直肠癌全系膜切除术后吻合口瘘原因分析及防治措施

目的：分析直肠癌全直肠系膜切除术后发生吻合口瘘的原因及防治措施.方法：回顾性分析自2003年1月至2007年12月在我院行全直肠系膜切除保肛手术的214例中低位直肠癌患者的临床资料.结果：214例患者术后共发生吻合口瘘16例（7.5％）.发生时间为术后4-15d,平均（6.8±1.4）d.其中性别、肿瘤Dukes分期、病理类型及有无结肠储袋等对术后吻合口瘘的发生率没有显著影响,差异无统计学意义（P＞0.05）.而年龄、术前有无贫血及低蛋白血症、糖尿病史、有无合并肠梗阻、手术方式、吻合器应用、吻合器吻合后手工缝合减张及术后直肠留置肛管引流减压对术后吻合口瘘的发生率均有明显影响（P＜0.05）.4例严重吻合口瘘的患者并发弥漫性腹膜炎行横结肠造瘘术,术后4个月成功闭瘘.12例较轻的吻合口瘘患者采用单纯完全静脉营养、抗生素治疗、经引流管局部冲洗等措施全部治愈,愈合时间为14d至3个月,平均（28.7±2.3）d.术后无死亡患者.结论：高龄、贫血、低蛋白血症、合并糖尿病及肠梗阻、低位吻合口等是术后发生吻合口瘘的高危因素.吻合器吻合后手工缝合加固减张,术后直肠内留置肛管减压引流可显著减少吻合口瘘的发生.积极合理的采取非手术或手术措施治疗吻合口瘘是促进吻合口愈合的关键.

Reason and prevention of anastomotic leakage after total mesorectal excision for rectal cancer

Objective：To investigate the reasons and prevention measures of anastomotic leakage after total mesorectal excision for rectal cancer.Methods：To retrospectively analyze the clinical data of 214 rectal cancer patients after total mesorectal excision（TME） frome 2003 to 2007 in our hospital.Results：There were 16（7.5％） anastomotic leakage cases among the 214 rectal cancer patients.The leakage occurred from 4 to 15 days postoperatively and the average time of appearance was （6.8 ± 1.4）d.The gender,dukes stage,pathological type and with the colonic pouch or no had no significant effect to the incidence of anastomotic leakage after TME（P ＞0.05）.But age,with the preoperative anemia or not and hypoproteinemia,history of diabetes,with the intestinal obstruction or not,surgical approach,anastomat applications,manual ataple-line reinforce after stapled anastomosis and postoperative placement of drainage in rectum had significant effect to the incidence of anastomotic leakage after TME （P ＜ 0.05）.4 cases of severe anastomotic fistula patients complicated by diffuse peritonitis got transverse colon fistulization and successfully closed the fistula after 4 months.12 cases lesser anastomotic fistula patients were cured by simple total parenteral nutrition,antibiotic treatment and partial flushing through the drainage tube,the healing time was from 14 d to 3 months,the average time was （28.7 ± 2.3） d.No deaths after surgery.Conclusion：Elderly patients,anemia,hypoproteinemia,preoperative diabetes and intestinal obstruction and low anastomotic are risk factors for the anastomotic leakage,manual ataple-line reinforce after stapled anastomosis and postoperative placement of drainage in rectum may significantly reduce the incidence of anastomotic leakage,and positive and reasonable to take the non-surgical or surgical measures for the therapy of anastomotic leakage is the key to promote the healing of anastomotic.