预防性回肠造口在直肠癌超低位前切除术中的应用价值

目的探讨预防性回肠造口降低直肠癌超低位前切除术后吻合口瘘发生率的临床价值。方法回顾性分析8年间行直肠癌超低位前切除术98例患者的临床资料。比较实施预防性回肠造口组(A)45例和未实施组(B)53例两组间吻合口瘘发生率的差异。结果A组仅1例发生吻合口瘘(2.2%);B组11例发生吻合口瘘(20.8%)(P(0.05)。结论有选择的预防性回肠造口,可有效降低直肠癌超低位前切除术后吻合口瘘的发生率。     

预防性横结肠造瘘对直肠低位前切除术吻合口瘘的影响

目的探讨预防性横结肠造瘘对直肠低位前切除术(LAR)吻合口瘘(AL)发生率的影响。方法回顾分析312例行直肠LAR的中下段直肠癌手术患者的临床资料,采用Fisher确切概率法对比分析行预防性横结肠造瘘对AL发生的影响。结果63例行预防性横结肠造瘘的直肠LAR发生AL有2例(3.2%),249例未行该造瘘的发生AL有21例(8.4%),两者无统计学差异(P0.05)。结论直肠LAR行预防性横结肠造瘘并不能有效地降低AL的发生率,且行预防性造瘘者,均需再次手术关瘘。     

Endoscopic stent insertion for anastomotic leakage following oesophagectomy

Introduction

Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls.

Methods

Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed.

Results

A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06–12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases.

Conclusions

Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.     

Endoscopic closure of a postoperative rectal anastomotic leakage with hemoclips: A case report

Introduction and importanceHemoclips have been used to protect leakage after endoscopic resection of large colorectal polyps or early-staged rectal cancer, or for perforation of the sigmoid colon during colonoscopy. However, endoscopic clips were seldom used to manage anastomotic leakage after low anterior resection of rectal cancer.Case presentationA patient with postoperative anastomotic leakage after low anterior resection for rectal cancer was successfully treated by endoscopic hemoclips under colonoscopic vision after failure of conservative treatment. Postoperative course was uncomplicated and the patient was discharged from the hospital seven days later.Clinical discussion and conclusionEndoscopic hemoclips should be considered as an alternative option for the treatment of an anastomotic leakage in cases where conservative treatment has failed. As they are safe and effective for closure, however good bowel preparation and strict inclusion criteria are required.     

Risk factors for anastomotic leakage after anterior resection of the rectum

Objective Surgical technique and peri‐operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re‐operations in relation to anastomotic leakage. Patients and methods In a nine‐year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient‐ and surgery‐related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients. Results The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30‐day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (≤ 6 cm), pre‐operative radiation, presence of intra‐operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5–61 days) and for patients with leakage 22 days (3–110 days). Conclusion In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30‐day mortality was 2.1%. Low anastomosis, pre‐operative radiation, presence of intra‐operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.     

The persisting presacral sinus after anastomotic leakage following anterior resection or restorative proctocolectomy

Aim Despite improvements in anastomotic technique, anastomotic leakage is frequently encountered following anterior resection. This can eventually evolve into a presacral sinus. This study assessed the incidence, the natural course and the outcome of persisting presacral sinus. Method Patients who underwent low anterior resection (LAR) for cancer or restorative proctocolectomy (RPC) for ulcerative colitis or familial polyposis were eligible. Patients with anastomotic leakage or a presacral abscess were included. Outcome parameters included a persistent presacral sinus, or its closure and average time to closure and the stoma closure rate. Results Twenty‐five patients were identified with a sinus after LAR (n = 20) or RPC (n = 5). A persistent sinus was present in nine (1%) of 834 patients after LAR and two (0.9%) of 229 patients after RPC. Definitive resolution of the sinus occurred in 12 (52%) of 23 assessable patients. This was achieved at a median of 340 days (range 23–731 days). At final follow‐up, nine of the 23 patients had permanent faecal diversion because of recurrent abscess or persistent sinus formation, seven after LAR and two after RPC. Conclusion A significant proportion of patients with anastomotic leakage after rectal surgery develop a chronic sinus, of which only half heal over time. Persisting sinus is the main reason for a permanent stoma.     

直肠癌前切除术后吻合口漏的危险因素分析

目的探讨直肠癌前切除术后吻合口漏发生的危险因素。方法对我院从2005年1月到2007年12月三年间114例直肠癌前切除术后发生吻合口漏11例的临床资料进行回顾性分析。结果11例确诊发生吻合口漏,总发生率为9.65%（11/114）吻合口漏发生在术后第6～10天。其中男性患者8例（11.76%,8/68）、年龄〉60岁者9例（14.52%,9/62）、肿瘤距肛缘距离≤6cm者6例（14.63%,6/41）、术前有糖尿病者3例（17.65%,3/17）、术前有贫血或低蛋白血症者2例（20%,2/10）、术前伴有肠梗阻者2例（22.22%,2/9）、行全直肠系膜切除者5例（13.89%,5/36）。结论男性患者、年龄〉60岁、肿瘤距肛缘距离≤6cm、术前合并糖尿病、贫血或低蛋白、伴有肠梗阻及全系膜切除者,是术后吻合口漏发生的危险因素。     

Transanal stent in anterior resection does not prevent anastomotic leakage

OBJECTIVE: A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither. PATIENTS AND METHODS: Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37-90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent. RESULTS: A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without (P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without (P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons. CONCLUSION: Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection.     

直肠癌前切除术后吻合口漏的预测研究

吻合口漏是直肠癌前切除术后严重并发症,早期诊断并针对性处理可减轻腹膜炎严重程度,降低再手术的必要性。血液、腹腔引流液、尿液等体液中存在多种成分,基于体液检验的吻合口漏早期诊断指标探索是具有临床及科研意义的研究方向,本文将针对此进行综述。     

消化道机械吻合术后早期吻合口出血的内镜治疗

目的 探讨内镜下止血治疗消化道机械吻合术后早期吻合口出血的疗效.方法 回顾性分析2005年1月至2010年6月间在复旦大学附属中山医院内镜中心接受内镜下止血的消化道机械吻合术后早期吻合口出血的14例患者的临床资料.结果 男性9例,女性5例,中位年龄57.5岁(26～74岁).术后出血时间6 h至14 d,出血量500～1500 ml.内镜下发现吻合口出血灶后,采取硬化剂注射、电凝止血或金属夹夹闭的方法 进行止血.所有患者均一次止血成功,术后均未出现吻合口瘘等严重并发症.随访至今,未见再次出血.结论 内镜下治疗消化道机械性吻合术后早期吻合口出血操作简单、安全、有效,可作为首选方法 在临床上推广应用.

Abstract：

Objective The study aimed to evaluate the efficacy of endoscopic therapy for early postoperative anastomotic hemorrhage. Methods Fourteen patients experienced an episode of early postoperative anastomotic hemorrhage and were treated endoscopically from January 2005 to June 2010. The clinical data was analyzed retrospectively. Results Fourteen patients (9 males and 5 females, median age 57.5 years,range 26-74 years) were diagnosed with postoperative hemorrhage between 6 hours to 14 days after surgery. The blood loss ranged from 500 to 1500 ml. Sclerosing agent injection, electrocoagulation, and hemoclips were attempted to control the bleeding. Endoscopic approach to control early postoperative anastomotic hemorrhage was successful in all the patients. No recurrent bleeding was observed during the follow-up. No complications associated with endoscopic therapy. Conclusion Endoscopic approach for the management of early postoperative anastomotic hemorrhage is feasible with high success rate and associated with no complications.     

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.     

低位直肠癌前切除术后吻合口漏的处理和预防（附183例报告）

目的探讨直肠癌低位前切除术后吻合口漏发生的原因及预防措施。方法回顾性分析183例下段直肠癌保肛术后发生吻合口漏的临床资料。结果在183例保肛术中,发生吻合口漏9例,占4.92%较国内平均水平为低。通过积极有效的处理均得到临床满意的治疗效果。结论吻合口漏是直肠癌保肛术后主要并发症之一,通过积极有效的预防措施,可完全将此并发症降至最低限度。     

腹腔镜低位直肠前切除术后吻合口漏的原因及预防

【摘要】 目的 探讨腹腔镜下低位直肠前切除术后吻合口漏的原因和预防措施。方法 回顾性分析2014年5月至2015年6月253例低位直肠癌患者行腹腔镜低位直肠前切除术的临床资料。结果 253例患者手术均获成功,无一例死亡。其中15例患者(5.9%)发生了术后吻合口漏,1例因腹膜炎行腹腔镜再手术并行回肠末端造口,14例经腹膜外骶前引流、局部冲洗、抗感染及肠外营养支持等保守治疗后痊愈;其余患者恢复良好。腹腔镜低位直肠前切除术发生术后吻合口漏的原因主要与术后肠管血运不良、吻合口张力较大以及直肠双吻合技术缺陷有关。结论 腹膜外骶前置管引流是是治疗术后吻合口漏的有效措施。     

术前营养风险评分与直肠癌前切除术后吻合口瘘的关系

目的探讨直肠癌前切除患者术前营养风险评分与术后吻合口瘘的关系。方法回顾性分析2003年1月至2012年7月间南方医科大学附属南方医院收治的641例直肠癌前切除患者的临床资料,采用营养风险筛查2002（NRS2002）进行术前营养风险评分,通过单因素x。检验和多因素Logistic回归模型来分析NRS2002评分与术后吻合口瘘发生的关系。结果全组术后吻合口瘘发生率为4．1％（26／641）,其中术前NRS2002评分大于或等于3分者与小于3分者术后吻合口瘘发生率分别为6．9％（18／259）和2．1％（8／382）,差异有统计学意义（P=0．002）。校正了年龄、吻合口距肛缘距离和临床病理分期等影响因素后证实,NRS2002评分是直肠癌前切除术后吻合口瘘的独立危险因素（OR=3．198,95％CI：1．324～7．722,P=0．010）。结论术前NRS2002营养风险评分有助于直肠癌前切除术后吻合口瘘的预测,从而为预防性造瘘的适应证选择提供科学依据。     

Factors affecting anastomotic complications following anterior resection in rectal cancer

OBJECTIVE: Anastomotic complications following sphincter saving rectal surgery remains a significant clinical problem in rectal cancer surgery. Preoperative combined modality therapy followed by anterior resection with total mesorectal excision (TME) has become the preferred treatment paradigm for locally advanced rectal cancer. However, its impact on anastomotic complications has not been adequately evaluated. This study aimed to assess the relationship between the response of the primary tumour to neo-adjuvant therapy with anastomotic complications and to evaluate the effect of other clinico-pathological factors previously implicated, in this patient cohort. METHOD: A total of 119 consecutive patients with primary rectal cancer were assessed of which there were 87 anterior resections. A prospectively collected database was queried to determine the incidence of anastomotic complications, association with response to neo-adjuvant therapy and other clinico-pathological factors. Data were analysed with SPSS 14.0. RESULTS: Anterior resection was performed in 87/111 (78.4%) patients of which 46/84 (56%) were low resections, with an abdominoperineal excision of rectum rate of 11/111 (9.9%). Anastomotic complications were seen as clinical leaks in 10/87 (11.5%) and late colo-visceral fistulae in 2/87 (2.2%) patients. Subclinical/ radiological 'leaks' were quantified as 4/87 (4.5%). A good pathological response to neo-adjuvant therapy was found to be strongly associated with anastomotic complications (P = 0.006). Presence of a perioperative cardiac event was the only other clinical factor associated with anastomotic complications (P = 0.004) in our study. CONCLUSION: Rectal cancer treated with neo-adjuvant therapy and radical resection with TME for better local control may be associated with greater anastomotic complications particularly when a good pathological response is seen.