结直肠癌术后吻合口漏预测因素研究进展

吻合口漏是结直肠癌术后严重的并发症之一,危险因素众多且发生隐匿,极大地影响患者术后疗效和生活质量.探寻有效的影响因素以提前预测吻合口漏的发生并给予相应处理对降低其发病率以期改善患者不良预后具有重要临床意义.本文将从围手术期相关因素和生物学标记物两个方面综述结直肠癌术后吻合口漏的危险因素,目的为预测吻合口漏的发生及改善吻...     

TGF-β1-509 T/T基因型与结直肠癌患者术后结肠吻合口瘘的关系

目的通过研究转化生长因子-β1（TGF-β1）基因功能的多态性,了解TGF-β1因子对结直肠癌术后结肠吻合口瘘的影响。方法采用PCR-RFLP方法检测结直肠癌组内157例伴有或不伴有术后结肠吻合口瘘患者及对照组117例的TGF-β1-509 T／C基因型。结果伴有术后结肠吻合口瘘的患者TGF-β1-509 T／T。基因型比例（0）低于无吻合口瘘的患者（13．2％）,两者差异有统计学意义（P=0．012）。结直肠癌组TGF-β1-509基因型或等位基因与对照组差异无统计学意义（基因型χ^2=0．981,P〉0．05;等位基因χ^2=0．000,P〉0．05）。结论具TGF-β1-509 T／T基因型者术后结肠吻合口瘘的发生率较低。而TGF-β1-509 T/C基因多态性与结直肠癌的发生及发展无关。     

食管癌术后颈部吻合口瘘引发脓胸的临床特点与处理对策

目的 探讨食管胃颈部吻合术后颈部吻合口瘘导致脓胸的发生特点及处理对策.方法 对2006年1月至2013年1月间河南省安阳肿瘤医院胸外科施行食管癌切除颈部吻合术患者的临床资料进行回顾性分析.结果 全组共计3342例食管癌患者行食管胃颈部吻合术,其中左颈左胸二切口2248例（左颈左胸术组）,右胸三切口1094例（右胸术组）.术后共计发生颈部吻合口瘘237例（7.1％,237/3342）,左颈左胸术组152例（6.8％）,右胸术组85例（7.8％）,差异无统计学意义 （P=0.287）.19例患者引致脓胸（8.0％,19/237）,左颈左胸术组3例（2.0％）,右胸术组16例（18.8％）,差异有统计学意义 （P＜0.01）.脓胸发生在3d以内者14例（73.7％,14/19）.19例脓胸患者均采用保守治疗,包括行胸腔闭式引流,经鼻腔放置十二指肠营养管或通过空肠造瘘管予以肠内营养支持治疗,并辅以肠外营养支持及抗炎对症治疗.最终治愈16例,死亡3例.结论 右侧开胸手术后发生颈部吻合口瘘易导致脓胸.充分引流及良好的营养支持是治疗的重点.     

The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty.

BACKGROUND: The morbidity and mortality associated with pulmonary embolism are well known, as is the benefit of the use of heparin in patients who have a pulmonary embolism. However, the patterns of heparin use as well as its undesirable effects, especially in patients who have recently had a total hip arthroplasty, have been less well studied. Thus, concern arises regarding the use of heparin in patients who have no firm evidence of a pulmonary embolism. The purpose of the current study was to track the use of heparin and associated orthopaedic complications in patients in whom a pulmonary embolism was suspected after a total hip arthroplasty. METHODS: The records of 150 patients in whom a pulmonary embolism had been suspected after a total hip arthroplasty were reviewed retrospectively. The rates of individual complications (such as stroke, infection, and hematoma) and those of groups of complications (such as medical complications, orthopaedic complications, and all complications combined) were recorded and then were stratified according to the treatment (with or without heparin), the presence or absence of pulmonary embolism, and other variables. RESULTS: Thirty-two (47 percent) of sixty-eight patients who were managed with heparin had complications compared with sixteen (20 percent) of eighty-two patients who were not thus managed (p = 0.0006). Specifically, patients who were managed with heparin were more likely to have gastrointestinal bleeding, hematological complications, a loose prosthesis, a hematoma, or an early revision arthroplasty (p<0.05 for all). With the numbers available, the use of heparin was not found to be significantly associated with an increased risk of death, stroke, or infection at the site of the prosthesis. Interestingly, thirty-one (31 percent) of ninety-nine patients who had ventilation-perfusion scans that demonstrated normal findings or findings indicating a low probability of pulmonary embolism were given heparin before the diagnosis of a pulmonary embolism was excluded, and sixteen (52 percent) of these thirty-one had complications. CONCLUSIONS: Given this risk profile, we advise against the use of heparin before the diagnosis of pulmonary embolism is established in patients who have had a total hip arthroplasty. This recommendation is supported by algorithms, in widely read medical texts, pertaining to the use of heparin in patients in whom a pulmonary embolism is suspected.     

Early postoperative anastomotic leakage due to necrotizing candidiasis after abdomino-thoracic resection for T1 esophageal cancer

We present a case of early postoperative anastomotic leakage after abdomino-thoracic esophageal resection for cancer in a female, due to a necrotizing, transmural infection with Candida species (spp). The infection was treated successfully with redo surgery and systemic antimycotic therapy with caspofungin. The patient was disease-free at 49 month follow-up, but her long-term quality of life, as assessed by the EORTC questionnaire (QLQ C-30) was reduced. Aggressive surgical and medical therapy led to successful treatment of this rare complication.     

不同引流方法预防直肠癌前切术后吻合口瘘的效果

目的 前瞻性观察直肠癌前切除术后3种不同引流方法预防吻合口瘘的效果.方法 2002年1月～2007年1月,450例中高位直肠癌并接受前切除术患者按人院次序随机均分为A、B、C3组.A组接受骶前引流;B组接受骶前引流+经肛单管引流;C组接受骶前引流+经肛双管引流,对3组患者的术后并发症进行对比分析.结果 A、B、C组切口感染发生率分别为7.33%(11/150)、8.00%(12/150)、6.67%(10/150),吻合口瘘发生率分别为8.67%(13/150)、6.67%(10/150)、1.33%(2/150).C组吻合口瘘率显著低于A、B两组(P＜0.05);A、B、C组间切口感染发生率差异无统计学意义(P＞0.05).结论 骶前引流+经肛双管引流能有效地预防直肠癌前切除吻合术后吻合口瘘的发生.     

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.     

降钙素原在吻合口漏中的应用现状

吻合口漏(AL)是食管癌及结直肠癌手术后常见的严重并发症,也是主要的致死原因,受多种危险因素影响。近年来外科手术技术的不断提高和围术期管理的经验积累,尤其是吻合器的临床应用,使得AL的发生率和死亡率已有所降低,不过仍是外科医生所面临的最为棘手问题之一。因此,早期发现或预测AL就显得尤为重要,进而可提早干预,避免或减轻AL带来的临床症状及不良后果,提高患者生存质量。然而,目前关于预测AL的方法并未有严格的标准,主要集中在术后生物标记物的检测,本文旨在对降钙素原(PCT)在预测AL中的应用现状进行综述。     

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目的 探讨长期使用糖皮质激素病人在胃肠道手术时发生吻合口瘘的预防措施。方法 对6例长期使用糖皮质激素的病人采取了综合性围手术期处理,包括术前贫血及低蛋白血症的纠正、肠道的准备、术中进行无菌的肠减压、采用无损伤的针线、运用医用胶涂布、营养管的安置以及术后生长激素与生长抑素的联合应用等。结果 6例长期使用糖皮质激素的病人均未发生吻合口瘘。结论 对长期使用糖皮质激素病人,严密的围手术期综合预防措施,可有效地预防胃肠道手术吻合口瘘的发生。     

吻合口漏患者结肠组织中基质胶原代谢异常的研究

目的探讨结肠术后患者吻合口漏与结肠组织中基质胶原代谢的关系。方法通过生物化学方法测定 16例吻合口漏患者和 16例对照组患者结肠组织中基质胶原的总量并通过免疫组化分别测定基质胶原Ⅰ ,Ⅲ和基质胶原酶 1,基质胶原酶 13的含量。结果吻合口漏组结肠组织基质胶原的总量和基质胶原Ⅰ ,Ⅲ含量远低于对照组 (t=3 417,t=2 841,t =2 2 6 1,P <0 0 1)。吻合口漏组分别为 (2 2 6± 0 34 ) μg/mg ,(1 0 8± 0 2 3)p·μm2 和 (1 11± 0 2 6 )p·μm2 ,而对照组分别为 (3 33±0 41) μg/mg ,(1 6 3± 0 31)p·μm2 和 (1 39± 0 37)p·μm2 。且基质胶原Ⅰ /Ⅲ的比值吻合口漏组也低于对照组 (t=1 938,P <0 0 5 ) ,分别为 0 97± 0 2 5和 1 17± 0 2 4。吻合口漏组 16例中有 13例基质胶原酶 13阳性 ,而对照组 16例中仅 2例阳性 (χ2 =12 74,P <0 0 1)。结论吻合口漏的发生与术前结肠组织中基质胶原的数量和质量相关 ,可能与基质胶原酶 13的异常表达有关     

High submucosal blood flow and low anastomotic tension prevent anastomotic leakage in rabbits

In many cases of long-gap congenital esophageal atresia, direct anastomosis is difficult. In these cases, the esophagus is first lengthened by myotomy before anastomosis. We determined the degree of submucosal blood flow and/or approximation force at the site of anastomosis in rabbits after (1) separation of the esophagus from the outer membrane, (2) 1 cm and 2 cm resection of the esophagus, and (3) circular or spiral myotomy of the esophagus after 2 cm resection. In the first experimental group, submucosal blood flow volume <115.2 ml/min/100 g resulted in anastomotic leakage. In the second experimental group, a 1 cm resected esophagus with an approximation force of 33.3 ± 8.2g did not result in leakage, while a 2 cm resected esophagus with an approximation force of 111.7±13.3 g resulted in leakage. It was found that leakage occurred when the approximation force was higher than 49.1 g even if submucosal blood flow volume was greater than 131.8 ml/min/100 g. In the third experiment, both circular and spiral myotomy reduced the approximation force. Although there was no difference in the changes in submucosal blood flow volume between the two types myotomy, circular myotomy was superior to spiral myotomy in the reduction of the approximation force at the site of anastomosis. We conclude that both approximation force and submucosal blood flow are important factors in preventing anastomotic leakage.     

Diverting colostomy increases anastomotic leakage in the rat colon

In the present study, we examined the effect of a diverting colostomy on the intestinal healing of colonic anastomosis in the rat. For this purpose, we created a colonic stenosis 2 days prior to the formation of a distal one-layer end-to-end anastomosis with or without a proximal double-barreled deviation colostomy in the rats. Radiological examination of anastomotic leakage was performed daily for 4 days and on day 7 after the operation. We found that anastomotic leakage was markedly increased in rats with a diverting colostomy compared to control animals; i.e. the leakage index (percentage of days with leakage during the experimental period) in colostomy rats was 29%, whereas in animals with no colostomy, the leakage index was only 7%. Interestingly, it was observed that anastomosis formation was associated with a higher mortality rate in rats with colostomy diversion (36%) compared to control animals (7%). However, there was no difference in suture holding capacity on day 7. Moreover, body weight decreased significantly in the colostomy group compared to rats without surgical defunctioning when followed for up to 7 days after surgery. Taken together, our novel findings suggest that a diverting colostomy may increase intestinal leakage after anastomosis formation in the rat colon. Thus, the role of proximal colostomy in the protection of colorectal anastomosis needs to be reevaluated and further investigations are required to resolve the influence of surgical defunctioning on intestinal healing.     

Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

Background

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

Methods

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

Results

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

Conclusions

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.     

Association of anastomotic leakage with long-term oncologic outcomes of patients with esophagogastric junction cancer

BACKGROUNDDespite improvements in surgical procedures and peri-operative patients management, the postoperative complications in esophagogastric junction (EGJ) cancer remain high because of technical aspects. Several studies have indicated the negative influence of postoperative infectious complications on long-term survival after gastrointestinal surgery. However, no study has shown the association between postoperative complications and long-term survival of patients with EGJ cancer. AIMTo elucidate influence of postoperative complications on the long-term outcomes of patients with EGJ cancer.METHODSA total of 122 patients who underwent surgery for EGJ cancer at the Keio University were included in this study. We examined the association between complications and long-term oncologic outcomes.RESULTSIn all patients, the 3-year overall survival (OS) rate was 71.9%, and the recurrence-free survival (RFS) rate was 67.5%. Compared with patients without anastomotic leakage, those with anastomotic leakage had poor median OS (8 mo vs not reached, P = 0.028) and median RFS (5 mo vs not reached, P = 0.055). Among patients with cervical anastomosis, there were not significant differences between patients with and without anastomotic leakage. However, among patients who underwent intrathoracic anastomosis, patients with anastomotic leakage had significantly worse OS (P = 0.002) and RFS (P = 0.005).CONCLUSIONAnastomotic leakage was significantly associated with long-term oncologic outcomes of patients with EGJ cancer, especially those who underwent intrathoracic anastomosis. Cervical anastomosis with subtotal esophagectomy may be an option for the patients who are at high risk for anastomotic leakage.     

重视结直肠癌根治术后吻合口瘘的远期影响

吻合口瘘是结直肠癌（colorectal cancer,CRC）术后早期严重并发症,临床上并不少见.然而,伴随的吻合口持续的炎症将可能增加吻合口狭窄及肿瘤的复发转移,降低患者的生存率及生活质量.早期发现、及时处理能有效减少其远期影响.     

术后C反应蛋白在预测腹腔镜结直肠癌术后早期吻合口漏中的作用：一项回顾性研究

目的:探讨腹腔镜结直肠癌术后吻合口漏与C反应蛋白(CRP)、CRP与白蛋白比值(CAR)的关系,比较CRP、CAR对术后吻合口漏的预测效能,以期为临床提供参考。方法:回顾分析162例腹腔镜结直肠癌手术患者术后第1天(POD1)、术后第2天(POD2)、术后第4天(POD4)的CRP值、CAR、CRP(POD4/POD1)、CRP(POD4/POD2)。结果:POD2观察到CRP的峰值水平。吻合口漏患者的CRA(POD4)、CRP(POD4/POD1)、CRP(POD4/POD2)均高于无吻合口漏患者。在受试者工作特征曲线分析中,POD1、POD2、POD4所测CRP曲线下面积分别为0.659、0.790与0.887。POD4的CRP截断值为86.70 mg/L,最佳组合的敏感性、特异性分别为100%与80.4%。结论:CRP(POD4)是预测吻合口漏的良好指标,在预测结直肠癌术后吻合口漏方面,CRP(POD4)较CRA(POD4)、CRP(POD4/POD1)、CRP(POD4/POD2)更可靠。     

适度扩肛预防直肠癌前切除术吻合口漏的发生

目的探讨适度扩肛对预防直肠癌前切除术后吻合口漏的作用。方法将375例直肠癌前切除术患者随机分为对照组（183例）和扩肛组（192例）,扩肛组术后48h开始扩肛,对照组术后未扩肛,比较两组术后吻合口漏发生情况。结果对照组186例发生吻合口漏11例,吻合口漏的发生率为6.01%;扩肛组189例发生吻合口漏3例,吻合口漏发生率为1.56%。两组相比,扩肛组吻合口漏的发生率较对照组低,其差异具有统计学意义,P=0.0456。结论适度扩肛对预防直肠癌前切除术后吻合口漏具有一定的作用。