新辅助放化疗后低位直肠癌术后吻合口漏危险因素分析

目的:探讨接受新辅助放化疗的患者行腹腔镜直肠癌低位前切除术（low anterior resection,LAR）术后发生吻合口漏的危险因素。方法:采用回顾性病例对照研究方法。收集2010年01月至2019年12月南通大学附属东台医院、苏州大学附属第一医院收治的146例cT3-4期和(或)N1-2期低位直肠癌患者临床资料。上述患者先行新辅助放化疗6~8周后行LAR术,所有肿瘤患者遵循全直肠系膜切除原则行根治性切除、低位保肛手术。根据收集的临床数据对比分析各组患者全身一般情况、肿瘤特征、检查指标及术后相关并发症发生率等,采用单因素和多因素分析方法探讨新辅助放化疗后低位直肠癌术后吻合口漏的危险因素。结果:新辅助放化疗后的低位直肠癌行腹腔镜直肠癌低位前切除术,整体吻合口漏发生率为 10.3%。通过单因素分析法,发现吻合口漏的发生在糖尿病、BMI、术前白蛋白、预防性回肠造口、保留左结肠血管、侧方淋巴结清扫不同的分组中存在差异（P均＜0.05）。进一步行Logistic回归多因素分析发现BMI(OR=1.172,95％CI:1.012～1.357,P=0.034）,术前白蛋白(OR=1.883,95％CI:1.001～3.993,P=0.037）,侧方淋巴结清扫(OR=10.353,95％CI:1.513~70.846,P=0.017）是术后发生吻合口漏的独立危险因素。结论:新辅助放化疗后低位直肠癌术后发生吻合口漏与患者的血糖水平、BMI指数、白蛋白、预防性回肠造口、保留左结肠血管、侧方淋巴结清扫等因素相关。对于肥胖、低蛋白血症、行侧方淋巴结清扫等危险因素的患者而言,术后发生吻合口漏的风险将增高;行预防性回肠造口、保留左结肠血管的患者吻合口漏的发生率可显著降低。     

腹腔镜直肠癌保肛手术后吻合口瘘的危险因素与对策

目的：吻合口瘘为直肠癌保肛手术后严重的并发症之一,增加和患者的痛苦和经济负担。腹腔镜直肠癌根治术已经发展为主流术式,因此研究此术式下吻合口瘘的危险因素显得尤为重要。本研究探讨腹腔镜直肠癌保肛手术后发生吻合口瘘的危险因素及吻合口瘘的防治办法,以期提高腹腔镜直肠癌保肛手术的综合效果,降低吻合口瘘的发生率。方法回顾性分析2010-01-01—2015-06-30北京大学第九临床医学院行腹腔镜直肠癌保肛手术160例患者的临床资料,总结患者性别、年龄、伴有糖尿病、体质量指数、肿瘤最大直径、术前血红蛋白、术前血白蛋白、病理结果、术中出血量、手术时间、离断血管水平、预防性造口、手术方式、肿瘤下极距齿状线距离和新辅助放化疗的情况,统计吻合口瘘的发生情况,并进行单因素和 Logistic 多因素回归分析。分析吻合口瘘的相关危险因素及处理措施和效果。结果吻合口瘘发生率为8．75％（14／160）。单因素分析显示,腹腔镜直肠癌保肛手术后发生吻合口瘘组与未发生瘘组在患者体质量指数（χ2＝4．974,P ＝0．026）、术前白蛋白水平（χ2＝5．749,P ＝0．016）、超低位保肛（χ2＝8．270,P ＝0．004）、手术方式（χ2＝10．27,P ＝0．001）和新辅助放化疗（χ2＝7．540,P ＝0．006）方面,差异有统计学意义。Logistic 多因素回归分析结果显示,体质量指数（OR＝22．156）、吻合口距齿状线距离（OR＝9．742）、手术方式（OR＝6．161）和新辅助放化疗（OR＝19．045）是腹腔镜直肠癌保肛手术后发生吻合口瘘的独立危险因子。经采取充分引流、静脉使用生长抑素、双套管冲洗及回肠或横结肠造口等方法进行处理后,吻合口瘘均痊愈。结论体质量指数、吻合口距齿状线距离、手术方式和新辅助放化疗等是腹腔镜直肠癌保肛手术后发生吻合口瘘的独立危险因子。对伴有独立危险因子病例采取预防性造口,可以降低非计划二次手术的概率,减轻瘘的程度,缩短瘘的愈合时间。围手术期采取适当措施,可有效降低吻合口瘘的发生率。     

老年直肠癌术后吻合口瘘的高危因素分析

目的:探讨老年直肠癌术后吻合口瘘的高危因素。方法:选择我院于2014年5月至2018年5月期间收治的老年直肠癌患者437例,均采用腹腔镜直肠癌根治法。分析影响老年直肠癌术后吻合口瘘的高危因素。影响因素包括性别、术前白蛋白、手术时间、合并高血压、合并糖尿病、吻合口距肛缘距离、肠梗阻、Dukes分期、BMI、出血量、血管侵犯和神经侵犯。结果:老年直肠癌患者行腹腔镜根治术后发生吻合口瘘29例,发生率为6.64%。经单因素分析表明,两组性别、合并高血压、合并糖尿病、Dukes分期、BMI、出血量和神经侵犯比较差异无统计学意义（P>0.05）;吻合口瘘组术前白蛋白≤35 g/L、手术时间＞3 h、吻合距肛缘距离≤7 cm、肠梗阻、血管侵犯人数明显增多,差异具有统计学意义（P<0.05）。将上述单因素分析差异具有统计学意义的纳入多因素分析显示,术前白蛋白≤35 g/L、手术时间＞3 h、吻合距肛缘距离≤7 cm、肠梗阻和血管侵犯为影响术后吻合口瘘的高危因素。结论:老年直肠癌术后吻合口瘘受术前白蛋白、手术时间、吻合距肛缘距离、肠梗阻和血管侵犯影响,为降低术后吻合口瘘,需按照相关因素采取针对性预防措施。     

直肠癌前切除术后吻合口瘘24例临床分析

[目的]探讨直肠癌前切除术后发生吻合VI瘘的影响因素、预防及治疗措施。[方法]对直肠癌患者行前切除术后发生吻合VI瘘患者的临床资料进行回顾分析。[结果]556例直肠癌患者均行前切除术,发生吻合口瘘24例,其中行保守治疗8例（7例治愈,1例转手术治疗后治愈）;行末端回肠造瘘术11例,横结肠造瘘术5例,均治愈。单因素分析显示吻合口瘘的发生与患者性别、是否合并糖尿病、术前肠梗阻、肿瘤与肛缘距离、肿瘤的分期等因素有关（P〈O．05）,多因素分析显示术前肠梗阻、肿瘤分期、肿瘤与肛缘距离为吻合口瘘发生主要危险因素（P〈0．05）。[结论]充分的术前准备,精细的手术操作,正确的治疗措施,是减少吻合口瘘发生,减轻吻合口瘘的关键。     

低位直肠癌术后吻合口瘘的危险因素及治疗

目的:探讨低位直肠癌保肛手术后发生吻合口瘘的危险因素及防治措施.方法:回顾性分析2005年至2007年155例低位直肠癌保肛手术患者的临床资料.结果:本组患者术后发生吻合口瘘12例(7.7%).肿瘤距肛缘距离≤5cm者吻合口瘘发生率(16.67%)明显高于≤7cm者(2.67%),差异有统计学意义(P＜0.05).Lo...     

腹腔镜直肠癌术后预防性应用止泻药物防止吻合口瘘的疗效观察

目的 吻合口瘘目前仍是直肠癌前切除术后的最严重并发症之一.本研究旨在探讨预防性应用止泻药物对防止腹腔镜直肠癌术后吻合口瘘的作用.方法 回顾性分析587例腹腔镜辅助直肠癌Dixon术后吻合口瘘的发生和治疗情况,对预防性应用止泻药物组(A组)、未应用止泻药物且未预防性回肠造瘘组(B组)、预防性回肠造瘘组(C组)患者的临床资料进行对比观察.结果 A组患者术后吻合口瘘发生率为2.29%(5/218),均经保守治疗治愈,平均治愈时间为(9.95±1.82)d;B组患者术后吻合口瘘发生率为8.72%(15/172),其中有2例经保守治疗治愈,其余患者予横结肠造瘘、局部冲洗引流治疗后愈合,平均治愈时间为(18.58±2.15)d;C组患者术后吻合口瘘发生率为2.54%(5/197),均经保守治疗治愈,平均治愈时间为(10.32±1.91)d.A组及C组的吻合口瘘发生率明显低于B组(χ2=13.028,P<0.001;χ2=12.852,P<0.001),A组与C组吻合口瘘发生率的比较差异无统计学意义,χ2=1.183,P=0.816.A组(t=4.127,P=0.001)及C组(t=3.963,P=0.001)的吻合口瘘平均愈合时间明显少于B组,A组与C组吻合口瘘平均愈合时间的比较差异无统计学意义,t=0.287,P=0.725.结论 预防性应用止泻药物能够有效防止腹腔镜辅助直肠癌Dixon术后吻合口瘘的发生.     

直肠癌术后预防性回肠造口决策因素及对围手术期康复影响的分析:单中心751例回顾性研究

目的 探讨直肠癌术后行预防性回肠造口的决策因素,并分析预防性回肠造口对围手术期预后的影响。方法 采用回顾性病例对照研究方法,纳入2013年1月至2021年12月广东省中医院胃肠肿瘤中心行前切除术的直肠癌患者751例,其中229例患者术后行预防性回肠造口(预防性回肠造口组),522例未行预防性回肠造口(非预防性回肠造口组),比较两组患者的术前、术中和肿瘤相关资料,并对比两组患者围手术期预后的差异。结果 术前影响因素方面,预防性回肠造口组中,男性、既往使用激素或免疫抑制剂、术前行放化疗和既往有吸烟史的患者比例多于非预防性回肠造口组(均P<0.05);术中影响因素方面,预防性回肠造口组中,离断肿瘤远端直肠肠管时使用的直线切割闭合器钉仓数目≥2个、吻合口与肛缘距离≤5 cm和手术时间>180 min的患者比例多于非预防性回肠造口组(均P<0.05);肿瘤影响因素方面,预防性回肠造口组的T分期晚于非预防性回肠造口组(P=0.001),肿瘤位置低于非预防性回肠造口组(P<0.001)。多因素Logistic回归分析提示,男性患者、伴有术前肠梗阻、术前进行放化疗、吻合口与肛缘...     

腹腔镜中低位直肠癌根治术经肛吻合口加固预防吻合口瘘

目的:探讨腹腔镜中低位直肠癌根治术(Dixon)经肛加固吻合口对预防直肠癌术后吻合口瘘的可行性。方法:收集2019年08月至2022年05月我院普外科行腹腔镜中低位直肠癌根治手术(Dixon)患者共127例。根据指南,中低位直肠癌为肿瘤下缘距离肛门10 cm以内,根据吻合口加固方式不同分为三组:经肛连续缝合组(n=43);经肛间断缝合组(n=42);对照组（未经肛门缝合组）(n=42)。对患者一般资料、手术时间、术中出血量、肛门首次排气时间、进流食时间、术后住院时间、吻合口瘘、吻合口出血、切口感染、肛周疼痛进行比较。结果:三组患者一般资料比较无统计学差异(P>0.05),与对照组比较,经肛连续缝合组和经肛间断缝合组在手术时间、术中出血量、进流食时间、术后肛门排气时间、切口感染、肛周疼痛无统计学差异(P>0.05),而吻合口瘘方面,连续缝合组为4.65%,间断缝合组为4.76%,对照组为16.67%,三组间比较虽无统计学差异（P=0.079）,但提示经肛缝合可降低吻合口瘘的发病,术后住院时间,间断缝合组为(8.17±1.52)d,连续缝合组为(8.15±1.69)d,对照组为(12.13±1.57)d,有统计学差异(P=0.035),经肛连续缝合组和经肛间断缝合组间比较术后住院时间无统计学差异(P>0.05)。C级吻合口瘘对照组例数为3例,多于经肛缝合组1例。结论:腹腔镜中低位直肠癌根治手术经肛连续吻合口加固和经肛间断吻合口加固能降低术后吻合口瘘,技术操作简单,并缩短住院时间,可以临床推广应用。     

双吻合器技术在直肠癌保肛手术中吻合口瘘的危险因素分析

背景与目的：直肠癌术后吻合口瘘是严重的并发症之一,降低吻合口瘘发生率是临床亟待进一步解决的问题,本研究探讨使用双吻合器进行直肠前切除术(Dixon术)后吻合口瘘的发生及原因分析。方法：回顾性分析150例使用双吻合器进行直肠前切除术的患者,对术后发生吻合口瘘的患者进行性别、年龄、身体质量指数(body mass index,BMI)、细胞分化程度、吻合口部位、TNM分期、是否合并糖尿病、是否合并术前贫血及是否进行术前新辅助放疗的单因素分析,旨在进一步判断直肠前切除术后吻合口瘘的风险。结果：150例患者中共7例发生吻合口瘘,其中3例行二次手术回肠造瘘,4例保守治疗后愈合。单因素分析及多因素分析证实,吻合口距肛距离、术前新辅助放疗是影响直肠癌术后吻合口瘘的独立危险因素。结论：使用双吻合器技术进行直肠前切除的吻合其术后吻合口瘘发生率相对较低,吻合口距肛距离、术前新辅助放疗是影响直肠癌术后吻合口瘘的独立危险因素,对于吻合口瘘的高危患者可以考虑选择性的进行保护性小肠造口。     

直肠癌前切除术后吻合口瘘的危险因素及治疗方法分析

[目的]探讨直肠癌前切除术后发生吻合口瘘的高危因素及其处理方法。[方法]回顾性分析自1999年1月至2008年7月1677例行直肠癌前切除术患者的临床资料及发生吻合口瘘后的治疗措施。[结果]共有44例患者（2．6％）术后发生吻合口瘘,其诊断发生吻合口瘘的中位时间为术后第6d。单因素分析显示,男性、肿瘤下缘距肛门小于7cm、术前肠道梗阻为术后吻合口瘘的独立危险因素。出现吻合口瘘后,有9例患者采取了保守治疗,19例患者立刻采取了积极手术治疗,另有16例患者在保守治疗无明显疗效后采取了手术治疗。[结论]男性、肿瘤下缘距肛门小于7cm、术前肠道梗阻的直肠癌前切除术患者易出现吻合口瘘,治疗方式应根据病人临床状况选择。     

Genetics of rectal cancer

Two operational subdivisions of hereditary colorectal cancer susceptibility are those with and those without premalignant adenomatous colonic polyp expression. In both of these subdivisions, reliable biomarkers of gene carriage would be of value in patient management as we have previously emphasized. Consideration must also be given to the familial (hereditary) occurrence of inflammatory bowel diseases associating with colorectal cancer susceptibility. The occurrence of rectal cancers should therefore alert the physician to investigate the possibility of a significant family medical history in order to fully elucidate the genetic heterogeneity of susceptibility to this disease. Clinicians should also be alert to the possibility of extracolonic malignancies where probable genetic colorectal cancer susceptibility is evident. Whenever possible, all potential biomarkers should be investigated to aid in definition of genetic heterogeneity.     

Imaging of rectal cancer

Radiologic evaluation of rectal cancer is invaluable in aiding the surgeon, gastroenterologist, and oncologist in the initial and follow-up management of patients with this malignancy. This review highlights recent developments in computed tomography; ultrasonographic, metabolic, and magnetic resonance imaging of rectal cancer; its clinical ramifications; and the direction of future efforts.     

MicroRNA in rectal cancer

In rectal cancer, one of the most common cancers worldwide, the proper staging of the disease determines the subsequent therapy. For those with locally advanced rectal cancer, a neoadjuvant chemoradiotherapy (CRT) is recommended before any surgery. However, response to CRT ranges from complete response (responders) to complete resistance (non-responders). To date we are not able to separate in advance the first group from the second, due to the absence of a valid biomarker. Therefore all patients receive the same therapy regardless of whether they reap benefits. On the other hand almost all patients receive a surgical resection after the CRT, although a watch-and-wait procedure or an endoscopic resection might be sufficient for those who responded well to the CRT. Being highly conserved regulators of gene expression, microRNAs (miRNAs) seem to be promising candidates for biomarkers. Many studies have been analyzing the miRNAs expressed in rectal cancer tissue to determine a specific miRNA profile for the ailment. Unfortunately, there is only a small overlap of identified miRNAs between different studies, posing the question as to whether different methods or differences in tissue storage may contribute to that fact or if the results simply are not reproducible, due to unknown factors with undetected influences on miRNA expression. Other studies sought to find miRNAs which correlate to clinical parameters (tumor grade, nodal stage, metastasis, survival) and therapy response. Although several miRNAs seem to have an impact on the response to CRT or might predict nodal stage, there is still only little overlap between different studies. We here aimed to summarize the current literature on rectal cancer and miRNA expression with respect to the different relevant clinical parameters.     

Prediction in rectal cancer

The treatment of rectal cancer largely depends on disease stage at diagnosis, based on which patients can be classified as low, intermediate, or high risk. Prognostic and predictive markers, specific to each risk category, can be applied for optimal risk classification and subsequent treatment allocation. These markers are either histopathological, determined with imaging, or have a biomolecular background. This review provides an overview of the current status of treatment options and the use of prognostic and predictive markers in each risk category. An effort was made to identify those markers that are currently lacking in, but have the potential to improve, the clinical decision process by discussing the data from recent studies aimed at the development of new prognostic and predictive markers. At this moment, none of the markers studied has been proven to be of significant, independent value, justifying implementation in daily clinical practice. However, recent developments in imaging techniques and biomolecular research do show great potential.     

Laparoscopy for rectal cancer

Several large case series and single-institution trials have shown that laparoscopy is feasible for rectal cancer. Pending the results of the UK CLASICC, COLOR II, Japanese JCOG 0404, and ACOSOG Z6051 trials, the oncologic and long-term safety of laparoscopic rectal cancer surgery is unclear and the technique is best used at centers that can effectively collect and analyze outcomes data. Robotic and endoluminal techniques may change our approach to the treatment of rectal cancer in the future. Training, credentialing, and quality control are important considerations as new and innovative surgical treatments for rectal cancer are developed.     

Chemotherapy and rectal cancer

Chemotherapy does not increase the survival time of patients treated for rectal cancer. Chemotherapy given concomitantly to radiotherapy and combined before or after radiation significantly reduces the risk of local recurrence. The sterilization of the tumour (complete pathological response) by chemotherapy is a favourable prognostic factor. New trials on optimisation of pathological complete response rates are based on using drugs effective on metastatic colorectal cancer, given prior to chemoradiotherapy and followed by a resection at least 8 weeks after the end of the radiotherapy. The level of evidence for postoperative chemotherapy is low due to lack of specific study. The indication of postoperative chemotherapy depends on the disease extent after preoperative treatment.     

Nonoperative management of rectal cancer

Surgery has long been the primary curative modality for localized rectal cancer. Neoadjuvant chemoradiation has significantly improved local control rates and, in a significant minority, eradicated all disease. Patients who achieve a pathologic complete response to neoadjuvant therapy have an excellent prognosis, although the combination treatment is associated with long‐term morbidity. Because of this, a nonoperative management (NOM) strategy has been pursued to preserve sphincter function in select patients. Clinical and radiographic findings are used to identify patients achieving a clinical complete response to chemoradiation, and they are then followed with intensive surveillance. Incomplete, nonresponding and those demonstrating local progression are referred for salvage with standard surgery. Habr‐Gama and colleagues have published extensively on this treatment strategy and have laid the groundwork for this approach. This watch‐and‐wait strategy has evolved over time, and several groups have now reported their results, including recent prospective experiences. Although initial results appear promising, several significant challenges remain for NOM of rectal cancer. Further study is warranted before routine implementation in the clinic. Cancer 2016;122:34–41. © 2015 American Cancer Society.