中国实用外科杂志

中国实用外科杂志

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直肠癌术后须再手术吻合口漏影响因素研究

从志杰1，2，秦    骏1，崔    然1，王    颢2，于恩达2，钟    鸣1   

  1. 1上海交通大学医学院附属仁济医院胃肠外科，上海200127；2海军军医大学附属长海医院普外二科，上海200433
  • 出版日期:2017-12-01 发布日期:2017-11-30

  • Online:2017-12-01 Published:2017-11-30

摘要：

目的    探讨直肠癌术后须再手术吻合口漏发生的危险因素。方法    回顾性分析上海两大型结直肠外科中心自2011年1月至2013年12月直肠癌经腹前切除的946例临床数据。对须再手术的吻合口漏及其可能的15个相关因素（包括病人因素和手术因素）分别进行单因素和多因素Logistic回归分析。结果    单因素分析显示非专科术者、预防性造口、放置肛管、远切缘距离和肿瘤TNM分期与须再手术的吻合口漏相关。多因素Logistic分析发现，术前放疗（P=0.002）、非专科术者（P=0.006）、肛管放置（P=0.001）、远切缘距离＜1 cm（P=0.003）被视为吻合口漏的危险因素；预防性造口则被视为保护因素（P=0.004）。而肿瘤TNM分期在多因素分析中剔除于方程外（P=0.109）。须再手术的吻合口漏在术前放疗组（9.8% vs. 2.0%）和远切缘距离＜1 cm组（11.1% vs. 2.1%）中的发生率明显更高。结直肠专科术者须再手术的吻合口漏发生率显著低于非专科术者组（1.9% vs. 7.5%）。结直肠专科术者和非专科术者的年均直肠癌前切除手术量分别为43例/年和2例/年，差异有统计学意义（P＜0.001）。值得注意的是，专科术者组的低位直肠癌病例要高于非专科组（60.6% vs. 44.2%，P=0.020）。预防性造口未能明显消除吻合口漏的发生（2.8% vs. 5.3%，P=0.108），但却能减轻其影响，降低再手术率（0.3% vs. 3.3%）。预防性造口组的低位直肠癌病例也同样要高于非造口组（93.7% vs. 42.7%，P＜0.001）。而放置肛管组的须再手术漏发生率反而明显高于未放置组（10.0% vs. 1.6%）。肿瘤距肛缘距离并未显示与须再手术漏存在相关性（P=0.211）。结论    （1）结直肠专科术者以及新辅助放疗增加了直肠癌术后须再手术的吻合口漏的发生风险。（2）预防性造口仍使得吻合口漏的发生率有所降低（但差异无统计学意义），并显著降低了须再手术的吻合口漏发生风险。（3）放置肛管无益于预防吻合口漏。（4）建议非专科术者行直肠癌手术时无论肿瘤位置高低均须行预防性造口。

关键词: 吻合口漏, 前切除, 直肠癌, 危险因素

Abstract:

Influence factors of postoperative rectal cancer needing reoperation of anastomotic leakage        CONG Zhi-jie*，QIN Jun，CUI Ran，et al.*Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
Corresponding authors：ZHONG Ming，E-mail：drzhongming1966@163.com；YU En-da，E-mail：yuenda@163.com
Abstract    Objective    To analyze the mortality of anastomotic leakage (AL) requiring reoperation after anterior resection （AR） for rectal carcinoma and risk factors associated with it. Methods    The consecutive data of 946 rectal cancer patients underwent AR between January 2011 and December 2013 in two large colorectal surgery center of Shanghai were analyzed retrospectively. The associations between AL requiring reoperation and 15 patient-related and surgical-related variables were studied by using univariate chi-square test and multivariate logistic regression analysis, respectively. Results    Univariate analysis showed that non-specialized surgeon，defunctioning stoma，transanal stent putting，free distal margins and TNM classification were associated with AL requiring reoperation. When in multivariate logistic regression analysis，neoadjuvant radiotherapy （P=0.002）， non-specialized surgeon （P=0.006），transanal stent putting （P=0.001） and free distal margins ＜1cm （P=0.003） were showed to be risk factors associated with AL requiring reoperation. Defunctioning stoma was associated as protective factor （P=0.004）. But TNM classification was excluded from the equation in multivariate analysis （P=0.109）. The rate of AL requiring reoperation was significantly higher in neoadjuvant radiotherapy group （9.8% vs. 2.0%） and in group of free distal margins＜1cm （11.1% vs. 2.1%）. The rate of AL requiring reoperation in colorectal surgeon group was significantly lower than that in non-specialized surgeon group （1.9% vs. 7.5%）. The mean surgeon case volume of AR for rectal cancer in colorectal surgeons and non-specialized general surgeons was 43 per year and 2 per year， respectively （P＜0.001）. It should be noted that colorectal surgeons group got a greater proportion of low rectal cancers than non-specialists group （60.6% vs. 44.2%，P=0.020）. A defunctioning stoma didn’t significantly eliminate leakage （2.8% vs. 5.3%，P=0.108）， but mitigated the consequences and reduced the reoperation rate （0.3% vs. 3.3%）. And there was also a tendency for defunctioning stoma group to have much more low rectal cancers than non-stoma group （93.7% vs. 42.7%，P＜0.001）. The rate of AL requiring reoperation in transanal stent-putting group was not lower but unexpectedly higher （10.0% vs. 1.6%）.Interestingly，the height of tumor didn’t affect the rate of AL requiring reoperation（P=0.211）. Conclusion （1）Low-rectal cancer，non-specialized surgeons and neoadjuvant radiotherapy are risk factors of AL requiring reoperation after rectal surgery，no matter the location of rectal carcinoma.（2）It should be noticed that the defunctioning stoma group has much more low anastomosis patients with the above risk factors. But AL rate in stoma group still get decreased （no significant difference） and the incidence rate of leakage requiring reoperation has been significantly reduced.（3）Transanal stent putting couldn’t protect the anastomosis.（4）It suggests that defunctioning stoma should be taken in AR by non-specialized surgeons， no matter the height of rectal carcinoma.

Key words: anastomotic leakage, anterior resection, rectal carcinoma, risk factor