直肠癌低位前切除中预防性造口113例临床分析

目的:探讨直肠癌低位前切除术中预防性造口与吻合口漏发生的关系.方法:对长海医院2005年1月至2006年10月期间施行直肠癌低位前切除(吻合口高度≤6 cm)的270例病例进行研究,共有113例施行预防性造口(41.9%),将临床及病理资料建立数据库,利用SPSS 10.0 软件对是否预防性造口患者的吻合口漏发生率进行χ2检验.结果:低位前切除的患者中20例发生症状性吻合口漏,发生率7.4%.症状包括:腹痛(37%)、脉搏增快(53%)、发热(47%)、白细胞升高(53%)、盆腔引流液性状改变(68%)、肛门流脓血性液(26%)、其他(10%),平均年龄57.8岁,吻合口高度皆≤6 cm,没有病例因吻合口漏死亡.其中预防性造口组发生4例漏(3.5%),未造口组发生16例(10.2%),P=0.04.在有术前放疗史的24例患者中预防性造口率达到75%,其中18例预防性造口者无一发生漏(0/18),而未造口者却有2例漏(2/6),经Fisher精确概率法检验P=0.054.在做保护措施的142例低位前切除病例中,漏发生率为4.9%(7例),而剩余未做任何保护性措施的128例中吻合口漏发生率却高达10.2%(13例),P=0.10.有预防性造口的4例吻合口漏皆经保守治疗缓解,而未造口的16例漏中有8例因症状严重需手术干预,其中1例发生弥漫性腹膜炎.两组平均进食时间也有明显差异(P<0.01),但两组术后肠梗阻发生率(P=0.24)及住院天数(P=0.91)皆无明显差异.结论:吻合口漏仍是目前直肠癌前切除术后的主要并发症,预防性造口可以明显降低高危人群吻合口漏的发生率.考虑到吻合口漏有其不可预见性,建议吻合口高度低于6 cm的低位前切除病例行预防性造口.

Defunctioning stoma in low anterior resection for rectal carcinoma:a clinical analysis of 113 cases

Purpose Low anterior resection with total mesorectal excision for rectal carcinoma is associated with a high anastomotic leakage rate, and the effectiveness of a defunctioning stoma in preventing anastomotic leakage remains controversial. The arm of this study is to present the incidence of anastomotic leakage after low anterior resection for rectal cancer with and without performance of a defunctioning stoma. Patients and methods During the period between January 2005 and October 2006, anterior rectal resection was performed on 270 patients with anastomoses created at a 6-cm or smaller distance to the anal edge. A defunctioning stoma was performed in 113 patients (113/270=41.9 per cent) considered at high risk of anastomotic leakage. Results There were 19 leakages in all the low anterior rectal resection cases, the rate was7.0%. Symptoms include: abdominal pain(37%), the increase of pulse(53%), fever(47%), leukocytosis(53%), pelvic fluid properties change(68%), anal discharging bloody fluid(26%) and others(10%). The average age was 57.8 years. Anastomotic heights were all at or less than 6cm. No death caused by anastomotic leakage. 4 leakages in defunctioning stoma group(3.5%), 15 leakages in no stoma group(9.6%),P=0.057. The defunctioning stoma rate of the 24 patients with preoperative radiotherapy history was as high as 75%,and none of the 18 low anterior resection cases with preoperative radiotherapy history and defunctioning stoma has a leakage, but two of the 6 cases who also have preoperative radiotherapy history but without defunctioning stoma have got a anastomotic leakage, and the fisher exact probability test shows P = 0.05. Due to the existence of selective bias, we think that the difference is significant. During the 142 low anterior resection cases doing protection measures, the leakage rate was 4.9%. But the remaining 128 cases without any protective measures had an anastomotic leakage rate as high as 9.4%. Leakage subsided with conservative treatment in the four patients with a stoma, but eight patients without a stoma developed severe symptoms requiring surgical intervention, One of which occurred peritonitis. The average fasting time also had significant differences between the two groups(p<0.01). But postoperative obstruction incidence and days of hospitalization were not significantly different. Conclusions Our data confirm that anastomotic leakage is still the most important complication of low anterior resection for rectal cancer,and a defunctioning stoma undoubtedly reduces the rate of anastomotic leakage in high-risk patients. Meanwhile, there is the existence of certain unpredictability of anastomotic leakage. We propose all the anterior resection cases with anastomotic height at or below 6 cm should be held in defunctioning stoma.