Rectal cancer is one of the common gastrointestinal malignancies in China, and its incidence is increasing year by year, among which low rectal cancer is common, accounting for about 70% of all rectal cancers [1], and Miles procedure is the classic procedure for the treatment of low rectal cancer. However, the traditional colostomy method has poor bowel control function and stoma complications are more common. Since March 2000, we have used the extraperitoneal U-tunnel stoma technique to conduct a comparative study on the improvement of defecation function and postoperative stoma complications in 122 patients with rectal and anal canal cancer, and achieved better clinical results. The results are reported as follows.
Clinical data
1. General data.
There were 122 cases of rectal cancer and anal canal cancer admitted to the Department of Anal Surgery of our hospital from March 2000 to January 2005. 61 cases in group A (using U-tunnel colostomy) and 61 cases in group B (using traditional intraperitoneal stoma), aged 23-71 years, median age 49 years; medical history 3-19 months, including 101 cases of rectal cancer and 21 cases of anal canal cancer, all cases were referred to the Chinese Common All cases were clearly diagnosed as rectal cancer based on clinical symptoms, rectal finger diagnosis, endoscopy, ultrasound, CT, carcinoembryonic antigen and pathological examination with reference to the Chinese Common Malignant Tumor Diagnosis and Treatment Standard and the 1978 National Clinical Staging Trial Program for Colorectal Cancer (Dukes Chinese modified method). Clinical observation and follow-up cases were selected by random sampling grouping method with low rectal cancer (within 5 cm from the dentate line) anal canal cancer as the study subjects.
The following patients were not considered as study subjects
(1) Hartmann’s operation for rectal cancer
(2)patients who underwent emergency surgery for acute obstruction of rectal and anal canal cancer
(3)Patients with Dukes stage D rectal anal canal cancer
(4) Patients with perineal and anastomotic local recurrence after Dixon’s operation for rectal cancer and reoperation
(5) Patients with simultaneous multiple primary colon cancer
(6) Patients with simultaneous cystectomy and ileostomy
(7) Combined with serious medical diseases, such as coronary heart disease, liver cirrhosis, diabetes, post-stroke, etc. (8) Combined with psychiatric symptoms, who cannot complete the follow-up.
2.Surgical points.
2.1. U-shaped tunnel colostomy
2.1.1 Method: After routine excision of the lesion by Miles, a garden-shaped incision of about 2.5 cm in diameter is made at the junction of the external and external 1/3 of the line between the umbilicus and the anterior superior iliac spine in the left lower abdomen (or at a position selected before surgery), the skin, subcutaneous fat, and the anterior sheath of the rectus abdominis muscle are excised, the rectus abdominis muscle is bluntly separated (or partially severed), the peritoneum is exposed, and the transverse abdominal muscle and the peritoneum are carefully dissected with a large curved vascular forceps or fingers toward the The sigmoid colon or descending colon to be fistulated is pulled out of the abdominal wall from this tunnel for about 3 cm. 6-8 stitches are intermittently sutured between the sigmoid plasma muscle layer and the anterior sheath of the rectus abdominis muscle, taking care not to damage the sigmoid mesenteric vessels. Then intermittently suture the broken end of the intestinal tube to the skin dermis, with the nipple of the intestinal stoma about 1 cm above the skin, and immediately put on a disposable adhesive stoma bag.
2.1.2 Surgical considerations.
(1) The stoma positioning should be selected according to the specific conditions of different patients before surgery, and the appropriate position should enable patients to see the stoma site by themselves in different positions, so as to facilitate self-care and the use of stoma appliances. Obese patients in particular should pay attention to the general choice of trans-rectus abdominis stoma
(2) The diameter of the extraperitoneal U-shaped tunnel should be slightly larger than the circumference of the sigmoid colon, so that it can smoothly pass through the colon and the mesentery, and the lateral peritoneum fixed with the sigmoid colon suture should be expanded free to loosely stretch and cover the sigmoid colon, so that the descending colon and the terminal colon also become U-shaped (about 60° garden slip angle) pouch-like changes, which is conducive to the buffering and storage of fecal movement and prevent the occurrence of intestinal obstruction and primary discharge syndrome.
(3) Avoid twisting of the intestinal tube and mesentery in the U-shaped tunnel, as well as lateral peritoneal jamming of the colon, and make the tension of the colon in the U-shaped tunnel section as moderate as possible, and free the splenic flexure if necessary, so as not to affect the blood supply to the sigmoid colon and the patency of the intestinal cavity.
2.2. Traditional intraperitoneal stoma.
After Miles’ operation to remove the lesion, the stoma site is selected and incised to the abdominal cavity as described above, the proposed fistula intestine is dragged out of the phase I papillary stoma, and the sigmoid colon is fixed with interrupted sutures to the lateral abdominal cavity.
3.Efficacy assessment.
Satisfactory: no intra-abdominal hernia and stoma complications (para-hernias, retraction, prolapse, stenosis, etc.), sense of defecation and gradual formation of regular defecation, clean stoma, no stoma apparatus or mild stoma complications without surgical treatment.
Unsatisfactory: no sense of defecation, irregular defecation, need to use stoma apparatus, often contaminate underwear, or combined with serious intra-abdominal hernia and stoma complications, need surgical treatment.
4. Results.
After the stoma technique surgery in groups A and B as described previously, the same routine measures such as fasting, indwelling gastric tube, urinary catheter, pelvic drainage tube, and nutritional support were taken, and daily observations were made to record changes in vital signs, abdominal signs, blood flow of the stoma pattern, and the color, quality, and quantity of the first and subsequent successive bowel movements and the patient’s self-conscious symptoms until straight discharge. The abnormalities were recorded and submitted to the research group for discussion and consultation, and the treatment plan was adjusted accordingly. 61 cases in group A were followed up for 6-10 days after surgery, and 54 of them had a sense of defecation (88.5%) and gradually developed regular defecation, and the stoma was clean, and only paper towels were used to cover the stoma without using a stoma bag. In group B, 61 cases were followed up for 3-60 (31.5±27.5) months. 6 cases had different degrees of difficulty in first defecation, which were discharged through measures such as paraffin oil infusion and Chinese medicine, and 13 had a sense of defecation (21.3%). 3 cases of parastomal hernia, 1 case of intra-abdominal hernia, 2 cases of stoma retraction, 1 case of intestinal prolapse, and 3 cases of stoma stenosis occurred. The incidence of complications was 16.4%.