预防性回肠末端造口在腹腔镜直肠癌根治术中的应用价值
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摘要
目的探讨预防性回肠末端造口在腹腔镜直肠癌根治术中的应用价值。方法收集该院2014年1月至2018年6月收治的直肠癌病例,将其分为造口组(n=128)和非造口组(n=126),造口组患者术后3个月返院行造口回纳术。术后随访6个月,收集相关临床资料并进行统计学分析。结果两组患者临床基线资料、术中出血量差异无统计学意义(P=0.77);造口组与非造口组比较除手术时间较长[(181±26)min vs.(169±22)min,P<0.01]外,患者术后排气/便时间[(1.6±0.8)d vs.(2.0±0.9)d,P=0.001]、首次进食时间[(1.7±0.7)d vs.(2.1±0.9)d,P=0.003]及术后住院时间[(9.5±1.7)d vs.(11.5±3.4)d,P<0.01]明显缩短。两组病例术后吻合口漏发生率差异无统计学意义(10.2%vs.14.3%,P=0.32),但造口组吻合口漏严重程度明显低于非造口组(P=0.036)。在肠梗阻、腹腔出血、腹部感染、切口感染及吻合口狭窄并发症发生率方面两组差异无统计学意义。多因素Logistic回归分析显示术前放疗(OR5.05,95%CI2.24～11.40,P<0.01)和吻合口高度(OR3.53,95%CI1.46～8.50,P=0.005)是术后发生吻合口漏的独立危险因素。结论预防性回肠末端造口不能显著降低腹腔镜直肠癌根治术后吻合口漏发生率,在临床上应充分权衡预防性造口的利弊,不建议常规应用。
Objective To investigate the application value of prophylactic terminal ileum enterostomy in laparoscopic radical resection of rectal cancer.Methods The cases of rectal cancer diagnosed in this hospital from January 2014 to June 2018 were collected and divided into the stoma group(n=128)and non-stoma group(n=126).The patients in the stoma group returned to the hospital for conducting the colostomy closure at postoperative 3 months.The relevant clinical data were collected and statistical analysis was performed subsequently after 6 months of follow-up.Results The clinical baseline data and intra-operative bleeding volume had no statistical difference between the two groups(P=0.77).the operation time in the stoma group was significantly longer than that in the non-stoma group[(181±26)min vs.(169±22)min,P<0.01],the postoperative exhaust/defecation time[(1.6±0.8)d vs.(2.0±0.9)d,P=0.001],first eating time[(1.7±0.7)d vs.(2.1±0.9)d,P=0.003]and postoperative hospitalization time[(9.5±1.7)d vs.(11.5±3.4)d,P<0.01]in the stoma group were significantly decreased compared with the non-stoma group.The incidence rate of postoperative anastomotic leakage had no statistical difference between the two groups(10.2%vs.14.3%,P=0.32),but the severity degree of anastomotic leak in the stoma group was significantly lower than that in the non-stoma group(P=0.036).No statistically significant differences were found in the aspects of the incidence of intestinal obstruction,intra-abdominal hemorrhage,abdominal infection,wound infection and anastomotic stenosis between the two groups.The multivariate Logistic regression analysis showed that preoperative radiotherapy(OR5.05,95% CI 2.24-11.40,P<0.01)and anastomotic height(OR3.53,95% CI 1.46-8.50,P=0.005)were the independent risk factors for postoperative anastomotic leakage.Conclusion The prophylactic terminal ileum enterostomy can not decrease the occurrence rate of anastomotic leakage of laparoscopic radical resection of rectal cancer,therefore its advantage and disadvantage should be fully weighed in clinic and its routine application is not recommended.
Objective To investigate the application value of prophylactic terminal ileum enterostomy in laparoscopic radical resection of rectal cancer.Methods The cases of rectal cancer diagnosed in this hospital from January 2014 to June 2018 were collected and divided into the stoma group(n=128)and non-stoma group(n=126).The patients in the stoma group returned to the hospital for conducting the colostomy closure at postoperative 3 months.The relevant clinical data were collected and statistical analysis was performed subsequently after 6 months of follow-up.Results The clinical baseline data and intra-operative bleeding volume had no statistical difference between the two groups(P=0.77).the operation time in the stoma group was significantly longer than that in the non-stoma group[(181±26)min vs.(169±22)min,P<0.01],the postoperative exhaust/defecation time[(1.6±0.8)d vs.(2.0±0.9)d,P=0.001],first eating time[(1.7±0.7)d vs.(2.1±0.9)d,P=0.003]and postoperative hospitalization time[(9.5±1.7)d vs.(11.5±3.4)d,P<0.01]in the stoma group were significantly decreased compared with the non-stoma group.The incidence rate of postoperative anastomotic leakage had no statistical difference between the two groups(10.2%vs.14.3%,P=0.32),but the severity degree of anastomotic leak in the stoma group was significantly lower than that in the non-stoma group(P=0.036).No statistically significant differences were found in the aspects of the incidence of intestinal obstruction,intra-abdominal hemorrhage,abdominal infection,wound infection and anastomotic stenosis between the two groups.The multivariate Logistic regression analysis showed that preoperative radiotherapy(OR5.05,95% CI 2.24-11.40,P<0.01)and anastomotic height(OR3.53,95% CI 1.46-8.50,P=0.005)were the independent risk factors for postoperative anastomotic leakage.Conclusion The prophylactic terminal ileum enterostomy can not decrease the occurrence rate of anastomotic leakage of laparoscopic radical resection of rectal cancer,therefore its advantage and disadvantage should be fully weighed in clinic and its routine application is not recommended.
引文
[1]CHEN W,ZHENG R,BAADE P D,et al.Cancer statistics in china,2015[J].CA,2016,66(2):115-132.
[2]PLATELL C,BARWOOD N,DORFMANN G,et al.The incidence of anastomotic leaks in patients undergoing colorectal surgery[J].Colorectal Dis,2007,9(1):71-79.
[3]DAVIS B,RIVADENEIRA DE.Complications of colorectal anastomoses:Leaks,strictures,and bleeding[J].Surg Clin North Am,2013,93(1):61-87.
[4]SNIJDERS H S,VAN DEN BROEK C B,WOUTERS MW,et al.An increasing use of defunctioning stomas after low anterior resection for rectal cancer.Is this the way to go?[J].Eur J Surg Oncol,2013,39(7):715-720.
[5]HANNA M H,VINCI A,PIGAZZI A.Diverting ileostomy in colorectal surgery:When is it necessary?[J].Langenbeck′s Arch Surg,2015,400(2):145-152.
[6]LIGHTNER A L,PEMBERTON J H.The role of temporary fecal diversion[J].Clinics in Colon Rectal surg,2017,30(3):178-183.
[7]RAHBARI NN,WEITZ J,HOHENBERGER W,et al.Definition and grading of anastomotic leakage following anterior resection of the rectum:A proposal by the international study group of rectal cancer[J].Surgery,2010,147(3):339-351.
[8]FROUWS M A,SNIJDERS H S,MALM S H,et al.Clinical relevance of a grading system for anastomotic leakage after low anterior resection:Analysis from a national cohort database[J].Dis Colon Rectum,2017,60(7):706-713.
[9]BONJER H J,DEIJEN C L,HAGLIND E.A randomized trial of laparoscopic versus open surgery for rectal cancer[J].N Engl J Med,2015,373(2):194.
[10]CORNISH J A,TILNEY H S,HERIOT A G,et al.Ameta-analysis of quality of life for abdominoperineal excision of rectum versus anterior resection for rectal cancer.[J].Ann Surg Oncol,2007,14(7):2056-2068.
[11]BEPPU N,MATSUBARA N,NODA M,et al.A′high tie′confers an increased risk of anastomotic leakage for lower rectal cancer surgery in patients treated with preoperative radiotherapy[J].Surg Tod,2015,45(5):600-605.
[12]CHUDE G G,RAYATE N V,PATRIS V,et al.Defunctioning loop ileostomy with low anterior resection for distal rectal cancer:Should we make an ileostomy as a routine procedure?A prospective randomized study[J].Hepato-gastroenterology,2008,55(86/87):1562-1567.
[13]裴炜,王锡山.低位直肠癌保肛术预防性回肠造口若干问题探讨[J].中华结直肠疾病电子杂志,2017,6(5):373-376.
[14]MRAK K,URANITSCH S,PEDROSS F,et al.Diverting ileostomy versus no diversion after low anterior resection for rectal cancer:A prospective,randomized,multicenter trial[J].Surgery,2016,159(4):1129-1139.
[15]SHIOMI A,ITO M,MAEDA K,et al.Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer:A propensity score matching analysis of 1 014consecutive patients[J].J Am Coll Surg,2015,220(2):186-194.
[16]CHIU A,CHAN H T,BROWN C J,et al.Failing to reverse a diverting stoma after lower anterior resection of rectal cancer[J].Am J Surg,2014,207(5):708-711.
[17]MATTHIESSEN P,HALLBOOK O,RUTEGARD J,et al.Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer:A randomized multicenter trial[J].Ann Surg,2007,246(2):207-214.
[18]姚宏伟,张忠涛.经腹及经肛全直肠系膜切除术吻合口漏发生的危险因素[J].中华胃肠外科杂志,2018,21(4):378-383.
[19]KANG C Y,HALABI W J,CHAUDHRY O O,et al.Risk factors for anastomotic leakage after anterior resection for rectal cancer[J].JAMA Surg,2013,148(1):65-71.
[20]TRENCHEVA K,MORRISSEY KP,WELLS M,et al.I-dentifying important predictors for anastomotic leak after colon and rectal resection:Prospective study on 616patients[J].Ann Surg,2013,257(1):108-113.
[21]QIN Q,MA T,DENG Y,et al.Impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection:Post hoc analysis of a randomized controlled trial[J].Dis Colon Rectum,2016,59(10):934-942.
[22]QU H,LIU Y,BI D S.Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer:A systematic review and meta-analysis[J].Surg Endosc,2015,29(12):3608-3617.
[2]PLATELL C,BARWOOD N,DORFMANN G,et al.The incidence of anastomotic leaks in patients undergoing colorectal surgery[J].Colorectal Dis,2007,9(1):71-79.
[3]DAVIS B,RIVADENEIRA DE.Complications of colorectal anastomoses:Leaks,strictures,and bleeding[J].Surg Clin North Am,2013,93(1):61-87.
[4]SNIJDERS H S,VAN DEN BROEK C B,WOUTERS MW,et al.An increasing use of defunctioning stomas after low anterior resection for rectal cancer.Is this the way to go?[J].Eur J Surg Oncol,2013,39(7):715-720.
[5]HANNA M H,VINCI A,PIGAZZI A.Diverting ileostomy in colorectal surgery:When is it necessary?[J].Langenbeck′s Arch Surg,2015,400(2):145-152.
[6]LIGHTNER A L,PEMBERTON J H.The role of temporary fecal diversion[J].Clinics in Colon Rectal surg,2017,30(3):178-183.
[7]RAHBARI NN,WEITZ J,HOHENBERGER W,et al.Definition and grading of anastomotic leakage following anterior resection of the rectum:A proposal by the international study group of rectal cancer[J].Surgery,2010,147(3):339-351.
[8]FROUWS M A,SNIJDERS H S,MALM S H,et al.Clinical relevance of a grading system for anastomotic leakage after low anterior resection:Analysis from a national cohort database[J].Dis Colon Rectum,2017,60(7):706-713.
[9]BONJER H J,DEIJEN C L,HAGLIND E.A randomized trial of laparoscopic versus open surgery for rectal cancer[J].N Engl J Med,2015,373(2):194.
[10]CORNISH J A,TILNEY H S,HERIOT A G,et al.Ameta-analysis of quality of life for abdominoperineal excision of rectum versus anterior resection for rectal cancer.[J].Ann Surg Oncol,2007,14(7):2056-2068.
[11]BEPPU N,MATSUBARA N,NODA M,et al.A′high tie′confers an increased risk of anastomotic leakage for lower rectal cancer surgery in patients treated with preoperative radiotherapy[J].Surg Tod,2015,45(5):600-605.
[12]CHUDE G G,RAYATE N V,PATRIS V,et al.Defunctioning loop ileostomy with low anterior resection for distal rectal cancer:Should we make an ileostomy as a routine procedure?A prospective randomized study[J].Hepato-gastroenterology,2008,55(86/87):1562-1567.
[13]裴炜,王锡山.低位直肠癌保肛术预防性回肠造口若干问题探讨[J].中华结直肠疾病电子杂志,2017,6(5):373-376.
[14]MRAK K,URANITSCH S,PEDROSS F,et al.Diverting ileostomy versus no diversion after low anterior resection for rectal cancer:A prospective,randomized,multicenter trial[J].Surgery,2016,159(4):1129-1139.
[15]SHIOMI A,ITO M,MAEDA K,et al.Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer:A propensity score matching analysis of 1 014consecutive patients[J].J Am Coll Surg,2015,220(2):186-194.
[16]CHIU A,CHAN H T,BROWN C J,et al.Failing to reverse a diverting stoma after lower anterior resection of rectal cancer[J].Am J Surg,2014,207(5):708-711.
[17]MATTHIESSEN P,HALLBOOK O,RUTEGARD J,et al.Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer:A randomized multicenter trial[J].Ann Surg,2007,246(2):207-214.
[18]姚宏伟,张忠涛.经腹及经肛全直肠系膜切除术吻合口漏发生的危险因素[J].中华胃肠外科杂志,2018,21(4):378-383.
[19]KANG C Y,HALABI W J,CHAUDHRY O O,et al.Risk factors for anastomotic leakage after anterior resection for rectal cancer[J].JAMA Surg,2013,148(1):65-71.
[20]TRENCHEVA K,MORRISSEY KP,WELLS M,et al.I-dentifying important predictors for anastomotic leak after colon and rectal resection:Prospective study on 616patients[J].Ann Surg,2013,257(1):108-113.
[21]QIN Q,MA T,DENG Y,et al.Impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection:Post hoc analysis of a randomized controlled trial[J].Dis Colon Rectum,2016,59(10):934-942.
[22]QU H,LIU Y,BI D S.Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer:A systematic review and meta-analysis[J].Surg Endosc,2015,29(12):3608-3617.