直肠癌全系膜切除及双吻合器术后吻合口瘘的相关因素分析与防治对策

目的探讨直肠癌行全系膜切除及双吻合器手术切除后吻合口瘘的相关原因及预防、诊断、治疗措施。方法回顾性分析我院2001年1月—2009年6月252例(男159例,女93例)直肠癌患者,行直肠全系膜切除及双吻合器术后吻合口瘘的发生率及治疗情况。结果 该组病例吻合口瘘的发生率为5.6%(14/252);确诊吻合口瘘发生时间为4~9 d,平均为6.8 d。其中8例高流量瘘采用早期横结肠造瘘与腹腔冲洗引流手术;6例低流量瘘采用非手术治疗,骶前双腔管冲洗与肛管固定引流术。2次治疗至出院时间为28~80 d,平均为48.6 d。术后吻合口瘘发生与患者的全身情况、吻合技术、吻合口位置,肿瘤Dukes分期、术前放化疗、是否行预防性造瘘等有相关性。结论术前充分的评估,术中细致的操作及选择性预防性造瘘的应用和围术期合理的处理是预防术后吻合口瘘的关键;术后及时正确的判断,恰当的手术时机的把握,充分的引流、营养支持等综合性措施是治疗吻合口瘘的必要手段。

Related causes of postoperative anastomotic leakage after total mesorectal excision followed by double-stapling for treatment of rectal cancers

Objective To investigate the related factors of postoperative anastomotic leakage(PAL) after total mesorectal excision(TME) combined with double-stapling(DS) for treatment of the rectal cancers,as well as the corresponding preventive and therapeutic measures.Methods A total of 252 patients(159 males,93 females) with rectal cancer,who received TME plus DS in our hospital from January 2001 to June 2009,were enrolled into the retrospectively study.Results The incidence rate of PAL was 5.6%(14/252),in which 8 cases with early high-flow fistula were dealt with early transverse colon fistula and abdominal washing and draining,and 6 cases with low-flow fistula received the conservative treatment using double lumen tube presacral drainage and fixed anal canal drainage.Timing of diagnosis on PAL ranged from 4 to 9(average=6.8)days,and the average length of hospitalization was 48.6 days.It was noted that age,general condition,anastomotic location,Dukes staging of tumor,preoperative chemotherapy and radiotherapy,preventive ostomy,etc.were related to the occurrence of anastomotic leakage.Conclusion Preoperative accurate evaluation,intraoperative careful manipulation,application of preventive ostomy,and adequate perioperative preparation are the keys to preventing the onset of PAL.The prompt diagnosis and choice of two-stage surgical indications and/or expectant treatment such as adequate drainage and nutrition support are beneficial to rehabilitation for the patients suffered from PAL.