切换至 "中华医学电子期刊资源库"

中华结直肠疾病电子杂志 ›› 2022, Vol. 11 ›› Issue (06) : 489 -496. doi: 10.3877/cma.j.issn.2095-3224.2022.06.007

论著

吻合口加固缝合与盆底腹膜重建在腹腔镜直肠癌前切除术中的临床应用研究
姜慧员1, 白文启1,(), 江波1, 王立春1, 曹海磊1   
  1. 1. 030013 太原,山西省肿瘤医院/中国医学科学院肿瘤医院山西医院/山西医科大学附属肿瘤医院结直肠肛门外科
  • 收稿日期:2021-05-23 出版日期:2022-12-25
  • 通信作者: 白文启
  • 基金资助:
    中央引导地方科技发展资金项目(YDZJSX2021B0416); 山西省卫生健康委科研课题(2021076)

Clinical application of anastomotic reinforcement suture and pelvic peritoneal reconstruction in laparoscopic anterior resection of rectal cancer

Huiyuan Jiang1, Wenqi Bai1(), Bo Jiang1, Lichun Wang1, Hailei Cao1   

  1. 1. Department of Colorectal and Anal Surgery, Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China
  • Received:2021-05-23 Published:2022-12-25
  • Corresponding author: Wenqi Bai
引用本文:

姜慧员, 白文启, 江波, 王立春, 曹海磊. 吻合口加固缝合与盆底腹膜重建在腹腔镜直肠癌前切除术中的临床应用研究[J/OL]. 中华结直肠疾病电子杂志, 2022, 11(06): 489-496.

Huiyuan Jiang, Wenqi Bai, Bo Jiang, Lichun Wang, Hailei Cao. Clinical application of anastomotic reinforcement suture and pelvic peritoneal reconstruction in laparoscopic anterior resection of rectal cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2022, 11(06): 489-496.

目的

探讨吻合口加固缝合与盆底腹膜重建在腹腔镜直肠癌前切除术中临床应用价值。

方法

选择2019年6月~2021年6月间山西省肿瘤医院结直肠肛门外科收治的260例行腹腔镜直肠癌前切除术治疗患者为研究对象。采用随机数字表法将患者随机分为两组,各130例。观察组为吻合口加固缝合及盆底腹膜重建组,对照组为常规吻合组。观察手术及术后恢复情况,并对腹腔镜直肠癌前切除术后吻合口漏的危险因素进行分析。

结果

两组共21例患者发生吻合口漏,吻合口漏发生率为8.08%(21/260),其中观察组吻合口漏4例,均为B级漏;对照组吻合口漏17例,其中B级漏10例,C级漏7例,两组在吻合口漏方面差异有统计学意义(χ2=8.755,P=0.003)。观察组均未行二次手术,对照组9例行二次手术,两组差异有统计学意义(χ2=9.409,P=0.002)。观察组手术时间长于对照组,差异有统计学意义(t=18.804,P<0.001)。观察组发生粘连性肠梗阻2例,对照组发生粘连性肠梗阻8例,差异有统计学意义(χ2=4.262,P=0.039)。单因素分析结果显示:性别、糖尿病、高血压、NRS 2002评分、肿瘤长径、肿瘤距肛缘距离、手术时间、直线切割闭合器使用次数、淋巴结转移情况、吻合口是否加固缝合是影响腹腔镜直肠癌前切除术后吻合口漏的相关因素(P<0.05)。多因素分析结果显示:吻合口未加固缝合(β=2.775,OR=16.042,95%CI:2.186~117.754)、NRS 2002评分≥3分(β=3.918,OR=50.298,95%CI:10.836~233.484)、肿瘤距肛缘距离≤5 cm(β=1.858,OR=6.409,95%CI:1.410~29.129)是影响腹腔镜直肠癌前切除术后吻合口漏的独立危险因素。

结论

吻合口加固缝合及盆底腹膜重建可明显减少吻合口漏的发生,缓解吻合口漏发生的后果,减少二次手术率,同时可预防术后粘连性肠梗阻的发生,值得推广应用。

Objective

To explore the clinical value of anastomotic reinforcement suture and pelvic peritoneal reconstruction in laparoscopic anterior resection of rectal cancer.

Methods

260 patients who underwent laparoscopic anterior resection of rectal cancer in the Department of Colorectal and Anal Surgery of Shanxi Province Cancer Hospital from June 2019 to June 2021 were selected as the study subjects. Patients were randomly divided into two groups with 130 cases in each group by random number table method. The observation group was anastomotic reinforcement suture and pelvic peritoneal reconstruction group, and the control group was routine anastomosis group. Observation indicators: intraoperative and postoperative situations; analysis of risk factors of anastomotic leakage after laparoscopic anterior resection of rectal cancer.

Results

A total of 21 patients in the two groups had anastomotic leakage, and the incidence of anastomotic leakage was 8.08% (21/260). There were 4 cases of anastomotic leakage in the observation group, all of which were grade B leakage, and 17 cases of anastomotic leakage in the control group, including 10 cases of grade B leakage and 7 cases of grade C leakage. The two groups were statistically significant (χ2=8.755, P=0.003). No secondary operation was performed in the observation group, and 9 cases in the control group. The two groups were statistically significant (χ2=9.409, P=0.002). The operation time of the observation group was longer than that of the control group, the difference was statistically significant (t=18.804, P=0.001). There were 2 cases of adhesive intestinal obstruction in the observation group and 8 cases of adhesive intestinal obstruction in the control group, the difference was statistically significant (χ2=4.262, P=0.039). The results of univariate analysis showed that gender, diabetes, hypertension, NRS 2002 score, tumor length, tumor distance from anal margin, operation time, times of using linear cutting closure device, lymph node metastasis, anastomotic reinforcement suture is a related factor affecting anastomotic leakage after laparoscopic anterior resection of rectal cancer (P<0.05). Multivariate analysis showed that the anastomotic leakage after laparoscopic anterior resection of rectal cancer was affected by the independent risk factors of anastomotic leakage after laparoscopic anterior resection of rectal cancer, including unreinforced anastomotic suture (β=2.775, OR=16.042, 95%CI: 2.186~117.754), NRS 2002 score ≥3 (β=3.918, OR=50.298, 95%CI: 10.836~233.484), and distance from tumor to anal margin ≤5 cm (β=1.858,OR=6.409,95%CI: 1.410~29.129).

Conclusions

Anastomotic reinforcement and suture and pelvic peritoneal reconstruction can significantly reduce the occurrence of anastomotic leakage, alleviate the consequences of anastomotic leakage, reduce the rate of secondary surgery, and prevent the occurrence of postoperative adhesive intestinal obstruction, which is worthy of promotion and application.

表1 吻合口加固缝合及盆底腹膜重建组与常规吻合组患者一般资料的比较(
xˉ
±s,例)
图1 吻合口加固手术步骤。1A:加固吻合口右侧“猫耳朵”区域;1B:加固吻合口前壁;1C:加固吻合口左侧“猫耳朵”区域;1D:加固吻合口左侧壁;1E:加固吻合口后壁;1F:加固吻合口右侧壁
图2 盆底腹膜重建步骤。2A:重建左侧盆底腹膜;2B:重建右侧盆底腹膜;2C:重建肠系膜下血管根部腹膜
表2 260例直肠癌患者发生吻合口漏单因素分析(例)
表3 260例直肠癌患者发生吻合口漏多因素分析
表4 吻合口加固缝合及盆底腹膜重建组与常规吻合组患者手术及术后情况比较[
xˉ
±s,例(%)]
[1]
Hida K, Okamura R, Sakai Y, et al. Open versus laparoscopic surgery for advanced low rectal cancer:a large, multicenter, propensity score matched cohort study in Japan[J]. Ann Surg, 2018, 268(2): 318-324.
[2]
Kinugasa T, Nagasu S, Murotani K, et al. Analysis of risk factors for anastomotic leakage after lower rectal cancer resection, including drain type: a retrospective single center study[J]. BMC Gastroenterol, 2020, 20(1): 315.
[3]
Leo E, Belli F, Miceli R, et al. Distal clearance margin of 1 cm or less: a safe distance in lower rectum cancer surgery[J]. Int J Colorectal Dis, 2009, 24(3): 317-322.
[4]
Kawada K, Sakai Y. Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis[J]. World J Gastroenterol, 2016, 22(25): 5718.
[5]
Frye J, Bokey EL, Chapuis PH, et al. Anastomotic leakage after resection of colorectal cancer generates prodigious use of hospital resources[J]. Colorectal Dis, 2009, 11(9): 917-920.
[6]
郑民华, 马君俊. 腹腔镜低位直肠癌切除保肛术的实践与技术[J/CD]. 中华普外科手术学杂志: 电子版, 2012, 6(1): 7-12.
[7]
中华医学会外科学分会结直肠外科学组. 中国直肠癌手术吻合口漏诊断、预防及处理专家共识(2019版)[J]. 中华胃肠外科杂志, 2019, 22(3): 201-206.
[8]
Hüttner FJ, Probst P, Mihaljevic A, et al. Ghost ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer(DRKS00013997): protocol for a randomised controlled trial[J]. BMJ Open, 2020, 10(10): e038930.
[9]
Sprenger T, Beißbarth T, Sauer R, et al. Long-term prognostic impact of surgical complications in the German Rectal Cancer Trial CAO/ARO/AIO-94[J]. Br J Surg, 2018, 105(11): 1510-1518.
[10]
Shen Y, Yang T, Yang J, et al. Intraoperative indocyanine green fluorescence angiography to prevent anatomotic leak after low anterior for rectal:a meta-analysis[J]. ANZ J Surg, 2020, 90(11): 2193-2200.
[11]
姚宏伟, 许峰铭, 安勇博, 等. 直肠癌术后吻合口漏的早期诊断和预防研究进展[J]. 中华胃肠外科杂志, 2021, 24(6): 480-486.
[12]
骆洋, 俞旻皓, 钟鸣, 等. 腹腔镜低位直肠癌前切除术后吻合口漏危险因素分析及其风险评估量表应用价值的多中心回顾性研究[J]. 中华消化外科杂志, 2021, 20(12): 1342-1350.
[13]
姜慧员, 刘海义, 江波, 等. 保留左结肠动脉在腹腔镜直肠癌前切除术中的临床应用和疗效观察[J/OL]. 中华结直肠疾病电子杂志, 2021, 10(1): 70-75.
[14]
黄海斌, 罗世坤, 张凯, 等. 留置肛管预防直肠癌术后吻合口漏的临床研究[J].中华普通外科杂志, 2018, 33(1): 38-40.
[15]
Kawada K, Hasegawa S, Hida K, et al. Risk factors foranastomotic leakage after laparoscopic low anterior resectionwith DST anastomosis[J]. Surg Endosc, 2014, 28(5): 2988-2995.
[16]
Chun LJ, Haigh PI, Tam MS, et al. Defunctioning loop ileostomy for pelvic anastomoses:predictors of morbidity and nonclosure[J]. Diseases of the Colon & Rectum, 2012, 55(2): 167-174.
[17]
骆洋, 俞旻皓, 陈建军, 等. 倒刺缝线在腹腔镜直肠癌根治术中加固吻合口的应用价值[J]. 中华消化外科杂志, 2020, 19(11): 1205-1210.
[18]
何义仁, 朱志强, 刘少军, 等. 吻合口加固缝合预防腹腔镜直肠癌根治术后发生吻合口漏的前瞻性随机对照试验[J]. 中华胃肠外科杂志, 2018, 21(4): 431-436.
[19]
Kim CW, Baek SJ, Hur H, et al. Anastomotic leakage after low anterior resection for rectal cancer is different between minimally invasive surgery and open surgery[J]. Ann Surg, 2016, 263(1): 130-137.
[20]
段耀星, 王赫, 王玲, 等. 加速康复外科联合关闭盆底腹膜在机器人直肠癌手术中的短期临床疗效[J]. 机器人外科学杂志(中英文), 2021, 2(1): 38-45.
[21]
Wang ZK, Xu J, Shang CC, et al. Clinical significance of pelvic peritonization in laparoscopic dixon surgery[J]. Chin Med J (Engl), 2018, 131(3): 289-294.
[22]
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.
[23]
付正伟, 王丽霞, 张振宇, 等. 盆底腹膜重建在3D腹腔镜辅助直肠前切除术中的价值[J/CD].中华腔镜外科杂志(电子版), 2018, 11(2): 94-97.
[1] 王振宁, 杨康, 王得晨, 邹敏, 归明彬, 王雅楠, 徐明. 机器人与腹腔镜手术联合经自然腔道取标本对中低位直肠癌患者远期疗效比较[J/OL]. 中华普通外科学文献(电子版), 2024, 18(06): 437-442.
[2] 赵丽霞, 王春霞, 陈一锋, 胡东平, 张维胜, 王涛, 张洪来. 内脏型肥胖对腹腔镜直肠癌根治术后早期并发症的影响[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 35-39.
[3] 吴晖, 佴永军, 施雪松, 魏晓为. 两种解剖入路下行直肠癌侧方淋巴结清扫的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 40-43.
[4] 周世振, 朱兴亚, 袁庆港, 刘理想, 王凯, 缪骥, 丁超, 汪灏, 管文贤. 吲哚菁绿荧光成像技术在腹腔镜直肠癌侧方淋巴结清扫中的应用效果分析[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 44-47.
[5] 徐逸男. 不同术式治疗梗阻性左半结直肠癌的疗效观察[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 72-75.
[6] 李代勤, 刘佩杰. 动态增强磁共振评估中晚期低位直肠癌同步放化疗后疗效及预后的价值[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 100-103.
[7] 庄宝雄, 邓海军. 单孔+1腹腔镜直肠癌侧方淋巴结清扫术[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 601-601.
[8] 郑民华, 蒋天宇, 赵轩, 马君俊. 中国腹腔镜直肠癌根治术30年发展历程与未来[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 591-595.
[9] 池畔, 黄胜辉. 中国腹腔镜直肠癌根治术30年来的巨大进步[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 596-600.
[10] 李明, 屠松, 闫鹏, 钱军, 高鹏程, 许文山, 杨发英, 胡振涛, 单永玮. 应用前列腺电切镜引导置管治疗直肠低位吻合口漏研究[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 603-606.
[11] 严虹霞, 王晓娟, 张毅勋. 2 型糖尿病对结直肠癌患者肿瘤标记物、临床病理及预后的影响[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 483-487.
[12] 赵磊, 刘文志, 林峰, 于剑, 孙铭骏, 崔佑刚, 张旭, 衣宇鹏, 于宝胜, 冯宁. 深部热疗在改善结直肠癌术后辅助化疗副反应及生活质量中的作用研究[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 488-493.
[13] 陈杰, 武明胜, 李一金, 李虎, 向源楚, 荣新奇, 彭健. 低位直肠癌冷冻治疗临床初步分析[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 494-498.
[14] 黄海洋, 邝永龙, 陈嘉胜. 基层医院结直肠肿瘤经自然腔道取标本手术30 例分析[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 510-518.
[15] 王灿, 樊昊, 张卫, 于冠宇. LARS 评分的研制回顾与应用现状[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 519-523.
阅读次数
全文


摘要