Efficacy analysis of natural orifice specimen extraction surgeries and Jinling surgery in treatment of intractable constipation
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摘要:目的
评价经自然腔道取标本手术(NOSES)联合金陵术治疗顽固性便秘的有效性与安全性。
方法回顾性收集在苏北人民医院接受NOSES联合金陵术的顽固性便秘患者的资料，采用胃肠生活质量指数(GIQLI)评分、Wexner便秘评分、每周完全自发排便(SCBM)次数、排便满意度、切口美容效果满意度、焦虑自评量表(SAS)和抑郁自评量表(SDS)评估手术效果。
结果本研究无围术期死亡患者。患者术前GIQLI评分为(53.0±5.1)分，术后3个月时GIQLI评分高于术前，且术后3个月开始评分持续增高，差异有统计学意义(P＜0.05); 术后1个月Wexner便秘评分为(13.1±2.5)分，3个月为(11.1±2.4)分，6个月为(8.1±2.0)分，12个月为(5.9±1.4)分，与术前Wexner便秘评分(23.8±3.5)分比较，差异有统计学意义(P＜0.05)。随着术后时间的延长，患者SCBM次数逐渐减少，术后6个月SCBM次数维持在(4.8±1.1)次/d, 术后12个月维持在(4.1±0.9)次/d。术后6、12个月，患者SAS评分和SDS评分较术前下降，差异有统计学意义(P＜0.05)。
结论NOSES联合金陵术能改善顽固性便秘患者躯体症状，也能解决患者心理障碍。
Abstract:ObjectiveTo evaluate the efficacy and safety of natural orifice specimen extraction surgeries (NOSES)combined with Jinling surgery in treatment of intractable constipation.
MethodsThe data of patients with intractable constipation who received NOSES combined with Jinling surgery in North Jiangsu People′s Hospital were retrospectively collected. The Gastrointestinal Quality of Life Index (GIQLI), Wexner constipation score, times of spontaneous bowel movements (SCBM) every week, defecation satisfaction, incision cosmetic effect satisfaction, Anxiety Self-Rating Scale (SAS) and Depression Self-Rating Scale (SDS) were used to evaluate the effect of surgery.
ResultsThere were no perioperative deaths. The preoperative GIQLI score was (53.0±5.1), and the GIQLI score three month after surgery was higher than that before surgery, and the score continued to increase afterwards, showing statistically significant differences (P < 0.05). The Wexner constipation score was (13.1±2.5), (11.1±2.4), (8.1±2.0), and (5.9±1.4) at one month, three months, six months, and 12 months after operation, which showed statistically significant differences compared with (23.8±3.5) of preoperative Wexner constipation score (P < 0.05). The patients′ SCBM gradually decreased with the prolongation of postoperative time, maintained at (4.8±1.1) times per day six months, and maintained at (4.1±0.9) times per day after 12 months. As the patient′s defecation frequency became normal, and the defecation satisfaction and incision cosmetic effect were better, the patient′s anxiety and depression symptoms gradually improved, and the SAS and SDS scores decreased significantly 6 to 12 months after the operation compared with treatment before(P < 0.05).
ConclusionNOSES combined with Jinling surgery can not only improve the somatic symptoms of patients with intractable constipation, but also solve the psychological barriers of patients.
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图 1 改良结肠慢传输试验
A: 正常对照(钡剂完全排空); B: 慢传输型便秘(钡剂残留在结肠); C: OOC型便秘(钡剂残留在直肠); D: 混合型便秘(钡剂残留在结直肠内)。
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图 3 NOSES联合金陵术手术示意图
A: 戳卡位置; B: 打开胃结肠韧带; C: 游离升结肠; D: 离断结肠中血管; E: 游离结肠脾区; F: 游离降结肠; G: 游离直肠后壁至尾骨尖水平; H: 打开直肠; I: 切除阑尾; J: 从肛门置入吻合器钉座; K: 在回盲部结肠置入吻合器钉座; L: 经直肠拖出标本; M: 闭合直肠残端并置入吻合器; N: 升结肠-直肠端侧吻合; O: 升结肠-直肠侧侧吻合。
表 1 便秘患者临床资料特征
患者编号 性别 年龄/岁 合并症 体质量指数/(kg/m2) 便秘时间/年 手术时间/min 术中出血量/mL 并发症 1 女 22 无 18.3 10 195 20 吻合口出血 2 男 68 糖尿病 20.2 20 280 50 吻合口瘘 3 男 76 高血压 20.4 32 310 50 无 4 男 73 高血压 23.1 15 310 50 无 5 女 25 无 21.2 5 270 30 无 6 女 74 糖尿病 19.6 30 300 50 腹腔感染 7 女 56 无 22.2 10 275 50 无 8 女 53 无 20.4 12 280 50 无 9 女 54 无 21.5 20 280 50 无 10 女 47 无 23.2 22 265 50 无 11 女 73 高血压 21.6 30 320 50 无 12 女 66 无 20.8 10 300 50 无 13 男 72 糖尿病 22.5 30 315 50 吻合口瘘 14 女 68 无 21.8 38 320 50 无 15 男 71 糖尿病 23.2 25 330 50 吻合口出血 16 女 51 无 20.5 19 285 50 无 17 女 35 无 20.1 10 280 30 无 18 女 19 无 18.2 4 200 30 无 19 女 43 无 22.7 20 280 50 无 20 女 45 无 19.5 25 285 50 无 21 女 50 高血压 21.4 20 300 50 术后肠梗阻 
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表 2 顽固性便秘患者手术前后GIQLI评分、Wexner便秘评分、SAS评分及SDS评分比较(x±s)
分 项目 术前(n=21) 术后1个月(n=21) 术后3个月(n=20) 术后6个月(n=15) 术后12个月(n=10) 胃肠生活质量指数评分 53.0±5.1 43.9±5.9* 63.1±7.3* 87.6±9.7* 103.7±9.7* Wexner便秘评分 20.3±4.0 13.1±2.5* 11.1±2.4* 8.1±2.0* 5.9±1.4* 焦虑自评量表评分 59.3±8.2 56.2±7.5 54.3±7.7 50.8±7.2* 42.2±6.8* 抑郁自评量表评分 58.6±6.6 55.8±7.0 54.3±6.9 46.4±5.8* 40.7±5.9* 与术前比较, * P＜0.05。
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表 3 术后排便满意度情况[n(%)]
术后随访时间 n 非常满意 满意 一般 不满意 随访1个月 21 3(14.3) 9(42.8) 9(42.9) 0 随访3个月 20 5(25.0) 5(25.0) 8(40.0) 2(10.0) 随访6个月 15 7(46.7) 5(33.3) 2(13.3) 1(6.7) 随访12个月 10 5(50.0) 3(30.0) 2(20.0) 0
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表 4 术后腹壁美容效果满意度情况[n(%)]
术后随访时间 n 满意 基本满意 不满意 随访1个月 21 8(38.1) 12(57.1) 1(4.8) 随访3个月 20 10(50.0) 9(45.0) 1(5.0) 随访6个月 15 10(66.7) 5(33.3) 0 随访12个月 10 8(80.0) 2(20.0) 0
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