楊立勝 何安琪 劉剛

直腸前突的外科治療進展

楊立勝 何安琪 劉剛

直腸前突（RC）是引起梗阻性排便障礙綜合征的重要原因之一，患者由于長期排便困難生活質(zhì)量受到嚴重影響。外科手術(shù)是治療RC的一種重要方法，患者若具備手術(shù)指征應(yīng)及時選擇合適的手術(shù)方法進行治療。RC手術(shù)方法眾多，按照手術(shù)入路可分為經(jīng)肛門手術(shù)、經(jīng)陰道手術(shù)、經(jīng)腹部手術(shù)和經(jīng)會陰手術(shù)。本文主要從上述四類手術(shù)方法進行介紹，通過綜述近年來新進展以期為RC的外科治療提供依據(jù)。

直腸； 治療； 直腸前突； 外科手術(shù)

直腸前突（rectocele，RC）是引起梗阻性排便障礙綜合征（obstructed defecation syndrome，ODS）的重要原因之一［1］，患者因長期忍受排便困難的困擾，生活質(zhì)量受到了嚴重影響。隨著生活方式的改變和社會老齡化的加快，RC發(fā)病率逐年升高，引起了國內(nèi)外眾多學(xué)者的關(guān)注。由于非手術(shù)治療效果常難以令人滿意，外科手術(shù)成為治療RC的一種重要方法。近年來伴隨科技的進步，RC的外科治療方法也在不斷改進，本文現(xiàn)對RC的外科治療進展做一綜述，以期為RC的外科治療提供依據(jù)。

一、RC概述

RC是一種由直腸前壁突向陰道后壁的疝［2］，又稱直腸前膨出，以中老年女性多見。多數(shù)學(xué)者認為RC與分娩、慢性便秘等過程致腹內(nèi)壓力升高、盆底組織結(jié)構(gòu)松弛、直腸陰道隔損傷相關(guān)［3］，也有學(xué)者報道其可能與肛門內(nèi)外括約肌薄弱、直腸陰道壓力梯度異常有關(guān)［4-5］。

按照解剖部位的不同，RC可分為低位、中位和高位三種類型，而中位RC又可進一步分為兩型，I型以肛管靜息壓力相對升高、慢性排便障礙為特點，II型則表現(xiàn)為肛管靜息壓力正?；蚪档桶橄嚓P(guān)盆腔臟器脫垂［6］。依據(jù)盆腔器官脫垂量化系統(tǒng)（pelvic organ prolapse quantifcation system，POP-Q），RC可分為0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期［7］。按照排糞造影所示前突深度，RC又可分為輕度、中度和重度［8］。

當RC深度大于15 mm時，往往引起便秘、大便干結(jié)、便不盡感、排便費力、腹痛腹脹、會陰部墜脹不適等癥狀［9-13］，部分患者甚至需要手助排便［14］。直腸指檢能觸及直腸前壁薄弱松弛區(qū)，陰道檢查可發(fā)現(xiàn)陰道后壁膨出［2］，排糞造影則直接顯示排便時直腸前下壁呈囊袋狀突向前方及相應(yīng)部位直腸陰道隔移位［15］。

輕度RC優(yōu)先考慮非手術(shù)治療，主要包括定期鍛煉、增加水分和膳食纖維攝入、應(yīng)用滲透性通便藥物、生物反饋訓(xùn)練等［2，15-16］。正規(guī)非手術(shù)治療癥狀不緩解者及中重度RC患者則需考慮外科手術(shù)［17］。手術(shù)目的在于消除薄弱區(qū)，加固直腸陰道隔。RC的外科手術(shù)適應(yīng)證包括［18］：（1）需用手協(xié)助排便；（2）直腸指檢、排糞造影或盆腔CT顯示直腸前壁呈囊袋狀向前突出；（3）排糞造影或CT顯示RC≥3.1 cm；（4）排糞造影時RC內(nèi)鋇劑殘留。

二、RC的外科治療

國外文獻報道的RC手術(shù)方式較多，根據(jù)手術(shù)入路可分為經(jīng)肛門手術(shù)、經(jīng)陰道手術(shù)、經(jīng)腹部手術(shù)和經(jīng)會陰手術(shù)，四類不同的手術(shù)方法各具特點——經(jīng)肛門手術(shù)操作簡單，能同時處理伴隨的其它直腸肛管疾病，但可能出現(xiàn)嚴重出血等并發(fā)癥；經(jīng)陰道手術(shù)可取得較好的解剖修復(fù)效果，但存在發(fā)生術(shù)后性交痛等風(fēng)險；經(jīng)腹部手術(shù)的優(yōu)勢在于可以精細地進行盆腔操作，卻無法切除直腸內(nèi)冗長的黏膜組織；而經(jīng)會陰手術(shù)雖少有術(shù)后性交痛發(fā)生，但對盆腔或直腸內(nèi)疾病均無治療作用。因此，很難確定治療RC的最佳術(shù)式，需要權(quán)衡利弊，選取適當手術(shù)方法。

（一）經(jīng)肛門手術(shù)

經(jīng)肛門入路治療RC是當今國外研究的熱點，傳統(tǒng)的Sehapayak法、Khubchandani法和Block法現(xiàn)已少用，隨著外科醫(yī)師經(jīng)驗的積累和吻合器技術(shù)的進步，一些新術(shù)式不斷產(chǎn)生，主要包括經(jīng)肛門吻合器直腸切除（stapled transanal rectal resection，STARR）術(shù)、Transtar術(shù)、TST STARR＋術(shù)以及Bresler術(shù)。

目前，STARR術(shù)是國際上治療ODS的常用術(shù)式，其利用2把環(huán)形吻合器分別切除直腸前、后壁黏膜和黏膜下層，既可減小RC深度，又能去除冗長的直腸后壁組織，同時吻合口瘢痕形成可使黏膜下層與肌層黏連，起到加固直腸壁的作用［19］，尤其適于RC合并其它直腸肛管疾?。ㄈ缰蹦c黏膜脫垂、直腸內(nèi)套疊）的治療。許多報道肯定了STARR的近期療效，如歐洲一項納入2 838名STARR術(shù)后患者的多中心研究［20］表明，術(shù)后12個月患者排便障礙顯著改善，ODS評分由15.8分降至5.8分。從遠期療效來看，STARR手術(shù)似乎也是安全、有效的［21］。但最近一項Meta分析顯示STARR手術(shù)療效可能被夸大，而且有報道稱STARR術(shù)后18個月復(fù)發(fā)率開始增加，術(shù)后24個月ODS評分也開始升高，遠期效果令人失望［22-23］。STARR手術(shù)因釘倉容量小、切除組織少，且術(shù)者無法在直視下進行操作，具有一定的技術(shù)局限，為探索新的手術(shù)技術(shù)學(xué)者們進行了不懈的努力。

Transtar術(shù)是STARR的一種改良術(shù)式，通過使用一把CCS-30 Contour Transtar弧形吻合器達到切除更多組織的目的［24］。Transtar術(shù)在短期內(nèi)可以緩解癥狀，顯著改善生活質(zhì)量，急便感發(fā)生率及復(fù)發(fā)率低［25-26］，但由于術(shù)后存在危及生命的直腸出血風(fēng)險［19］，Transtar手術(shù)安全性問題仍不能忽視。2014年意大利學(xué)者Naldini等［27］提出STARR的一種最新改良術(shù)式——TST STARR＋術(shù)，該術(shù)式使用一把具有4個可視開窗、外徑36 mm的環(huán)形吻合器，既可改善術(shù)者視野又能增加切除組織量。在Ren等［28］的研究中，術(shù)后78%患者表示滿意，Wexner便秘評分也顯著下降，吻合口出血、急便感等并發(fā)癥發(fā)生率及復(fù)發(fā)率降低。但由于目前此術(shù)式開展較少，遠期療效尚需進一步研究證實。

Bresler術(shù)最早由法國學(xué)者Bresler于1993年提出，利用一把直線縫合器縱行切除直腸前壁冗長的黏膜、黏膜下層和部分肌層，同時鈦釘閉合并縫合切割線，達到修補加固直腸陰道隔的目的［29］。該術(shù)式治療RC簡單、安全，具有良好的近期和遠期療效，但不足之處是吻合口易形成肉芽腫和出血［29-30］；近年，國內(nèi)始有改良Bresler術(shù)的報道，并取得了滿意的近期療效，且無嚴重并發(fā)癥發(fā)生［31］，展現(xiàn)了良好的應(yīng)用前景。隨后Liu等［32］將Bresler術(shù)與part-STARR聯(lián)合治療RC合并直腸內(nèi)套疊的患者，結(jié)果表明聯(lián)合術(shù)式雖然平均手術(shù)時間長，但術(shù)后6個月在Wexner便秘評分、滿意度調(diào)查、排糞造影三方面均優(yōu)于STARR術(shù)式，顯示出更佳的遠期療效，不過此結(jié)果尚需大樣本、多中心隨機研究的驗證。

（二）經(jīng)陰道手術(shù)

經(jīng)陰道手術(shù)可較好地暴露盆內(nèi)筋膜和肛提肌，利于解剖修復(fù)，但可能發(fā)生術(shù)后性交痛［2，19］。傳統(tǒng)經(jīng)陰道手術(shù)主要包括經(jīng)陰道閉式修補術(shù)、切開修補術(shù)，前者直接貫穿縫合陰道壁及其深部組織，而后者則需切開陰道后壁，將直腸陰道隔折疊、縫合至中線，或?qū)⒅蹦c陰道隔特定缺損部位與宮頸周圍環(huán)、陰道穹隆縫合從而發(fā)揮加固作用［19，33］。國外文獻報道上述方法的解剖成功率約73～96%，然而也存在約3～27%的術(shù)后性交痛發(fā)生率［34］。為減小疼痛、提高解剖修補效果，人們開始探索將補片用于經(jīng)陰道RC修補術(shù)中。補片主要包括合成補片和生物補片，盡管合成補片可取得良好的解剖修復(fù)效果，但并發(fā)癥（如補片磨損、性交痛、感染等）限制了其廣泛使用，而生物補片可能減少這些并發(fā)癥［34］，如Marinkovic等［35］對41名RC患者行經(jīng)陰道生物補片植入術(shù)，術(shù)后8年并發(fā)癥發(fā)生率僅為12.1%。由于目前相關(guān)數(shù)據(jù)尚不完善，有關(guān)經(jīng)陰道補片植入的探索仍需要深入進行。

國外研究顯示RC患者會陰體中央薄弱并向兩側(cè)移位［36］，組織固定系統(tǒng)（tissue fxation system，TFS）經(jīng)陰道會陰體修補術(shù)可以糾正上述改變。該術(shù)式通過將TFS錨狀物插入至?xí)幧顧M肌，利用7 mm寬的聚丙烯吊帶使側(cè)方移位的會陰體升高并向中央聚集，術(shù)后膠原組織形成新的中心腱使直腸漿肌層、陰道及會陰體相連而發(fā)揮加固作用［37］。Wagenlehner等［38］利用此方法治療重度RC 30例，術(shù)后1年90%患者治愈，ODS評分由19分降至4分，達到良好的解剖修復(fù)效果，且無術(shù)后性交痛發(fā)生。近來，Shafk等［39］在陰道入路中采用直線縫合器治療RC獲得了良好的近期療效，此術(shù)式在減小RC深度的同時又不會導(dǎo)致大便失禁，術(shù)后并發(fā)癥少，主要為急便感（8.3%）。由于這項經(jīng)陰道吻合器直腸切除術(shù)開展時間不長，遠期療效尚需進一步研究的評估。

（三）經(jīng)腹部手術(shù)

傳統(tǒng)的直腸懸吊固定術(shù)需要廣泛游離直腸后壁，可能因損傷神經(jīng)而致便秘加重或出現(xiàn)新發(fā)便秘癥狀，文獻報道發(fā)生率在30～50%［40］。自2004年D′Hoore等［41］報道腹腔鏡直腸懸吊固定術(shù)可取得良好療效以來，多項研究均得出相似結(jié)論，如法國學(xué)者Wong等［42］利用此術(shù)式治療84例復(fù)雜性RC患者，術(shù)后29個月便秘癥狀由83%顯著下降至46%，且無新的便秘癥狀產(chǎn)生。機器人手術(shù)是近年新興的一種手術(shù)方式，具有三維放大、震顫濾過、清晰顯示盆底重要結(jié)構(gòu)等固有優(yōu)勢，其與腹腔鏡手術(shù)在中轉(zhuǎn)開腹率、復(fù)發(fā)率及功能預(yù)后（如大便失禁、排便障礙及性功能影響等）方面均無顯著差異［43-44］。雖然機器人手術(shù)時間長、費用高，但其可在狹小的盆腔范圍內(nèi)進行更為精細的操作，術(shù)中出血更少，對于治療復(fù)雜性RC安全可行［44］。

（四）經(jīng)會陰手術(shù)

經(jīng)會陰手術(shù)主要包括傳統(tǒng)的經(jīng)會陰修補術(shù)（transperineal repair，TPR）和經(jīng)會陰補片植入術(shù)。TPR需在陰道口背側(cè)做一橫向弧形切口，將陰道后壁與會陰體、直腸陰道隔分離至子宮頸水平，再縫合兩側(cè)的肛提肌筋膜使其向中線聚集，并修復(fù)、重建會陰體以加固直腸陰道隔薄弱區(qū)［6］。近來有報道稱將TPR與局部內(nèi)括約肌切開術(shù)（limited internal sphincterotomy，LIS）聯(lián)合治療RC可取得更好的臨床療效，但由于LIS可能導(dǎo)致暫時性大便失禁［6］，TPR聯(lián)合LIS術(shù)的遠期療效還需進一步觀察。雖然早在1996年就有經(jīng)會陰補片植入術(shù)的報道［45］，但此術(shù)式并未得到廣泛開展，相關(guān)文獻報道較少。隨后的幾項小樣本研究表明經(jīng)會陰途徑植入合成補片或生物補片均可獲得良好的近期療效，與經(jīng)陰道補片植入術(shù)相似，經(jīng)會陰生物補片植入術(shù)可以避免合成補片相關(guān)的并發(fā)癥發(fā)生［46-47］，在降低并發(fā)癥方面可能更具優(yōu)勢。

綜上，RC的外科治療始于20世紀初期，雖然經(jīng)過了數(shù)十年的發(fā)展歷程，但手術(shù)效果仍未達到理想水平。由于存在研究設(shè)計欠嚴謹、樣本量小、納入排除標準不統(tǒng)一、手術(shù)操作不規(guī)范、術(shù)后療效評價標準不一致、術(shù)后隨訪時間短等問題，RC外科治療的遠期效果尚需大樣本多中心隨機對照研究的評估。相信隨著今后外科治療方法的不斷完善和規(guī)范化，RC患者將會獲得更佳的療效和更滿意的生活質(zhì)量。

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Progress in the surgical treatment of rectocele

Yang Lisheng, He Anqi, Liu Gang.
Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China

Liu Gang, Email: landmark1059@163.com

Rectocele is one of the major reasons of obstructed defecation syndrome, and the quality of life for many patients has been seriously affected due to long-term constipation. Surgical operation is an important method for the therapy of rectocele. Prompt surgery and appropriate surgical procedures are critical when surgery is indicated. According to the different surgical approaches, surgery can be divided into transanal, transvaginal, transabdominal and transperineal procedures. This article, which was introduced mainly from the above four surgical approaches, reviewed the recent research advances in order to provide the evidence for the surgical treatment of rectocele.

Rectum; Therapy; Rectocele; Surgical procedures, operative

2016-12-29）

（本文編輯：楊明）

10.3877/cma.j.issn.2095-3224.2017.05.012

天津市衛(wèi)生局科技基金資助項目（No.2010KZ114）

300052 天津醫(yī)科大學(xué)總醫(yī)院普通外科

劉剛，Email：landmark1059@163.com

楊立勝, 何安琪, 劉剛. 直腸前突的外科治療進展[J/CD]. 中華結(jié)直腸疾病電子雜志, 2017, 6(5): 410-413.