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。

Risk factors of anastomotic fistula after laparoscopic rectal cancer anus-preserving operation and counter-measures

OBJECTIVE Anastomotic fistula is one of the most serious complications after rectal cancer anus-preser-ving operation,and it increases the patients pain and burden.It becomes very important to research the risk factors of anastomotic fistula after laparoscopic rectal cancer anus-preserving operation which has been developed into the main-stream surgical procedure.To study the risk factors of anastomotic leakage after laparoscopic resection of rectal cancer and the methods of prevention and treatment of anastomotic leakage so as to improve the comprehensive effect of laparo-scopic operation for rectal cancer,and reduce the incidence of anastomotic leakage.METHODS Between January 1,2010 and June 30,2015,a retrospective analysis of 160 cases of laparoscopic anus-preserving rectal cancer resection was per-formed in our hospital.The data of gender,age,diabetes,body mass index,maximum tumor diameter,preoperative hemo-globin,preoperative serum albumin,pathological findings,intraoperative bleeding,operation time,severed vascular level and a defunctioning stoma,operation method,anastomosis distance to dentate line and neoadjuvant chemoradiation and anastomotic leakage were recorded.Single factor and logistic multivariate regression analysis was performed.Treatment measures and effects of anastomotic leakage were summarized.RESULTS The incidence of anastomotic leakage was 8.75%(14/160)in this study.The single factor analysis showed that the differences between anastomotic leakage group and non anastomotic leakage group were statistically significant in the patients’body mass index (χ2 =4.974,P =0.026), preoperative serum albumin level (χ2 = 5.749,P = 0.016),super low rectal cancer (χ2 = 8.270,P = 0.004),operation method (χ2 =10.27,P =0.001)and neoadjuvant chemoradiation (χ2 =7.540,P =0.006).Logistic multiple regression a-nalysis showed that the body mass index(OR=22.156),anastomosis distance to dentate line(OR=9.742),the operation method(OR=6.161)and the new adjuvant chemoradiation(OR=19.045)were considered as the independent risk factors for the occurrence of anastomotic leakage after laparoscopic surgery for rectal cancer.After the adoption of adequate drainage and intravenous somatostatin,double cannula douche,ileum or colon stoma,anastomotic fistulas were cured. CONCLUSIONS The body mass index,the anastomosis distance to dentate line,operation mode and new adjuvant chemo-radiation were considered as the independent risk factors for the occurrence of anastomotic leakage after laparoscopic sur-gery for rectal cancer.The probability of non planned second operations can be reduced by taking preventive stoma in pa-tients with independent risk factors.The preventive stoma can also reduce the degree of fistula,and shorten the healing time of fistula.