的共21例顽固性便秘病人临床资料进行回顾性分析。结果所有病例既往均为进展期乙状结肠癌或直肠上段癌于外院行根治性手术,原手术均明确记录为肠系膜下动脉高位结扎。术后2~4年(平均3.4年)逐渐出现顽固性便秘,以腹痛、腹胀、大便次数减少及排便困难为主要临床表现。所有病例术前行X线钡剂灌肠造影均显示一共同特征,即结肠脾曲未游离,降结肠未切除,降结肠结肠袋消失,犹如小肠;结肠传输试验均提示为慢传输型,排粪造影均未见出口梗阻。12例再次接受手术,余9例因个人因素放弃手术,仍选择保守治疗(灌肠或口服泻药通便)。所有病人均随访至今,随访时间24~168个月,平均87.8个月,手术组术后效果显著,1年内均恢复正常排便(1~2次/d);而保守治疗组便秘症状无改善。结论乙状结肠癌或直肠上段癌根治术中行肠系膜下动脉高位结扎,而未游离结肠脾曲行包括降结肠、乙状结肠和直肠腹膜返折以上部分肠切除。其后果是部分病人降结肠慢性缺血,结肠形态及生理功能退化,导致顽固性便秘发生(慢传输型便秘)。其有效治疗为再手术行降结肠切除,横结肠-直肠吻合。

Clinical analysis of 21 cases of intractable constipation after high ligation of inferior mesenteric artery

Objective To analyze the pathogenic factors of intractable constipation in patients with advanced colorectal cancer or rectal cancer after radical resection,and to summarize the experience of treatment.Methods A total of 21 patients with intractable constipation were enrolled in this study from January 2004 to December 2014 in the Department of Gastroenterology,Affiliated Hospital of Jianghan University.Results The radical surgery was given on all patients with advanced sigmoid colon or rectal cancer in other hospitals,and the high ligation of inferior mesenteric artery was recorded in the operation files.After 2 to 4 years (mean 3.4 years),intractable constipation gradually appeared.The main clinical manifestations were abdominal pain,abdominal distension,stool frequency and defecation difficulty.X-ray barium enema angiography on all cases showed a common feature:not free of splenic flexure of colon,no resection of descending colon,disappearance of colon bag.The colonic transit test showed slow transmission type,and defecography showed no outlet obstructior.Twelve cases were subjected to re-operation,and rest 9 cases gave up surgical operation due to personal factors and were given conservative treatment (oral laxative or enema).All patients were followed up for 24 to 168 months,with an average of 87.8 months.The effect of the operation group was significant,and the normal defecation (1-2 times/day) recovered within the following 1 year.There was no improvement in constipation in conservative treatment group.Conclusions The high ligation of inferior mesenteric artery was performed in the treatment of sigmoid colon cancer or rectal cancer,and the resection of descending colon,sigmoid colon and rectal peritoneal reflex without free of free colonic splenic curvature,which will result in chronic ischemia of the colon,colon morphology and physiological function degradation,leading to intractable constipation (slow transit constipation).The effective treatment is reoperation of descending colon resection and transverse colon-rectal anastomosis.