淺談大腸手術跟造口loop ileostoma vs. loop colostoma ileostoma colostoma 分泌量多,...
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淺談大腸手術跟造口台南市立醫院
GS 周易韋
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名詞釋義
• Stomy: 做造口的這個”術式”
• Stoma: 指“造口”本身
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Stoma的種類
T-loop colostoma
End-colostoma
Double barrel colostoma
Ileostoma
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T-loop colostoma
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End-colostoma
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Double barrel colostoma
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Loop ileostoma
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Loop ileostoma vs. Loop colostoma
Ileostoma Colostoma
分泌量多, 液體狀, bile色�700-800mL/day, 動輒破1000以上�容易電解質不平衡
分泌量很少, 已經是糞便�更換次數少, 比較好照顧�越近端則糞便越液狀, 越遠端則糞便越固體狀
Decompression效果差�因為有ileo-cecal valve
�術後保護吻合口多
Decompression效果好
手術較簡單�小腸在腹腔中是浮動的
手術較困難�大腸相對比較固定, 且很漲的時候手術不易
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為什麼要有stoma?
Afraid of leakage !!!!!
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Proximal Distal
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考慮需要stoma的因素
•還是一樣, 怕leak !!!
• 術前colon因阻塞而非常漲
• 病人太多內科的co-morbidity
• Liver cirrhosis
• ESRD (End-stage renal disease)
• 年紀太大
• Anastomosis太低• 低位直腸癌
• 術前, 術中或者術後生命徵象不穩…
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常見的大腸術式
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Right hemi-colectomy
血流很豐富, 幾乎不需要術後造口保護
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Left hemi-colectomy
左側大腸血流較差, 有時需術後造口
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Sigmoid & LAR(low anterior resection)
LAR需要造口的機會較多
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APR(abdomino-perineal resection)
APR為永久之造口
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Hartmann’s procedure
造口可以是永久, 也可以是暫時的
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觀念No.1
End-colostoma跟Loop colostoma take-down的方式有什麼不同?
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T-loop colostoma
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Hartmann’s procedure
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觀念No.2
Colon cancer完全阻塞治療的方式
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Colon cancer with total obstruction
3 stages treatment
VS.
2 stages treatment
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3 stages treatment
• 1st operation• Decompressive colostomy
• 2nd operation• Curativer resection � Laparoscopic or open
• Left hemi-colectomy
• Sigmoid colectomy
• LAR
• 3rd operation• Colo-stoma take down
Tumo
r
Stoma
10-14 days later…
3 months later…
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2 stages operation
• 1st + 2nd operation
• OPEN curative resection + intra-OP colon irrigation
• 因為病人肚子很漲,再加上術中洗腸子清理糞便,通常也只能open手術
• Need diverting colostoma to protect anastomosis from leakage
• 3rd operation
• Colostoma take down
3 months later…
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Alternative 2 stages operation• 1st operation
• Decompressive colostomy
• 10-14 days interval• FFP transfusion
• Parenteral nutrition support
• Stoma decompression
• 2nd + 3rd operation• Curative resection + colostoma take dwon
• 因為已經有了colostoma for decompression,腸子已經不漲,可以好好的colon preparation
• 可以LAPAROSCOPIC approach
• 此時take down手術後的leak機率已經降低
10-14 days later…
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Case
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許O菱 1064-01X
• 49 y/o
• Admission on 2017-07-15
• Discharge on 2017-08-07
• Past history
• Medical history
• HTN(-), type II DM(-)
• Surgical history
• Denied operation before
• Alcohol(-), Betel nut(-), Cigarette(-)
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History summary
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• 2017-07-15
• Sent to ER due to abdominal fullness
• KUB
• Abdominal CT with/without contrast
• Admission
• 2017-07-17
• Panendoscopic exam
• 2018-07-19 Colonoscopic exam + biopsy
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Pathological report
• PATHOLOGIC DIAGNOSIS
• Intestine, large, colon, 50 cm. from anal verge, endoscopic biopsy.
• Adenocarcinoma
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LUQ T-loop colostomy2017-07-21
1st operation
DiagnosisDiagnosis
Descending colon adenocarcinoma with total obstructionDescending colon adenocarcinoma with total obstruction
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Extremely Extremely
distended !!distended !!
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Tumo
r
Stoma
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Between 1st and 2nd operation…
• On clear liquid diet
• FFP x 2 units BID transfusion
• To reduce colon wall edema
• Parenteral nutrition support
• Bluid(1000mL) 1 pack QD IVD
• Arrange HRCT for excluding lung metastasis
• 2 days before 2nd operation
• Start colon preparation
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Laparoscopic left hemi-colectomy + LUQ T-loop
colostoma take down2017-07-31
2nd operation
DiagnosisDiagnosis
Descending colon adenocarcinoma with total obstruction s/p LUQ TDescending colon adenocarcinoma with total obstruction s/p LUQ T--loop loop
colostomycolostomy
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Tumo
r
Stoma
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Tumo
r
Stoma
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Course after operation…
• Post-OP transfer to AICU
• 2017-08-01, POD-1
• Remove NG
• Transfer to general ward
• 2017-08-03, POD-3
• Sip water
• Remove Foley
• 2017-08-04, POD-4
• On clear liquid diet
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Course after operation…
• 2017-08-05, POD-5
• On liquid diet
• 2017-08-06, POD-6
• On soft diet
• 2017-08-07, POD-7
• Remove J-P drain
• Discharge and follow up at OPD
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Pathological report
• PATHOLOGIC DIAGNOSIS• Intestine, D-colon, left hemicolectomy (LH)
• Adenocarcinoma, moderately differentiated, invaded into pericolic soft tissue
• Surgical margin, bilateral and CRM, LH• Free of malignancy
• Lymph nodes, regional (4/16), IMA (0/1), dissection• Metastatic adenocarcinoma (4/17)
• Intestine, colon, colostomy take down• Fibrosis
• Final stage pT3N2aM0
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有stoma的缺點?1. Stoma也有complication!
2. 病人主觀的感受…
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常見的造口併發症
•造口周圍皮膚發炎
•造口狹窄 (stenosis)
•造口腸段脫出 (prolapse)
•造口周圍疝氣 (hernia)
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Prolapse & Hernia
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Case presentation
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郭O 0499-84X
• 74 y/o
• Admission on 2017-12-01
• Discharge on 2017-12-26
• Past history
• Medical history
• HTN(-), type II DM(-)
• Surgical history
• Denied operation before
• Alcohol(-), Betel nut(-), Cigarette(-)
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S-loop colostomy2017-12-02
1st operation
DiagnosisDiagnosis
Sigmoid colon adenocarcinoma with total obstructionSigmoid colon adenocarcinoma with total obstruction
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Extremely Extremely
distended !!distended !!
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Tumo
r
Stoma
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Laparoscopic sigmoid colectomy + small bowel segmental
resection + S-loop colostoma take down
2017-12-14
2nd operation
DiagnosisDiagnosis
Sigmoid colon adenocarcinoma with total obstruction s/p SSigmoid colon adenocarcinoma with total obstruction s/p S--loop loop
colostomycolostomy
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Tumo
r
Stoma
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Course after operation…
• Post-OP transfer to AICU
• 2017-12-15, POD-1
• Transfer to general ward
• 2017-12-16, POD-2
• Remove NG
• 2017-12-18, POD-4
• Remove Foley
• Sip water
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Course after operation…
• 2017-12-19, POD-5• Remove anal tube
• 2017-12-20, POD-6• On clear liquid diet
• 2017-12-21, POD-7• On liquid diet
• 2017-12-22, POD-8• On soft diet
• 2017-12-26, POD-12• Remove J-P drain
• Discharge and follow up at OPD
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Pathological report
• PATHOLOGIC DIAGNOSIS• Intestine, large, sigmoid colon, sigmoid colectomy.
• Adenocarcinoma, well differentiated, invading subserosa, pT3N0
• Surgical margin, bilateral and radial, sigmoid colectomy.• Free of tumor
• Intestine, small, segmental resection.• Free of tumor
• Lymph node, regional, dissection.• Free of metastasis (0/10)
• Soft tissue, labeled as "IMA LN", dissection.• Free of tumor
• Final stage pT3N0M0
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Case presentation
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陳O福 0499-84X
• 64 y/o
• Admission on 2017-09-05
• Discharge on 2017-09-28
• Past history
• Medical history
• HTN(+), type II DM(-)
• Surgical history
• s/p left inguinal herniorrhaphy
• Alcohol(-), Betel nut(-), Cigarette(-)
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S-loop colostomy + right inguinal herniorrhaphy
2017-09-08
1st operation
DiagnosisDiagnosis
Sigmoid colon adenocarcinoma with total obstruction + right inguSigmoid colon adenocarcinoma with total obstruction + right inguinal inal
herniahernia
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Extremely Extremely
distended !!distended !!
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Tumo
r
Stoma
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Laparoscopic sigmoid colectomy + S-loop
colostoma take down2017-09-18
2nd operation
DiagnosisDiagnosis
Sigmoid colon adenocarcinoma with total obstruction s/p SSigmoid colon adenocarcinoma with total obstruction s/p S--loop loop
colostomycolostomy
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Stoma
Tumo
r
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Tumo
r
Stoma
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Course after operation…
• 2017-09-21, POD-3• Remove NG tube• Remove Foley
• 2017-09-22, POD-4• Sip water
• 2017-09-23, POD-5• Remove anal tube• On clear liquid diet
• 2017-09-24, POD-6• On liquid diet
• 2017-09-25, POD-7• On soft diet
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Pathological report
• PATHOLOGIC DIAGNOSIS
• Intestine, S-colon, sigmoid colectomy
• Adenocarcinoma, G2, moderately differentiated, invaded into subserosa
• Surgical margin, bilateral and CRM
• Free of malignancy
• Lymph nodes, regional, dissection
• Metastatic adenocarcinoma (5/20)
• Final stage pT3N2aM0
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Course after operation…
• 2017-09-26, POD-8
• OP: Left IV port-A implant
• 2017-09-28, POD-10
• Remove J-P drain
• Discharge and follow up at OPD
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Summary
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•為何需要stoma?
• 3 stages treatment
• 最基本的觀念
• 2 stages treatment
• Open approach
• Alternative 2 stages treatment
• Laparoscopic approach
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Thanks for your attention!