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中华结直肠疾病电子杂志 ›› 2018, Vol. 07 ›› Issue (02) : 156 -161. doi: 10.3877/cma.j.issn.2095-3224.2018.02.011

所属专题: 文献

论著

腹腔镜直肠前切除术后吻合口漏发生的危险因素及其防治措施
陈智1, 张轲2, 芮元祎2, 徐琳2, 刘超2, 易波2, 李建科1, 燕锦3,()   
  1. 1. 646000 泸州,西南医科大学
    2. 610000 成都,四川省肿瘤医院/电子科技大学医学院附属肿瘤医院胃肠外科
    3. 646000 泸州,西南医科大学;610000 成都,四川省肿瘤医院/电子科技大学医学院附属肿瘤医院胃肠外科
  • 收稿日期:2017-11-27 出版日期:2018-04-25
  • 通信作者: 燕锦

Risk factors, prevention and treatment of anastomotic leakage after laparoscopic anterior resection of rectum

Zhi Chen1, Ke Zhang2, Yuanyi Rui2, Lin Xu2, Chao Liu2, Bo Yi2, Jianke Li1, Jin Yan3,()   

  1. 1. Southwest Medical University, Luzhou 646000, China
    2. Department of Gastrointestinal Surgery, Sichuan Cancer Hospital /Cancer Hospital Affiliate to School of Medicine, UESTC, Chendu 610041, China
    3. Southwest Medical University, Luzhou 646000, China; Department of Gastrointestinal Surgery, Sichuan Cancer Hospital /Cancer Hospital Affiliate to School of Medicine, UESTC, Chendu 610041, China
  • Received:2017-11-27 Published:2018-04-25
  • Corresponding author: Jin Yan
  • About author:
    Corresponding author: Yan Jin, Email:
引用本文:

陈智, 张轲, 芮元祎, 徐琳, 刘超, 易波, 李建科, 燕锦. 腹腔镜直肠前切除术后吻合口漏发生的危险因素及其防治措施[J/OL]. 中华结直肠疾病电子杂志, 2018, 07(02): 156-161.

Zhi Chen, Ke Zhang, Yuanyi Rui, Lin Xu, Chao Liu, Bo Yi, Jianke Li, Jin Yan. Risk factors, prevention and treatment of anastomotic leakage after laparoscopic anterior resection of rectum[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2018, 07(02): 156-161.

目的

通过对结直肠漏评分(CLS)系统在腹腔镜直肠前切除术中的运用来探讨发生吻合口漏(AL)的相关因素及吻合口漏防治的经验分享。

方法

纳入2014年1月至2017年6月期间于四川省肿瘤医院行腹腔镜直肠前切除术的患者,采用CLS评分系统来分析术后发生吻合口漏的危险因素,总结腹腔镜直肠前切除术并发AL的防治经验。

结果

共582例患者纳入本研究,术后发生吻合口漏43例(7.3%),其中有症状吻合口漏29例(4.9%)。单因素分析显示:性别、ASA麻醉分级、不健康个人史、新辅助治疗、吻合口距肛缘距离、附加的手术程序、术中失血与输血及手术时间与腹腔镜直肠前切除术后吻合口漏的发生相关(均P<0.05)。多因素回归分析显示:术前麻醉分级ASA(OR 3.173,95%CI:1.848~5.448)、不健康生活行为(OR 3.898,95%CI:2.144~7.085)、吻合口与肛缘的距离(OR 1.718,95%CI:1.3605~2.262)、附加的手术程序(OR 11.353,95%CI:3.387~38.058)、手术时间(OR 1.622,95%CI:1.144~2.301)、术中保护性造口(OR 0.024,95%CI:0.005~0.123)、改良技术的运用与否(OR 0.271,95%CI:0.091~0.803)是影响术后吻合口漏发生的独立危险因素(均P<0.05)。CLS评分系统对腹腔镜直肠前切除术后吻合口漏的发生有良好的预测作用,CLS 12分可以作为腹腔镜直肠前切除术后吻合口漏发生的高风险临界预测值。

结论

对于腹腔镜直肠前切除术后CLS评分>12分,应警惕术后吻合口漏的发生,运用相关腹腔镜改良技术可以有效防治AL的发生。

Objective

To explore the related factors about the occurrence of anastomotic leakage by Colorectal Leakage Scoring System (CLS) in laparoscopic anterior resection and share the experience on the prevention and treatment of anastomotic leakage in our department.

Methods

Clinical data of 582 rectal cancer patients who underwent elective laparoscopic anterior resection from January 2014 to June 2017 at Affiliated Sichuan Tumor Hospital of Electronic Science and Technology University were retrieved. Demographic data were collected in CLS to evaluate the risk of anastomotic leakage.

Results

Of all the 582 enrolled patients, the cases of anastomotic leakage and symptomatic anastomotic leakage were 43 (7.3%) and 29 (4.9%) respectively. In univariate analysis, gender, American Society of Anesthesiologists (ASA), intoxication, neoadjuvant therapy, distance between anastomosis and anal verge, additional procedures, blood loss (mL) and blood transfusion, duration of operation were significantly associated with postoperative anastomotic leak (P<0.05) . Multivariate analysis showed that ASA (OR 3.173, 95%CI: 1.848~5.448) , intoxication (OR 3.898, 95%CI: 2.144~7.085), distance between anastomosis and anal verge (OR 1.718, 95%CI: 1.3605~2.262) , additional procedures (OR 11.353, 95%CI: 3.387~38.058) , duration of operation (OR 1.622, 95%CI: 1.144~2.301) , protective enterostomy (OR 0.024, 95%CI: 0.005~0.123) and the application of modified pelvic reconstruction or not (OR 0.271, 95%CI: 0.091~0.803) were the independent risk factors of anastomotic leak following laparoscopic anterior resection for the rectal cancer. The CLS has a good value of predicting anastomotic leakage after laparoscopic anterior resection of rectal cancer. CLS scored 12 could be considered as a high critical risk predictive value of anastomotic leakage after laparoscopic anterior resection.

Conclusion

For patients with the CLS score of more than 12 after laparoscopic anterior resection, the occurrence of postoperative anastomotic leakage should be monitored. Modified laparoscopic technique can effectively prevent the occurrence of AL.

表1 吻合口漏发生的单因素分析(例)
表2 吻合口漏发生的多因素分析
表4 诊断价值
图1 ROC曲线。关于CLS评分系统预测吻合口漏发生概率的有效性分析的受试者工作特征曲线(ROC)。吻合口漏发生率的AUC即曲线下面积0.869(95%CI:0.799~0.940;标准误:0.036)。(通常认为曲线下面积在0.5~0.7之间有低预测价值,在0.7~0.9之间有中度的预估价值,大于0.9是有很好的预估价值。)
表3 概率预测表
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