直肠癌根治会阴部造口术后二期股薄肌移植肛门成形

目的回顾性总结32例直肠癌根治会阴部造口术后二期股薄肌移植肛门成形术的治疗效果。方法采用Williams5级评分法对重建前后肛门功能进行评价。结果二期股薄肌移植肛门成形术前，32例患者肛门功能均在4级以上[4级28．4％(9／32)，5级71.6％(23／32)]，二期股薄肌移植肛门成形术后肛门功能明显好转。结论二期股薄肌移植肛门成形术是直肠癌根治会阴部造口术后有效的肛门重建手段。     

重建肛门外括肌和直肠肛管角治疗先天性肛门闭锁肛门成形术后大便失禁(附32例报告)

目的:观察重建肛门外括肌和直肠肛管角治疗先天性肛门闭锁肛门成形术后大便失禁的临床疗效。方法:对32例先天性肛门闭锁肛门成形术后大便失禁患者用股薄肌重建肛门外括肌并重建直肠肛管角。结果:32例患者术后随访1年,肛门功能优19例,良9例,较好4例,无效者未发现,总满意率为87·5%(28/32)。结论:用股薄肌重建肛门外括肌并重建直肠肛管角,术后患者肛门功能满意率高,患者生活质量明显提高。     

股薄肌移植肛门括约肌功能重建的临床进展

采用肌肉移植代替括约肌行原位肛门成形术能够改善肛门失禁患者的生存能力和生活质量。股薄肌位于大腿最内侧,部位隐蔽、便于切取、血管固定、供血丰富、神经支配单一,用于重建肛门括约肌功能的效果良好。现对股薄肌移植重建肛门括约肌功能的临床进展作一综述。     

低位直肠癌的外科治疗

本文报道1980年12月～1988年12月收治直肠癌205例,肿块距肛门齿线7cm以下者占78.5%。保留肛门者84例,占41%;会阴部肛门再造30例,占14.6%;Miles手术75例,占36.6%;仅探查和单纯造瘘16例,占7.8%,手术切除率为92.2%。再造的方法有股薄肌移植19例,带蒂幽门代替肛门9例,结肠套叠加股薄肌移植2例。文中对各种手术方法作了介绍,强调会阴部造瘘优于腹壁造瘘。但病情较晚,恶性呈度高,年龄在60岁以上或有严重器质性病变和肥胖者,不适宜此种术式。     

直肠瓣肛门括约肌重建在直肠癌根治术中的应用

我院自1989年始,采用直肠瓣成形,用股薄肌代替肛门括约肌重建肛门,治疗下段直肠癌26例,其中男12例,女14例,年龄28～50岁。病变部位距肛缘4～7cm,肿块占肠壁1/2周13例,2/3周9例,1/3周4例,病史4个月～1年半,肿块可活动,均经病理证实为直肠腺癌。临床检查未发现远处转移。术后25例切口Ⅰ期愈合,1例因会阴部切口感染,经切开引流治愈。术后每日平均排便2～3次,控制排便功能基本满意。     

双侧股薄肌代括约肌原位肛门再造术的疗效分析

目的 研究双侧股薄肌代括约肌原位肛门再造术在低位直肠癌术后控制排便的治疗效果。方法 通过近10年来诊治低位直肠癌56例病人,采用双侧股薄肌代括约肌原位肛门再造术,并制定肛门排便功能的临床评定标准,以8分法进行评定,8～6分为优.6～4分为良.4～2分为差.2～0分为无效。术后随访客观分析其疗效。结果 根据评定标准56例病人中优32例,良17例,差5例,无效2例,我们把优及良病例定为有效,总有效率为87.5％。结论 双侧股薄肌代括约肌原位肛门再造术疗效可靠,是人工肛门手术方式中较理想、较科学的术式之一。     

股薄肌岛状肌皮瓣转位修复复杂性后尿道皮肤瘘一例报告

我们采用股薄肌岛状肌皮瓣修补治疗复杂性后尿道瘘患者 1例成功 ,现报告如下。患者 ,男 ,5 8岁。胃癌胃部分切除 ,直肠癌根治 ,永久性结肠造口术后 2年 ,直肠癌局部复发。行超声刀治疗 ,复发肿块无缩小 ;采用氩氦刀治疗 ,复发的肿瘤组织坏死 ,前列腺部尿道后壁组织坏死 ,缺损 3.0cm× 1.8cm ,形成后尿道陶氏腔瘘 (urethro Douglas’pouchfistula) ,腐蚀陶氏腔 ,形成 9cm× 3cm空腔 ,尿液长期经原肛门切除伤口外流 ,会阴部皮肤形成大片湿疹。于 2 0 0 4年 1月 14日在腰麻下手术治疗。患者取截石位。扩创 ,清除坏死、水肿肉芽组织 ,3%过氧化…     

电刺激股薄肌成形术原位肛门重建的犬实验研究

目的　评价电刺激股薄肌成形术原位肛门重建的犬实验模型临床应用前景。方法　采用杂种犬 17条 ,分对照组和实验组两组 ,第 1期单行股薄肌原位游离 ,实验组术后行电刺激连续 6周 ;2组第 2期均行腹会阴联合切除肛门 股薄肌原位肛门括约肌重建 ,术后 2周测量基础新肛压、功能性新肛压和移位股薄肌肌肉耐疲劳性曲线 ,取肌肉样本进行显微结构观察。结果　实验组的I型纤维所占比例明显高于对照组 (P <0 0 0 1) ;两组间基础肛压、基础新肛压的差异无显著性意义 (P >0 0 5 ) ,而功能性新肛压的差异有显著性意义 (P <0 0 1) ;实验组的移位股薄肌肌肉耐疲劳性曲线更平缓 ,平台期更长。结论　经过长期电刺激后 ,股薄肌纤维构成发生适应性改变 ,抗疲劳性改善 ,可替代括约肌的功能。     

全臂丛根性撕脱伤后神经移位联合早期股薄肌移植重建术

目的 探讨重建全臂丛根性撕脱伤后上肢主要功能的新方法。方法 8例全臂丛根性撕脱伤后2～4月一期行膈神经移位修复肩胛上神经,联合对侧股薄肌移植重建屈肘、伸指伸拇5例或屈拇屈指3例。前者其中2例二期再行同侧股薄肌移植重建屈拇屈指等。结果 一期手术1年以上5例,术后4～5月移植肌肉出现收缩,5～7月伸指伸拇或屈拇屈指、屈肘,12月屈肘60°～90°、肌力M_4,伸拇伸指或屈拇屈指M_3～M_4,肩外展30°～60°、M_3。二期手术的1例术后7月移植肌肉收缩,12月屈拇屈指M_4。重建屈拇屈指者可握持物品。结论 神经移位联合早期股薄肌移植,可在短时间内恢复全臂丛根性撕脱伤肢体的部分功能,初步重建手握持功能。     

双重股薄肌移植重建全臂丛根性撕脱伤后手握持功能

目的 探讨双重股薄肌移植重建全臂丛根性撕脱伤后手握持功能的疗效。方法 24例全臂丛根性撕脱伤患者,行吻合血管、神经的双重股薄肌移植,一期重建屈肘、伸指、伸拇,二期重建屈指、屈拇,以重建手握持功能。结果 随访16例二期手术后时间超过24月患者,最长62月,平均36月。16例均恢复屈肘、伸指、伸拇功能,屈肘90°～135°,肌力M_4(Highet法),伸指伸拇M_3～M_4。14例屈拇、屈指恢复,肌力M_3～M_4,可握持200～500g物品;2例屈拇屈指肌力M_1。结论 吻合血管、神经的双重股薄肌移植治疗全臂丛根性撕脱伤,可很好恢复屈肘、伸拇伸指功能,较好恢复屈指屈拇功能,初步重建手握持功能。     

Immediate Reconstruction of the Perineal Wound With Gracilis Muscle Flaps Following Abdominoperineal Resection and Intraoperative Radiation Therapy for Recurrent Carcinoma of the Rectum

Background: Morbidity associated with a nonhealing perineal wound is the most common complication following proctectomy, particularly in the setting of recurrent carcinoma of the rectum and radiation therapy. Immediate reconstruction using the gracilis myocutaneous and muscle flaps significantly reduces the incidence of major infection associated with perineal wound closure. The purpose of this study was to assess the value of immediate reconstruction of the perineal wound using a gracilis flap in patients undergoing abdominoperineal resection and intraoperative radiation therapy.Methods: This study retrospectively reviewed our experience with immediate pelvic reconstruction using gracilis muscle flaps for patients undergoing rectal extirpation and irradiation for recurrent carcinoma of the rectum. From 1990 to 1995, 16 patients underwent abdominoperineal resection (APR) or pelvic exenteration accompanied by immediate wound closure with unilateral or bilateral gracilis muscle flaps. Morbidity and mortality outcomes were compared to those of 24 patients from our institution who, between 1988 and 1992, underwent proctectomy and irradiation for recurrent rectal carcinoma with primary closure of the perineal wound.Results: Major complications (i.e., major infection requiring hospitalization and/or operation) occurred in 2 (12%) of the patients with gracilis flaps versus 11 (46%) of the patients with primary closure (P = .028 by ² analysis for flap vs. primary closure). Minor complications (i.e., persistent sinus and subcutaneous abscess) occurred in 4 (25%) of the patients with gracilis flaps versus 5 (21%) of those with primary closure.Conclusion: Immediate perineal reconstruction using the gracilis myocutaneous flap following proctectomy and irradiation for recurrent rectal carcinoma significantly reduces the incidence of major infection associated with perineal wound closure.     

Morbidity and functional outcome after double dynamic graciloplasty for anorectal reconstruction

BACKGROUND: After abdominoperineal resection (APR), anorectal reconstruction with dynamic graciloplasty has been proposed to avoid abdominal colostomy and improve quality of life. Graciloplasties involving one or two gracilis muscles with various configurations have been described. The aim of this study was to evaluate morbidity and functional results in a homogeneous series of patients undergoing double dynamic graciloplasty following APR for rectal cancer. PATIENTS AND METHODS:: From May 1995 to May 1998, 15 patients (ten men and five women; mean age 54 (range 39-77) years) underwent anorectal reconstruction with double dynamic graciloplasty after APR for low rectal carcinoma. All patients had preoperative radiotherapy (45 Gy), 11 with concomitant chemotherapy, eight had intraoperative radiotherapy (15 Gy) and ten received adjuvant chemotherapy for 6 months. The surgical procedure was performed in three stages: APR with coloperineal anastomosis and double graciloplasty (double muscle wrap); implantation of the stimulator 2 months later; and ileostomy closure after a training period. RESULTS: There was no operative death. At a mean of 28 (range 3-48) months of follow-up, there was no local recurrence; two patients had lung metastases. Early and late morbidity occurred in 11 patients, mainly related to the neosphincter (12 of 16 complications). The main complication was stenosis of the neosphincter (n = 6), which developed with electrical stimulation. Of 12 patients available for functional outcome, seven were continent, two were incontinent and three had an abdominal colostomy (two for incontinence, one for sepsis). Compared with patients without stenosis, patients with neosphincter stenosis required major reoperations (four versus zero) and had a poor outcome (two of six versus five of six with a good result). CONCLUSION: The double dynamic graciloplasty is associated with a high risk of neosphincter stenosis, which may entail morbidity, reintervention and poor functional results. The stenosis is a heterogeneous feature of the neosphincter induced by asymmetrical traction of both gracilis muscles. It is suggested that single dynamic graciloplasty should be used for anorectal reconstruction after APR. Presented to the 101st congress of the Association Fran?aise de Chirurgie in Paris, France, October 1999, and to the European Council of Coloproctology in Munich, Germany, October-November 1999     

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.     

Extensive perineal and pelvic defects reconstructed simultaneously using bilateral pedicled gracilis and rectus abdominis muscle flaps after en-bloc excision of locally invasive perineal mucinous adenocarcinoma

We report a case of successful simultaneous reconstruction of pelvic and perineal defects using bilateral pedicled gracilis and inferiorly based rectus abdominis muscle flaps after en-bloc excision of the tumour and abdominoperineal resection of locally advanced invasive perineal mucinous adenocarcinoma originating from a chronic anal fistula.     

STIMULATED GRACILIS NEOSPHINCTER: A NEW PROCEDURE FOR ANAL INCONTINENCE

Background: The gracilis muscle has been used previously to construct an anal neosphincter, but this was not successful since a short-lived muscle contraction was insufficient to restore continence. Recently, a procedure was described in which conversion to a fatigue-resistant muscle was achieved by chronic low frequency electrical stimulation, and the resultant ability to sustain a constant contraction was associated with improved continence. Our initial results with this procedure, using a standardized operation and treatment protocol in 12 consecutive patients. is reported. Methods: Seven women (mean age 50 years, range 22–71 years) had faecal incontinence, and five patients (F:M. 3:2; aged 53–72 years) underwent reconstruction after abdominoperineal excision of the rectum for cancer. A detailed questionnaire including continence score was completed pre-operatively. Eight patients have been assessed after ileostomy closure at a mean time of 10 months. Results: Slow-twitch muscle conversion was achieved in each case and all patients have a functional neosphincter. Mean continence score was 6.8 (range 4–12), and seven patients were continent. There was significant improvement in continence in the non-cancer group (p= 0.03). Mean pre-operative resting anal pressure, functional neosphincter pressure (NPfunc), and maximal neosphincter pressure (NPmax) were 36, 102 and 207 cmH₂O, respectively. There was a significant improvement in pressure comparing NPfunc (P= 0.03) and NPmax (P= 0.03) with pre-operative pressure. Complications included deep vein thrombosis. pulmonary embolism, saphenous nerve injury, leg wound haematoma, and late pacemaker infection. Conclusion: The stimulated gracilis neosphincter achieves satisfactory continence in a majority of patients.     

Factors influencing perineal wound healing after proctectomy

The hospital and office records of 86 patients who underwent proctectomy for cancer of inflammatory bowel disease with primary closure of the perineal wound were reviewed. Almost one fourth of all patients suffered a significant perineal wound complication, the majority of which were infections. The incidence of postoperative perineal wound complications was comparable in both groups of patients. Urinary retention occurred in 24 percent of patients who underwent abdominoperineal resection or rectal cancer, and half of these patients required transurethral resection which indicates the need for more thorough preoperative assessment of bladder function, especially in older men. The development of leg ischemia that resulted in amputation in two elderly patients who had preoperative evidence of obstructive peripheral vascular disease suggests that a synchronous two-team abdominoperineal resection with the patient in the modified lithotomy position for a prolonged period should be avoided. One third of all patients were discharged less than 10 days after surgery and two thirds within 2 weeks. Prolonged stays were more frequent in cancer patients and appeared to be related to age rather than to the development of postoperative complications. The perineal wound after abdominoperineal resection for cancer healed more rapidly and more completely than did the wound after proctectomy for inflammatory bowel disease. Fourteen percent of the inflammatory bowel disease patients did not have a healed wound 1 year after surgery. The extent of rectal cancer as determined by Duke's classification played no role in healing of the perineal wound, but women with rectal cancer healed at a slower rate than did men. The location of the exit site for wound catheters and the use of cautery and preoperative steroid therapy appeared too have no effect on the healing of the perineal wound.     

Rectal sphincter reconstruction in perineal colostomies after abdominoperineal resection for cancer.

A surgical technique is proposed for the reconstruction of the anal sphincter in perineal colostomies after abdominoperineal resection for cancer. The procedure, which employs the gracilis muscle for the sphincteric reconstruction is described and the operative results and complications are analysed in 24 patients submitted to this type of surgery. Of the 22 patients who were followed up, 17 had excellent or good results with retention of solid or soft stools. Three patients had poor results with no voluntary retention, while 2 others were partly incontinent of solid faeces. In this group of 5 patients, 3 had stenosis of the colostomy and 1 had no sensibility of impending defaecation.     

Bioffedback reeducation in gracilis muscle transposition after rectal trauma: A case presentation

A 20-year-old male patient had a significant rectal trauma and underwent colostomy and subsequent creation of a neosphincter through gracilis muscle transposition. The patient was referred for biofeedback training to learn to use the transplanted gracilis muscle as a substitute for the external anal sphincter. Through a period of 10 weeks, the patient became able to identify this transplanted muscle and to increase the amplitude and duration of contraction as measured by surface electromyography. Further, resting tone of the neosphincter was increased. The patient gained continence with respect to liquid, gaseous, and solid stool within 26 weeks of the first bioffedback muscle training session.     

The electrically stimulated gracilis neosphincter incorporated as part of total anorectal reconstruction after abdominoperineal excision of the rectum.

OBJECTIVE: The authors investigated the feasibility and effectiveness of combining electrically stimulated gracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients after abdominoperineal excision of the rectum (APER). SUMMARY BACKGROUND DATA: The ESGN is effective in the treatment of idiopathic fecal incontinence. METHODS: Between March 1989 and September 1993, 12 patients (9 men, 3 women) with a median age of 59.25 years (range, 45-70) underwent the procedure. The underlying disease was adenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in the other. In all patients, a sphincter saving resection was contraindicated. The procedure was performed in stages. Stage 1 involved a conventional APER with the formation of a perineal stoma. Eleven patients underwent a vascular delay procedure. All patients were defunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, and the electrodes and hardware needed for electrical stimulation were implanted. Once muscle conversion was complete, the defunctioning stoma was closed. RESULTS: Eight patients were closed successfully. In seven of the eight patients, complete physiologic measurements were taken. Median basal and maximum neosphincter pressures were 30 and 122 cm H2O, respectively, at the start of electrical stimulation and 22.5 and 76.2 cm H2O, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H2O at 1 year. All of the patients whose stomas were closed experienced episodes of incontinence to solid stool and wore pads for persistent fecal soiling. They all reported difficulty in evacuation. Despite imperfect continence, no patient wished to go back to life with a stoma. CONCLUSIONS: The incorporation of ESGN as part of total anorectal reconstruction is technically feasible. The majority of patients are satisfied with their function and pleased to avoid a permanent stoma.     

Perineal hernias after proctectomy. A new approach to repair

Perineal herniation of pelvic organs rarely occurs after abdominoperineal resection of the rectum, but it does present a difficult surgical dilemma. The case of a patient with perineal herniation of the small bowel and urinary bladder into a proctectomy wound has been described. This was repaired using a transabdominal pelvic sling with Marlex followed by gracilis muscle transplantation. Review of the literature yielded 18 previous case reports of perineal hernia after proctectomy, and the results of various surgical approaches have been detailed and discussed. The technique of gracilis muscle transplantation offers a definite advantage when the hernia occurs in a contaminated perineal wound.