直肠癌保肛手术后吻合口漏的危险因素分析
摘要
直肠癌(rectal cancer)是我国常见的恶性肿瘤,占消化道恶性肿瘤第二位,我国直肠癌中低位直肠癌所占比例高,约占75%,多数直肠癌在直肠指诊时可见触及,青年人(<30岁)比例较高,约占15%。直肠癌根治性切除术后5年生存率约为50%~70%。Dukes A期病人癌根治性切除术后5年生存率可达90%以上。直肠癌的外科治疗最早开始于十八世纪初。经历了3个世纪,直肠癌手术有了很大的发展。本文就直肠癌的治疗进展进行综述。吻合口漏是直肠癌手术后常见的并发症。本文回顾性分析了自2002年1月～2006年12月在吉林大学附属第三医院(中日联谊医院)普通外科对317例直肠癌行保肛手术,对术后资料进行回顾性统计分析,探讨直肠癌保肛手术术后吻合口漏的发生率和相关危险因素,及吻合口漏的预防、诊断和治疗,总结经验,以提高直肠癌的治疗水平。
Objective: To investigate the anastomotic leakage rate risk factors and treatment methods after anus-preserving for rectal carcinoma.
Methods: Three hundred and fourteen patients with rectal cancers (3~14 cm from anal verge) underwent anus-preserving for rectal carcinoma with stapling technique, data were analyzed and compared retrospectively.
Results: Anastomotic leakage rate was 7.6%, in which 95.8% (23/24)of patents were treated successfully with tube irrigation alone, 4.2% (1/24) received transverse colostomy after failure of conservative treatment. Age, distance of tumor from anal verge, low albumen, rectal carcinoma with intestinal obstruction, and diabetes were related to the leakage (P<0.05 or 0.01), while sex was not related to leakage.
Conclusion: Anastomotic leakage is one of the commonest intraoperative complications after anus-preserving operation for rectal carcinoma; low rectal cancers will have more anastomotic leakage rate; The majority of anastomotic leakage can be treated successfully by tran drainage tube irrigation alone, laparotomy and proximal colostomy is necessary for a few cases. We suggest giving patients enteral nutrition after anastomotic leakage as early as possible.
Objective: To investigate the anastomotic leakage rate risk factors and treatment methods after anus-preserving for rectal carcinoma.
Methods: Three hundred and fourteen patients with rectal cancers (3~14 cm from anal verge) underwent anus-preserving for rectal carcinoma with stapling technique, data were analyzed and compared retrospectively.
Results: Anastomotic leakage rate was 7.6%, in which 95.8% (23/24)of patents were treated successfully with tube irrigation alone, 4.2% (1/24) received transverse colostomy after failure of conservative treatment. Age, distance of tumor from anal verge, low albumen, rectal carcinoma with intestinal obstruction, and diabetes were related to the leakage (P<0.05 or 0.01), while sex was not related to leakage.
Conclusion: Anastomotic leakage is one of the commonest intraoperative complications after anus-preserving operation for rectal carcinoma; low rectal cancers will have more anastomotic leakage rate; The majority of anastomotic leakage can be treated successfully by tran drainage tube irrigation alone, laparotomy and proximal colostomy is necessary for a few cases. We suggest giving patients enteral nutrition after anastomotic leakage as early as possible.
引文
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1. 胡从兵, 陈洪俊, 刘永安 双吻合器在超低位直肠癌保肛术中的应用 长江大学学报, 2006,3(4):284.
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3. Wolmark N, Cruz I, Redmond CK, Fisher B, Fisher ER. Tumor size and regional lymph node metastasis in colorectal cancer. Cancer, 1983;51:1315-1322.
4. 马雅, 孟繁龄, 黄金颖, 李阴棠, 刘建伟. 大肠癌病理形态学特点与淋巴结转移关系的研究. 中国肛肠病杂志, 1995:(6):11-16.
5. 殷志韬, 孙纪元, 吴威等. 直肠癌淋巴结转移影响因素的临床研究. 中国实用外科杂志, 2004,24(3):161-162.
6. 蒋会勇, 卿三华. 大肠癌淋巴结转移相关因素研究现况. 世界华人消化杂志, 1999;7(1):982-984.
7. 彭海霞, 周林法, 徐明, 钱爱华, 王赛玉. 大肠癌病理分型、浸润深度与淋巴结转移相关关系的研究 现代医 药卫生2005,21(11):1319.
8. 韩洪秋, 刘彤, 赵丽中, 戚峰, 王鹏志. 国际新的 TNM 分期对分析结直肠癌预后的临床意义. 中华医学杂志. 2006,86(12): 820.
9. SLATTERYML, KERBENRA. The impact of family history ofcolon cancer on survival after diagnosis with colon cancer [J]. In J Epidemiol, 1995,24(5):888-896.
10. KUNEGA, KUNES, WATSONLF. The effect of family history of cancer, religion, parity and migrant status on survival in colorectal cancer. The Melbourne colorectal cancer study [J]. EurJ Cancer1992, 28A(8-9):1484-1487.
11. CONIOM, BONELLIL, MARTNESH, et al. Colorectal cancer in patients with family history [J]. In J Colorectal Dis, 1987,2(4): 190-192.
12. 李力人, 万德森, 潘志忠, 周志伟. 中国肿瘤. 大肠癌淋巴结转移预测模型的建立, 2006,15(12):878.
13. KNIGHT C D, GRIFFEN F D. An improved technique for low anterior resection of the rectum using EEA staper [J]. Surgery, 1980,88:7102714.
14. 柏木宏, 小泽昭人, 仙波真吾, 他. 局部切除术の适应と手术成绩 [J]. 外科, 1997,59(5):511-515.
15. Killingback M. Local excision of carcinoma of the rectum: indications [J]. World J Surg, 1992,16(3):437-446.
16. 寺本龙生, 渡边昌彦, 北岛政树. 低位直肠肿瘤性病变の鉴别诊断と治疗方针 [J]. 外科治疗, 1996,74(1):1-6.
17. 畿本浩晴, 荒木青三, 唐宇飞, 他. 早期直肠癌に对する EMR (endoscopic mucosal resection) [J]. 临 床 外 科 , 1998,53(4): 413-418.
18. 本浩晴, 荒木青三, 唐宇飞, et al. 临床外科, 1998.53(4):413.
19. Rosenberg N, Brunswick NJ. Submucosal saline wheals as safety factor in fulguration of rectal and sigmoidalpolyp [J]. Arch Surg, 1995,70(1):120.
20. Buess G, Kipfmueller K, Hack K, et al. Surg Endosc, 1998,2:71.
21. 小平进, 八尾恒良, 中村恭, 他. SM 细分类がらみた转移大肠SM 癌の实态 [J]. 胃と肠, 1994,29(11):1137-1142.
22. Buess G, Kip Mueller K, Hack D, et al. Technique of transanal endoscopic microsurgery [J]. Surg Endosc, 1988,2(1):71-75.
23. Heberer G, Denecke H, Demmel N, et al. Local proce-dure in the management of rectal cancer. World J Surg, 1987,11(4):499-503.
24. 柏木宏, 小泽昭人, 仙波真吾, 他. 局部切除术の适应と手术成 绩. 外科, 1997,59(5):511-515.
25. 前田耕太郎, 丸田守人, 内海俊明, et al. 临床外科, 1998, 53(4):419.
26. Killingback M. Local excision of carcinoma of the rectum: indications [J]. World J Surg, 1992,16(3):437-446.
27. Shoji BT, Becher JM. Colorectal disease in the elder patient. Surg Clin North Am, 1994,74(2):293-295.
28. 安泽武, 王茹, 宋少柏, 等. 老年结直肠癌的外科治疗. 中国医师杂志, 2003,5(6):772-773.
29. 叶松, 徐友魁.结、直肠癌并发急性肠梗阻 65 例临床分析, 锦州医学院学报, 2003,24(4):62-63.
30. 何维杰, 张永明. 左半结肠急症一期治疗体会. 腹部外科, 1998,11(6):268.
31. Menthes B, Buses G, Shaeter D, et al. Dis Colon Rectum, 1996,39:886.
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