中国实用外科杂志

中国实用外科杂志 ›› 2022, Vol. 42 ›› Issue (02): 199-205.DOI: 10.19538/j.cjps.issn1005-2208.2022.02.14

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腹腔镜直肠癌超低位前切除术造口回纳后再发吻合口漏危险因素分析

刘军广1，陈贺凯2，郑利军3，汤坚强4   

  1. 1北京大学第一医院普通外科，北京 100034；2 天津市第五中心医院，天津 300450；3 大同第三人民医院肛肠科，山西大同037045；4 中国医学科学院肿瘤医院结直肠外科，北京 100021
  • 出版日期:2022-02-01 发布日期:2022-01-27

  • Online:2022-02-01 Published:2022-01-27

摘要： 目的    探讨腹腔镜直肠癌超低位前切除术（Ls-uLAR）并发直肠吻合口漏病人的转归，并对造口回纳后再发吻合口漏的危险因素进行初步分析。方法    回顾性分析北京大学第一医院普通外科2012年1月至2020年12月同一手术团队完成的Ls-uLAR并发吻合口漏的31例直肠癌病人的临床资料及随访结果，对造口回纳后再发吻合口漏的临床特征及危险因素进行分析。结果    371例接受Ls-uLAR的病人中有31例（8.4%）术后并发吻合口漏。其中预防性造口术后吻合口漏23例（23/307，7.5%），其转归为：1例围手术期死亡，1例吻合口复发再次行经腹-会阴联合切除术，6例吻合口重度狭窄难以回纳，15例经保守治疗吻合口漏临床愈合（其中2例因肺转移而放弃回纳）；无预防性造口术后吻合口漏8例（8/64，12.5%），其转归为：1例围手术期死亡，2例急诊行回肠造口，5例经保守治疗愈合。符合吻合口漏临床愈合标准的15例病人于初次术后3~16个月行造口回纳，其中8例（8/15，53.3%）再次出现吻合口漏。单因素分析结果显示：新辅助放化疗（是vs.否：100.0% vs. 30.0%，P=0.026）、初次术中出血量（> 50 mL vs. ≤ 50 mL 87.5%  vs. 14.3%，P=0.010）及吻合口内镜下缺血征象（有vs.无：85.7% vs. 25.0%，P=0.041）与再发吻合口漏相关。8例再发吻合口漏病人表现为骶前脓肿并继发不完全性肠梗阻4例，反复发作肛周脓肿和肛瘘2例，直肠阴道瘘2例。所有再发漏病人经保守治疗1～2个月均未能愈合，除1例直肠阴道瘘拒绝再次造口外，其余7例均改行横结肠造口。结论    腹腔镜直肠癌超低位前切除术并发吻合口漏结局不良，继发吻合口狭窄及回纳后再发吻合口漏的风险较高，对吻合口漏病人的临床愈合标准、造口回纳时机和手术方式，尤其是新辅助放化疗后病人仍有待进一步研究。

关键词: 直肠癌, 腹腔镜超低位前切除术, 吻合口漏, 再发吻合口漏, 新辅助放化疗

Abstract: Analysis of risk factors for anastomotic re-leakage after stoma closure for rectal cancer patients receiving laparoscopic ultralow anterior resection        LIU Jun-guang*，CHEN He-kai，ZHENG Li-jun，et al. *Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Corresponding author: TANG Jian-qiang, E-mail: doc_tjq@hotmail.com
LIU Jun-guang and CHEN He-kai are the first authors who contributed equally to the article.
Abstract    Objective    To explore the outcomes of rectal cancer patients complicated with anastomotic leakage (AL) after laparoscopic ultralow anterior resection (Ls-uLAR), and preliminarily study the risk factors for anastomotic re-leakage after stoma closure. Methods    The clinical data and follow-up results of 31 rectal cancer patients complicated with AL after Ls-uLAR by the same surgical team from January 2012 to December 2020 in the Department of General Surgery, Peking University First Hospital were collected retrospectively. The clinical features and risk factors for anastomotic re-leakage after stoma closure were analyzed. Results    Among 371 patients who received Ls-uLAR, 31 patients (8.4%) were complicated with AL postoperatively, including 23 patients (23/307, 7.5%) with a protective stoma and 8 patients (8/64, 12.5%) without a protective stoma. For the 23 patients with protective stoma, one patient died during the perioperative period, one patient had an anastomotic recurrence and abdominoperineal resection was subsequently performed, 6 patients were not eligible to close the protective stoma due to severe anastomotic stenosis, 15 patients were cured through nonoperative treatment (2 patients rejected to close the protective stoma due to pulmonary metastasis). For the 8 patients without a protective stoma, one patient died during the perioperative period, 2 patients underwent emergency ileostomy, 5 patients were cured through nonoperative treatment. 15 patients who met the AL healing criteria finally received secondary surgery to close the stoma, 8 patients (8/15, 53.3%) complicated with anastomotic re-leakage. Univariate analysis showed that neoadjuvant chemoradiotherapy (nCRT)(nCRT vs. non-nCRT: 100.0% vs. 30.0%, P=0.026), blood loss during Ls-uLAR (> 50 mL vs. ≤50 mL: 87.5% vs.14.3%, P=0.010) and positive sign of anastomotic ischemia under colonoscopy (positive vs. negative: 85.7% vs.25.0%, P=0.041) were correlated with re-leakage. The manifestations of 8  cases with re-leakage were presacral abscess with incomplete bowel obstruction(4 cases), repeated perianal abscess and anal fistula(2 cases) ,and rectovaginal fistula(2 cases) . All the 8 patients with re-leakage failed to be cured with nonoperative treatment for 1-2 months, except that 1 patient with rectovaginal fistula was rejected to receive colostomy, all the other 7 patients finally underwent transverse colostomy. Conclusion    With a high risk of anastomotic stenosis and re-leakage after stoma closure, patients complicated with AL after Ls-uLAR generally had an unfavorable prognosis. The clinical healing criteria of AL, when to close the stoma and how to choose the optimum operative method, especially for patients after neoadjuvant chemoradiotherapy, still need to be further studied.

Key words: rectal cancer, laparoscopic ultralow anterior resection, anastomotic leakage, anastomotic re-leakage, neoadjuvant chemoradiotherapy