腹腔镜直肠癌前切除术学习曲线中并发吻合口瘘的原因

目的：探讨腹腔镜直肠前切除术学习曲线中并发吻合口瘘的主要原因。方法：将179例直肠前切除(Dixon)术患者按手术团队和手术方式分为腹腔镜初学组63例、开放组55例和腹腔镜成熟组61例，对3组患者术后并发吻合口瘘的情况进行对比分析；分析吻合口多次切割对腹腔镜初学组和腹腔镜成熟组的影响，同时分析男性、高龄、肥胖、营养合并症、吻合口位置5种危险因素对3组的影响。结果：腹腔镜初学组吻合口瘘发生率高于另外2组，差异有统计学意义(P<0.05)；吻合口多次切割显著影响腹腔镜初学组吻合口瘘的发生率，对腹腔镜成熟组没有明显影响；除肥胖因素外，其他4个因素对腹腔镜初学组吻合口瘘的发生率都有影响，差异有统计学意义(P<0.05)，各个因素对开放组、腹腔镜成熟组影响无统计学意义(P>0.05)。结论：操作技术缺陷是初学团队腹腔镜直肠前切除术后并发吻合口瘘的主要原因，初学团队应尽量避免选择男性、高龄、肿瘤位置低及有营养合并症的高危患者进行手术，以降低术后吻合口瘘的发生率。

Reasons for anastomotic leakage following the learningcurve by laparoscopic anterior resection of rectal cancer

Objective: To investigate the reasons of anastomotic leakage following learning curve bylaparoscopic anterior resection of rectal cancer.Methods: From December, 2011 to March, 2015, the clinical information of 179 patients inour hospital who underwent dixon of rectal cancer were collected. The patients were dividedinto a laparoscopic learning group, a laparotomy group and a laparoscopic group. Th e reasons ofanastomotic leakage for each group were comparatively analyzed. Repeated cutt ing of anastomoticstoma was compared between the laparoscopic learning group and the laparoscopic group. Themale, age, obesity, nutrition complications and the position of anastomotic stoma were comparedamong the 3 groups.Results: The rate of anastomotic leakage in the laparoscopic learning group was significantly higherthan that in the laparotomy group and the laparoscopic group (P<0.05). Repeated cutting wasa significant risk factor in the laparoscopic learning group (P<0.05), but not in the laparoscopicgroup. Except obesity, the four factors were significant risk factors in the laparoscopic learninggroup (P<0.05). All of the five factors were not the significant risk factors in the laparotomy groupand the laparoscopic group (P>0.05).Conclusion: The operation technical shortcoming is the major factor in the learning of thelaparoscopic anterior resection of rectal cancer. In order to reduce the rate of anastomotic leakage inthe learning curve period, the selection of patients following the laparoscopic anterior resection ofrectal cancer should avoid the following factors: male, older age, the low position of the tumor andthe nutrition complications.