直肠癌前切除术后吻合口漏的影响因素分析

目的 探讨直肠癌全直肠系膜切除术后吻合口漏的相关影响因素.方法 对2005年1月至2007年12月施行直肠癌前切除手术的738例连续患者的临床资料行回顾性研究.分析影响吻合口漏发生的相关因素.结果 单因素分析显示低位直肠癌(肿瘤距肛缘≤7cm)、非结直肠专科术者和放置肛管与吻合口漏发生率相关.低位直肠癌的吻合口漏发生率显著高于高位直肠癌(5.9%vs.0.9%.P=0.003).结直肠专科术者手术吻合口漏发生率显著低于非专科术者(3.9%vs.11.3%.P=0.031).结直肠专科术者手术的患者中低位直肠癌比例也明显高于非专科术者(72.1%vs.52.8%,P=0.003).放置肛管组的吻合口漏发生率反而明显高于未放置组(14.5%vs.3.6%.P<0.001).多因素分析显示除低位直肠癌、非结直肠专科术者和放置肛管外,糖尿病(P=0.027)、远端切缘肿瘤距离<1 cm(P=0.009)和预防性造口(P=0.031)也与吻合口漏的发生相关.在522例低位直肠癌中进一步分析发现,预防性造口组的吻合口漏发生率明显低于未造口组(2.9%vs.8.5%,P=0.007);而由于保护作用较差及选择偏倚存在,肛管放置组的吻合口漏发生率仍显著高于未放置组(15.1%vs.4.9%,P=0.008).结论 低位直肠癌、非结直肠专科术者以及糖尿病是直肠癌术后吻合口漏的危险因素,而预防性造口能有效预防低位直肠癌术后吻合口漏的发生.

Factors associated with anastomotic leakage after anterior resection in rectal cancer

Objective To analyze the factors associated with anastomofie leakage after anterior resection in rectal cancer with the technique of total mesorectal excision (TME). Methods From January 2005 and December 2007, 738 consecutive patients with rectal cancer underwent anterior resection. The data of those patients was collected and reviewed retrospectively. The associations between anastomotie leakage and 9 patient-related variables as well as 7 surgical-related variables were examined. Results Low rectal cancer(located 7 cm or less above the anal edge), non-specialized surgeon and transanal tube use were the risk factors associated with anastomotic leakage on univarlate analysis. The anastomotic leakage rate of low-rectal cancer was significantly higher than that of high-rectal cancer(5.9% vs. O. 9% , P = 0. 003). The anastomotie leakage rate of the cases operatecl by colorectal surgeon was significantly lower than that of the cases operated by non-specialized surgeon (3. 9% vs. 11.3%, P = 0. 031). There was a tendency for eolorectal surgeons to operate on a greater proportion of low rectal cancer than non-specialized surgeons (72. 1% vs. 52.8%, P=0.003). The leakage rate of transanal tube group was unexpectedly higher than that in patients without transanal tube (14. 5% vs. 3.6%, P <0. 001). On multivariate logistic regression analysis, diabetes mellitus(P = 0. 027), distance less than 1 cm from tumor to distal resection margin(P = 0. 009) and defunetioning stoma (P = 0. 031) were also associated with anastomotic leakage rate besides low rectal cancer, non-specialized surgeon and transanal tube use. In a further analysis of 522 patients with low rectal cancer, the leakage rate of defunctioning stoma group was significantly lower than that of non-stoma group(2. 9% vs. 8.5%, P=0.007). By contract, the leakage rate of transanal tube group was still higher than that in patients without transanal tube (15. 1% vs. 4.9%, P =0.008) because of its poor protective effect as well as the selection bias. Conclusions Low-rectal cancer, non-specialized surgeons and diabetes mellitus are risk factors of anastomotic leakage after rectal surgery. A defunctioning stoma was effective in preventing leakage after low-rectal cancer surgery.