预防性回肠造口在腹腔镜超低位直肠癌保肛术中的应用

为评价预防性回肠造口在腹腔镜超低位直肠癌保肛术中应用的安全性和有效性,回顾性分析113例腹腔镜超低位直肠癌保肛并行预防性回肠造口患者的临床资料。结果显示,113例患者均行根治性手术,并预防性末段回肠双腔造口,术后3月造瘘口还纳。术后并发症:吻合口漏4例,肠梗阻9例,造瘘口旁疝1例,切口感染3例。随访3~24月,吻合口处肿瘤复发1例。结果表明,预防性回肠造口在腹腔镜超低位直肠癌保肛术中的应用安全、有效,显著降低术后吻合口瘘发生率。     

低位直肠癌保肛术无预防性造口的意义

目的探讨低位直肠癌保肛术中不行预防性造口的意义。方法57例低位直肠癌前切除术中,32例未行预防性回肠末端造口(A组),吻合后行漏气实验以确认缝合严密,并内置肛管,顶端达吻合口上方3~5 cm。25例行预防性造口(B组)。结果A组术后发生吻合口漏1例(3.1%),吻合口出血2例(6.2%),切口感染1例(3.1%),肠梗阻2例(6.2%);B组发生吻合口漏1例(4.0%),吻合口出血3例(12.0%),废用性肠炎19例(76.0%),切口感染8例(32.0%),肠梗阻4例(16.0%)。结论应用合适的技术及围手术期处理方法进行无预防性造口的低位直肠癌保肛术效果好,克服了许多预防性造口的并发症。     

预防性造口在低位直肠癌手术中的应用分析

目的探讨预防性造口在低位直肠癌手术中的应用价值。方法采用病例对照研究,将湖南省攸县人民医院普外科2011年1月~2013年4月期间共46例低位直肠癌患者分为两组:26例行预防性回肠造口(A组),其中23例为回肠双腔造口,3例为回肠单腔造口,术后3月回纳造口;20例未行预防性造口(B组)。对比其术后吻合口漏、肠梗阻、切口感染等并发症发生率。结果 46例患者中共发生7例吻合口漏,其中A组2例(7.7%),B组5例(25%),且死亡1例,两组比较无显著性差异(P0.05);切口感染率A组6例(23.1%),B组5例(25%),两组比较无明显差异(P0.05);肠梗阻发生率A组1例(3.8%),B组3例(15%),两组比较无显著性差异(P0.05)。结论预防性造口可有效降低低位直肠癌术后吻合口漏发生率。对存在2个以上危险因素,尤其是超低位直肠癌(距肛缘低于5cm)推荐行预防性造口术。     

预防性横结肠造瘘与末端回肠造瘘在直肠癌低位前切除术中应用比较

目的:比较预防性横结肠造瘘与末端回肠造瘘应用于直肠癌低位前切除术的临床效果。方法:回顾分析79例低位直肠癌行保肛并预防性肠造瘘手术患者临床资料,其中预防性横结肠造瘘33例,预防性末端回肠造瘘46例。比较两组患者术后吻合口瘘、造瘘口相关并发症发生情况以及血清炎症因子水平。结果:两组患者术前资料具有可比性。横结肠造瘘组发生吻合口瘘2例(6.06%),末端回肠造瘘组4例(8.70%),两组间差异无统计学意义(P0.05);横结肠造瘘组切口感染发生率高于末端回肠造瘘组(P0.05),其他造瘘口相关并发症发生率两组间差异无统计学意义(均P0.05);与术前两组血清C-RP及IL-6水平比较,差异无统计学意义(均P0.05);横结肠造瘘组术后24、48、72 h血清C-RP及IL-6水平均明显高于末端回肠造瘘组(均P0.05)。结论:低位直肠癌前切术中,采用预防性横结肠造瘘与预防性末端回肠造瘘在防止吻合口瘘方面效果相似,但末端回肠造瘘术在减轻术后创伤应激反应,减少并发症方面优于横结肠造瘘术。     

预防性造口在低位直肠癌保肛术中的应用

目的:探讨预防性造口在低位直肠癌保肛术中的应用价值。方法:回顾性分析2013年10月—2016年9月在广东省中医院肛肠科接受手术治疗的低位直肠癌患者的临床资料,根据其是否施行预防性造瘘术将分为两组,各组50例,即预防性末段回肠造口组(造口组)和未行预防性末段回肠造口组(对照组)。比较术后两组患者肛门功能、并发症发生率和生活质量的差异。结果:造口组患者术后肛门功能的优良率明显高于对照组(80.00%vs.56.00%,P0.05);造口组吻合口瘘发生率明显低于对照组(0.00%vs.10.00%,P0.05),两组再次手术率无统计学差异(0.00%vs.6.00%,P0.05);造口组患者术后躯体功能、躯体角色和肢体疼痛等生活质量得分均高于对照组,差异均有统计学意义(P0.05)。结论:预防性造口在低位直肠癌保肛术中的应用可较好的保留患者肛门功能,减轻并发症发生率,提高患者术后生活质量。     

预防性回肠造口在低位直肠癌保肛手术中临床体会

目的 探讨回肠造口术预防直肠癌低位前切除术后的临床价值. 方法 回顾性分析本院近3年来72例低位直肠癌的病例资料,分为预防性回肠造口组35例（试验组）,未造口37例（对照组）.两组患者术后吻合口愈合进行对比分析. 结果 试验组35例吻合口无发生瘘,无医疗纠纷,对照组37例发生吻合口瘘7例（18.92％）,差异有统计学意义. 结论 低位直肠癌在肿瘤达到根治术的基础上可以成功保肛,预防性回肠造口明显降低术后吻合口瘘的发生率,预防医疗纠纷的发生,能在一定程度上提高患者的生活质量.     

末端回肠气管导管造瘘术预防低位直肠癌根治术吻合口漏的临床应用

目的探讨末端回肠气管导管造瘘术在低位直肠癌保肛术中预防吻合口漏的应用价值。方法 2013年7月~10月我科对15例低位直肠癌患者行低位直肠癌根治术(Dixon),术中应用7号气管导管经末端回肠置管造口。结果本组手术时间3~4 h,术中造瘘时间8~10 min。术后第7 d出现吻合口漏1例(6.7%),造瘘管处腹壁疼痛1例,一过性造瘘管梗阻2例,无再次手术病例。结论末端回肠气管导管造瘘术是一种安全的造瘘方法,能有效预防和治疗低位直肠癌根治术后吻合口漏。     

预防性造口在低位直肠癌前切除术中应用价值的Meta分析

目的:评估预防性造口在低位直肠癌全系膜切除术中的价值.方法:检索PubMed和Embase数据库中有关低位直肠癌术中实施预防性造口的相关研究和文献,将预防性造口组与未造口组患者术后吻合口瘘的发生率和与吻合口瘘相关的再手术率进行比较.结果:5项最近的研究符合纳入标准,累计病例878例.Meta分析表明预防性造口能明显降低吻合口瘘及再手术的发生率,合并风险率分别为0.34(95％ Cl:0.22 ～ 0.53,P＜0.00001)和0.27 (95％Cl:0.16～0.48,P＜0.00001),差异有统计学意义.结论:预防性造口可有效的降低吻合口瘘的发生率和与吻合口瘘相关的再手术率,且不影响术后直肠肠管功能;但是否影响患者远期生存率和术后生活质量,目前尚无定论.     

中低位直肠癌手术后吻合口瘘与预防性造口

根据我国国家癌症资料库,从1991年至2005年间,结直肠癌是发病率上升最快的恶性肿瘤之一;在我国的直肠癌病例中,中低位直肠癌所占比例高达50%[1].中低位直肠癌手术治疗后的一个难题是如何预防和及早发现吻合口瘘并采取相应措施,而其中预防更加重要.国内外很多医疗机构术中行预防性肠造口来避免术后吻合口瘘的发生和减轻出现吻合口瘘以后的中毒症状,然而这方面的研究还存在很多争议.本文对中低位直肠癌预防性造口与术后吻合口瘘的关系作一综述.     

中低位直肠癌手术后吻合口瘘与预防性造口

根据我国国家癌症资料库,从1991年至2005年间,结直肠癌是发病率上升最快的恶性肿瘤之一;在我国的直肠癌病例中,中低位直肠癌所占比例高达50%[1].中低位直肠癌手术治疗后的一个难题是如何预防和及早发现吻合口瘘并采取相应措施,而其中预防更加重要.国内外很多医疗机构术中行预防性肠造口来避免术后吻合口瘘的发生和减轻出现吻合口瘘以后的中毒症状,然而这方面的研究还存在很多争议.本文对中低位直肠癌预防性造口与术后吻合口瘘的关系作一综述.     

骶前引流方式对直肠癌低位前切除术后吻合口漏愈合的影响

目的比较经会阴和经腹壁两种不同的骶前引流方式对直肠癌低位前切除术后吻合口漏愈合的影响。方法总结2010年1月至2015年12月间45例直肠癌低位前切除术后吻合口漏的临床资料。结果经会阴和经腹壁两种引流方式在病人年龄、性别、是否接受新辅助放化疗、平均手术时间、p TNM分期、术后发生漏的确定时间、初次手术后平均住院时间等方面差异均无统计学意义(P0.05)。但经会阴引流组的保护性造口率(16.7%)、腹膜炎发生率(8.3%)及再次手术率(16.7%)均明显低于经腹壁引流组(分别为75.8%、39.4%、93.9%,P0.05)。结论经会阴骶前引流可降低低位直肠吻合口漏的相关并发症,有助于吻合口漏的愈合。     

Septic complications after low anterior rectal resection--is diverting stoma still justified?

A retrospective study was designed to determine the effects of faecal diversion on the rate and severity of clinical anastomotic leaks after low anterior resection. The study explored the complications of stoma closure as well. During the period between 1 January 1995 and 30 July 2000, anterior rectal resection was performed on 249 patients with anastomoses created at a 6-cm or smaller distance to the dentate line. In 74 cases, the anastomosis was protected by loop ileostomy. The indications for creating a stoma were evaluated subjectively, by the operating surgeon. In 64 patients, the ileostoma was closed 3 months later. A 'clinical leak' after anterior resection was defined as an anastomotic insufficiency with clinically relevant consequences. The overall rate of anastomotic leak was 6.4 per cent; it was 5.1% (9/175) without and 9.4% (7/74) with a protective stoma. In 8 out of 9 patients, the anastomotic leak that had occurred without a protective stoma warranted laparatomy and defunctioning colostomy. Lavage and drainage of the peritoneal cavity and the presacral space were necessary in 6 out of these 8 cases- and furthermore, the deranged anastomosis had to be removed in 2 patients. Local management was successful in a single case only. Although relaparotomy entails long-term intensive care, all reoperated patients survived anastomotic leakage. Seven patients with a leak despite a protective did not require laparatomy; transanal drainage was appropriate in all cases. There were no fatalities in this group either. Only one fatal complication from suture leakage occurred after stoma-closure. Abdominal exploration was inevitable in almost all patients with a clinical anastomotic leak and without defunctioning stoma. By contrast, patients with anastomotic insufficiency despite a protective stoma were successfully managed without further intra-abdominal intervention. As shown by these results, faecal diversion undoubtedly mitigates the clinical consequences of anastomotic leaks, but cannot prevent its occurrence. When considering the cumulative risk of surgical complications associated with anterior resection, the complications of stoma-closure must also be taken into account. Our data confirm that a defunctioning stoma is beneficial for high-risk patients, who are unfit for a second abdominal procedure required to control suture leakage.     

High 1-Year Complication Rate after Anterior Resection for Rectal Cancer

Background

Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies.

Methods

Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality.

Results

Nineteen percent of 388 included patients received a primary anastomosis, 55 % an anastomosis with defunctioning stoma, and 27 % an end colostomy. Short-term anastomotic leakage was 10 % in patients with a primary anastomosis vs. 7 % with a defunctioning stoma (P?=?0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18 %) readmissions and re-intervention (12 %) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30 % increase in patients with an end colostomy.

Conclusions

This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.     

直肠癌全直肠系膜切除术后吻合口漏的危险因素分析

目的 探讨直肠癌全直肠系膜切除术(total mesorectal excision,TME)后吻合口漏的危险因素.方法 对498例直肠癌全直肠系膜切除(TME)术患者的资料进行回顾性分析,应用SPSS软件对数据进行统计处理,采用x2检验.结果 36例(7.2%,36/498)术后出现吻合口漏.发生吻合口漏与患者的性别、肿瘤距肛缘距离、术前放疗密切相关(P＜0.05或0.01),而与年龄、糖尿病、高血压病、预防造瘘、脉管癌栓、吻合方式等无明显关系.37例手术同时即行预防性造瘘的患者,仍有3例发生吻合口漏,未经特殊处理后自愈.另外33例吻合口漏的患者中10例经保守治疗痊愈,23例行近端肠造瘘粪便转流术,吻合口漏愈合后二期还纳治愈.结论 直肠癌全直肠系膜切除术(TME)后吻合口漏的发生与性别、肿瘤距肛缘距离、术前放疗密切相关;控制好围手术期血糖可以明显降低吻合口漏的发生.     

Prospective Evaluation of Selective Defunctioning Stoma for Low Anterior Resection with Total Mesorectal Excision

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. In this study a policy of selective defunctioning stoma for stapled colorectal anastomosis after low anterior resection with total mesorectal excision in 148 consecutive patients was evaluated prospectively. A defunctioning stoma was performed in 61 patients (41%) considered at high risk of anastomotic leakage. Clinical leakage occurred in 2 patients (3.3%) with a stoma and 11 patients (12.6%) without a stoma (p= 0.047). Among those without a stoma, the leakage rate among male patients (20.9%) was significantly higher than that for female patients (4.5%) (p= 0.022). Leakage subsided with conservative treatment in the two patients with a stoma, but seven patients without a stoma developed peritonitis requiring laparotomy. No deaths resulted from leakage, and there was one hospital death (0.6%) in the whole group. Median hospital stay was similar with and without a stoma (13.0 vs. 12.0 days) (p= 0.290). Closure of the stoma was associated with no mortality, a morbidity rate of 8.7%, and a median hospital stay of 6.0 days. In conclusion, a defunctioning stoma is effective in preventing clinical anastomotic leakage after low anterior resection with total mesorectal excision. The relatively high incidence of leakage in the low risk group indicates the difficulty of predicting anastomotic leakage and hence the need for more liberal use of a defunctioning stoma especially in male patients.     

Morbidity related to the use of a protective stoma in anterior resection for rectal cancer

Objective To evaluate morbidity related to the use of a protective stoma in rectal resection for cancer. Method Seventy‐two patients undergoing anterior rectal resection for cancer combined with a protective stoma (1993–2005) were included. Loop ileostomy was applied in 61 patients, loop colostomy in 10, and end ileostomy in one. Data regarding the primary operation were recorded prospectively, and stoma complications retrospectively. Results Five patients (7%) developed stoma complications immediately after the primary operation, and 14/70 (20%) following hospital discharge. The stoma was closed in 62 (86%) patients after median 4 (range 1–11) months. Five patients (8%) developed complications in hospital after closure. Two patients (3%) died, one of ileal anastomotic leak and one of myocardial infarction. Five patients (8%) had late complications after closure. A total of 19 patients (26%) developed stoma related complications. Eight (11%) of these were reoperated. Premature stoma closure was necessary in two additional patients. Nine patients (13%) ended up with a permanent stoma. Fourteen (19%) patients developed signs of rectal anastomotic failure, six (8%) of whom needed reoperation. One died. Conclusion Significant morbidity is related to the use of defunctioning stomas. A protective stoma cannot always prevent serious complications of a rectal anastomotic leak, and a proportion of the patients will not have the stoma closed.     

腹腔镜直肠癌前切除术后吻合口漏危险因素的Meta分析

目的 系统分析影响腹腔镜直肠癌前切除术后吻合口漏发生的危险因素.方法 对2003年8月至2013年8月国内外公开发表的有关腹腔镜直肠癌前切除术后吻合口漏发生危险因素的文献进行Meta分析.数据采用优势比（OR）和95％可信区间（95％ CI）表示,采用x2检验和I2对异质性进行分析,采用固定或随机效应模型合并数据.结果 共纳入文献8篇,包括3 289例直肠癌患者,吻合口漏的发生率为6.050％（199/3 289）.男性腹腔镜直肠癌前切除术患者术后吻合口漏发生风险高于女性（OR =2.17,95％ CI：1.54 ～ 3.06,P＜0.05）;新辅助化疗亦可能增加术后吻合口漏发生风险（OR=1.53,95％ CI：1.00～2.32,P＜0.05）;围手术期输血可能增加术后吻合口漏发生风险（OR=4.80,95％ CI：2.98 ～7.73,P＜0.05）;低位直肠癌较高位直肠癌术后吻合口漏发生风险高（OR=1.60,95％CI：1.14～2.23,P＜0.05）;切割闭合器钉匣数目≥3个增加术后吻合口漏发生风险（OR =0.46,95％CI：0.27 ～0.78,P＜0.05）.而ASA分级、肿瘤浸润深度、淋巴结转移、预防性肠造口与术后吻合口瘘发生风险无关（OR=0.66,0.91,1.25,0.78,95％CI：0.36～1.20,0.55～1.51,0.75 ～2.09,0.50 ～1.23,P＞0.05）.结论 男性、新辅助化疗、围手术期输血、低位直肠癌、切割闭合器钉匣数目≥3个是腹腔镜直肠癌前切除术后吻合口漏发生的主要危险因素.     

腹腔镜直肠前切除术后并发症及其相关因素分析

目的分析腹腔镜直肠前切除术后并发症发生率及其相关危险因素,进一步预防术后并发症的发生。方法回顾性分析解放军总医院普通外科2013年1月至2016年6月间施行腹腔镜直肠前切除术的663例病人的临床资料,观察术后并发症发生情况,对发生术后并发症的危险因素进行分析,分析并发症组与无并发症组临床资料的差异性。结果全组663例病人出现并发症76例(11.5%);单因素分析显示:病人的性别、肥胖、术前合并症、肿瘤位置、淋巴结清扫数目、TNM分期、手术时间与腹腔镜直肠前切除术后并发症相关(P0.05)。多因素回归分析显示:性别(OR=2.120,95%CI:1.150~3.909)、术前合并症(OR=2.618,95%CI:1.483~4.621)、肿瘤位置(OR=10.338,95%CI:5.672~18.842)、TNM分期(OR=3.111,95%CI:1.774~5.457)是影响术后并发症发生的独立危险因素(均P0.05)。结论性别、术前合并症、肿瘤位置、TNM分期是腹腔镜直肠前切除术后并发症发生的危险因素,腹腔镜直肠前切除术后并发症以吻合口瘘常见。     

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??Anastomotic leakage after anterior resection of rectal cancer??An analysis of 506 cases WANG Xin??ZHOU Jian-ping??ZHANG Dan-hua??et al. Department of General Surgery??the First Affiliated Hospital of China Medical University, Shenyang 110001??China
Corresponding author??ZHOU Jian-ping??E-mail??zjphama@163.com
Abstract Objective To analyze the risk factors for anastomotic leakage (AL) after anterior resection (AR) of the rectal cancer. Methods The clinical data of 506 cases of rectal cancer underwent AR from August 2010 to May 2013 in the First Affiliated Hospital of China Medical University were analyzed retrospectively. A total of 13 patients-related and surgery-related variables were studied with SPSS software. Results The overall anastomotic leakage rate was 6.32% (32 of 506). Among them one combined an anastomotic-vaginal fistula and one developed a rectovesical fistula. There is no perioperative death. Significant differences were present between groups regarding of age??anastomotic location??intestinal obstruction and albumin levels before operation. Other groups like gender??preoperative anemia??diabetes??Dukes stage??intraperitoneal chemotherapy didn’t show important statistical significance. Still others like long-term applications of corticosteroids (n=1)??defunctioning stoma (n=9)??preoperative neoadjuvant therapy (n=9) didn’t get a satisfactory conclusion due to the small sample size. Conclusion Anastomotic location (below the pelvic peritoneal reflexion)??intestinal obstruction and lower albumin levels??<40 g/L??are independent risk factors (P<0.05) for anastomotic leakage. Patients combined with two or more risk factors have a high risk of AL rate and a defunctioning stoma should be performed