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目的通过分析吻合口水平对肛门排便功能和生活质量的影响,探讨直肠癌超低位吻合保肛极限。方法 2010年6月至2012年9月河北省4家三级综合医院:河北省涿州市医院、河北大学附属医院(原河北省人民医院)、河北省邯郸市中心医院、河北省保定市第二中心医院,对570例直肠癌低位吻合患者,按吻合口到肛缘的距离分3组A组:<2.0 cm(切除全部内括约肌),B组:2.0~4.0 cm(相当于齿状线平面,切除部分内括约肌),C组:>4.0 cm(保留全部内括约肌)。分别在术后3个月及1年以徐忠法五项十分评价标准及大便失禁生活质量问卷(the fecal incontinence quality of life questionnaire,FIQL)综合分析判断。结果在术后3个月,吻合口位置越低肛门功能评分越低(2.79 vs.4.94 vs.8.82,P<0.05),经过1年的适应及功能锻炼后,各组的肛门功能评分稍有升高,A组评分仍然要低于B、C两组(5.38 vs.7.55,9.12,P<0.05)。对自身生活质量满意方面,在术后1年A组患者的生活方式、心理应付/行为、抑郁/自我感受及窘迫尴尬方面均劣于B、C(P<0.05)两组。结论对于直肠癌的低位前切除术,吻合口位置越低肛门功能和生活质量就越差,对于吻合口距离肛缘<2 cm者,术后肛门功能、生活质量明显下降。故在肿瘤学安全的基础上,吻合口距肛缘距离>2.0 cm视实际情况保肛,而非为单纯保留肛门,追求保肛率,无视患者术后生活质量严重下降而强行保肛。
Objective To analyze the effect of anastomotic level on anal defecation function and quality of life and explore the ultralow anal anus limit of rectal cancer. Methods From June 2010 to September 2012, four level three general hospitals in Hebei Province were: Danzhou Municipal Hospital of Hebei Province, Affiliated Hospital of Hebei University (formerly Hebei Provincial People’s Hospital), Handan Central Hospital of Hebei Province, Baoding Second Hospital of Hebei Province In the central hospital, 570 patients with low anastomosis of rectal cancer were divided into three groups according to the distance from the anastomosis to the anal verge: group A: 2.0 cm (total internal sphincter excision); group B: 2.0-4.0 cm (equivalent to the dentate line plane , Resection of part of the internal sphincter), Group C:> 4.0 cm (retaining the entire internal sphincter). Three months and one year after operation, the five criteria of Xu Zhongfa and the fecal incontinence quality of life questionnaire (FIQL) were analyzed respectively. Results At 3 months after operation, the lower the anastomosis position was, the lower the anal function score was (2.79 vs.4.94 vs.8.82, P <0.05). After 1 year of acclimation and functional exercise, the anal function score of each group was slightly (P <0.05). The scores of A group were still lower than those of B and C groups (5.38 vs.7.55,9.12, P <0.05). In terms of their quality of life, patients in group A were worse than those in group B and C (P <0.05) in lifestyle, psychological coping / behavior, depression / self-feeling and distress embarrassment in group A at 1 year after operation. Conclusions For low anterior resection of rectal cancer, the lower the anastomotic site is, the worse the anal function and quality of life are. The anal function and quality of life after operation are significantly lower for an anastomotic distance less than 2 cm. Therefore, on the basis of oncology safety, anastomotic distance> 2.0 cm depending on the actual situation of the anal margin, rather than simply retaining the anus, the pursuit of the rate of anus, ignoring the serious decline in the quality of life of patients and forcing anus.