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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2023, Vol. 12 ›› Issue (02) : 145 -151. doi: 10.3877/cma.j.issn.2095-3224.2023.02.009

论著

吻合口加强对中低位直肠癌患者手术疗效与短期并发症的影响：倾向性评分匹配研究
封益飞1, 季东健1, 张悦1, 张川1, 张冬生1, 唐俊伟1, 孙跃明1,†()   
  1. 1. 210029　南京医科大学第一附属医院结直肠外科
  • 收稿日期:2022-08-05 出版日期:2023-04-25
  • 通信作者: 孙跃明
  • 基金资助:
    江苏省自然科学基金(BK20211378)

Effects of anastomotic reinforcement on surgical outcomes and short-term complications in patients with mid-low rectal cancer: a propensity score matching study

Yifei Feng1, Dongjian Ji1, Yue Zhang1, Chuan Zhang1, Dongsheng Zhang1, Junwei Tang1, Yueming Sun1,†()   

  1. 1. Department of Colorectal Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
  • Received:2022-08-05 Published:2023-04-25
  • Corresponding author: Yueming Sun
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引用本文：

封益飞, 季东健, 张悦, 张川, 张冬生, 唐俊伟, 孙跃明. 吻合口加强对中低位直肠癌患者手术疗效与短期并发症的影响：倾向性评分匹配研究[J/OL]. 中华结直肠疾病电子杂志, 2023, 12(02): 145-151.

Yifei Feng, Dongjian Ji, Yue Zhang, Chuan Zhang, Dongsheng Zhang, Junwei Tang, Yueming Sun. Effects of anastomotic reinforcement on surgical outcomes and short-term complications in patients with mid-low rectal cancer: a propensity score matching study[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2023, 12(02): 145-151.

目的

比较中低位直肠癌患者行直肠癌根治术中吻合口加强（AR）与吻合口未加强（AU）的手术疗效和术后短期并发症。

方法

采用倾向性评分匹配法，对2019年1月至2021年12月期间施行直肠癌根治术的498例中低位直肠癌患者进行AR与AU的匹配，比较两组手术时间、术中失血量、造口率、吻合口漏率、吻合口出血率、肠功能恢复时间及术后住院时间。

结果

本研究共238名患者被配对（每组119名患者），两组的临床特征具有可比性。与AU组相比，AR组的手术时间更长（95.6±13.5 min vs. 84.3±15.2 min，t=6.07，P＜0.001）、造口和术中预防性造口的比例更低（5.88% vs. 22.69%，χ2=13.73，P＜0.001；5.04% vs. 16.81%，χ2=8.46，P=0.004）、症状性吻合口漏（B/C级）及吻合口出血的发生率更低（3.36% vs. 11.76%，χ2=13.73，P=0.014；3.36% vs. 17.65%，χ2=12.92，P＜0.001）。而两组在术中失血量、肠道功能恢复及术后住院时间上差异没有统计学意义。此外，男性、BMI≥24 kg/m2、糖尿病、新辅助放化疗、距离肛缘＜5 cm是吻合口漏的独立危险因素。AR能够显著减少高危患者（危险因素≥2个）吻合口漏的发生（χ2=5.10，P=0.024），而在低危患者（危险因素＜2个）中差异没有统计学意义。

结论

中低位直肠癌术中行吻合口加强在减少造口率、降低吻合口漏和吻合口出血方面具有显著优势，尤其在高危患者中获益明显。

关键词: 直肠肿瘤, 造瘘术, 吻合口加强, 吻合口漏, 倾向性评分匹配
Objective

To compare the surgical efficacy and short-term postoperative complications of anastomotic reinforcement (AR) and anastomotic unreinforcement (AU) in radical resection of middle and low rectal cancer.

Methods

The propensity score matching method was used to match AR and AU in 498 patients with mid-low rectal cancer who underwent radical resection for rectal cancer from January 2019 to December 2021. The surgical effects and short-term postoperative complications were compared between the two groups.

Results

A total of 238 patients were paired (119 patients in each group). The clinical characteristics of the two groups were similar. Compared with AU Group, AR group had longer operation time (95.6±13.5 min vs. 84.3±15.2 min, t=6.07, P＜0.001), lower proportion of stoma and intraoperative preventive stoma (5.88% vs. 22.69%, χ2=13.73, P＜0.001; 5.04% vs. 16.81%, χ2=8.46, P=0.004), lower incidence of symptomatic anastomotic leakage (Grade B/C) and anastomotic bleeding (3.36% vs. 11.76%, χ2=13.73, P=0.014; 3.36% vs. 17.65%, χ2=12.92, P＜0.001). There was no difference in intraoperative blood loss, intestinal function recovery and postoperative hospital stay between the two groups. In addition, male, BMI≥24 kg/m2, diabetes, neoadjuvant chemotherapy, distance＜5 cm from the anal verge were independent risk factors for anastomotic leakage. AR significantly reduced the incidence of anastomotic leakage in high-risk patients (risk factors ≥2) (χ2=5.10, P=0.024), while there was no difference in low-risk patients (risk factors <2).

Conclusion

Intraoperative anastomotic reinforcement for middle and low rectal cancer has significant advantages in reducing stoma rate, anastomotic leakage and anastomotic bleeding, especially in high-risk patients.

Key words: Rectal neoplasms, Ostomy, Anastomotic reinforcement, Anastomotic leakage, Propensity score matching
表1 患者的一般临床资料
观察指标 中位数（范围）/患者例数（%）
年龄（岁） 62（27~87）
性别
男 301（60.4）
女 197（39.6）
BMI（kg/m2） 21.8（14.8~32.3）
糖尿病
有 33（6.6）
无 465（93.4）
新辅助治疗
有 96（19.3）
无 402（80.7）
肿瘤大小（cm） 3.1（0.9~6.5）
肿瘤距肛缘距离（cm） 8.0（3.5~12）
浸润深度
T1/T2 351（70.5）
T3/T4 147（29.5）
淋巴结转移
有 119（23.9）
无 379（76.1）
表2 非配对和倾向性匹配患者的临床特征
非配对患者 倾向性匹配患者
加强缝合 t/χ2值 P值 加强缝合 t/χ2值 P值
有 无 有 无
总数 119 379 119 119
年龄（岁） 64.09±13.16 60.88±14.09 -2.20 0.027* 64.09±13.16 62.97±13.62 -0.69 0.49
性别 2.90 0.09 2.84 0.092
男 64 237 64 51
女 55 142 55 68
BMI（kg/m2） 22.58±2.76 22.19±2.85 1.31 0.19 22.58±2.76 22.83±2.96 -0.66 0.51
糖尿病 4.67 0.03* 0.93 0.34
有 13 20 13 18
无 106 359 106 101
新辅助治疗 3.54 0.06 0.023 0.88
是 30 66 30 29
否 89 313 89 90
肿瘤大小（cm） 3.38±1.57 3.35±1.42 0.18 0.85 3.38±1.57 3.26±1.35 0.63 0.53
距肛缘距离（cm） 7.53±2.52 8.03±2.36 -2.01 0.045* 7.53±2.52 7.46±2.49 0.21 0.83
分化类型 1.26 0.74 2.48 0.48
高分化 8 26 8 11
中分化 61 194 61 59
低分化 39 111 39 32
黏液腺癌 11 48 11 17
肿瘤分期 1.19 0.55 1.65 0.44
Ⅰ 45 125 45 37
Ⅱ 49 160 49 50
Ⅲ 25 94 25 32
表3 两组术中和术后的情况［
xˉ
±s，例（%）］
指标 吻合口加强 t/χ2值 P值
是 否
总例数 119 119
手术时间（min） 95.6±13.5 84.3±15.2 6.07 ＜0.001*
术中失血（mL） 31.3±24.3 32.4±22.5 -0.35 0.73
预防性造口 6（5.04） 20（16.81） 8.46 0.004*
总造口 7（5.88） 27（22.69） 13.73 ＜0.001*
吻合口漏 9（7.56） 17（14.29） 2.76 0.096
B/C级漏 4（3.36） 14（11.76） 6.01 0.014*
吻合口出血 4（3.36） 21（17.65） 12.92 ＜0.001*
肠功能恢复（d） 2.38±0.89 2.34±0.98 0.28 0.78
术后住院时间（d） 8.61±2.04 8.50±2.04 0.38 0.70
表4 吻合口漏危险因素的Logistic回归分析
指标 单变量分析 多变量分析
OR 95%CI P值 OR 95%CI P值
年龄（＞75 vs. ≤75） 1.91 0.80~4.57 0.15
性别（男性vs.女性） 3.28 1.32~8.13 0.01 3.61 1.23~10.59 0.02
肿瘤大小（＞3 cm vs. ≤3 cm） 0.58 0.25~1.34 0.20
距肛缘距离（＜5 cm vs. ≥5 cm） 3.18 1.38~7.36 0.007 6.41 2.22~18.49 0.001
分化类型（低分化/黏液腺癌vs.中/高分化） 0.86 0.37~1.99 0.73
肿瘤分期（Ⅲ vs. Ⅰ/Ⅱ） 1.48 0.61~3.61 0.39
BMI（≥24 vs. <24） 4.30 1.85~9.98 0.001 3.20 1.20~8.49 0.02
糖尿病（有vs.无） 3.65 1.43~9.34 0.007 10.49 2.96~37.19 ＜0.001
新辅助治疗（有vs.无） 3.01 1.30~6.95 0.01 5.21 1.83~14.89 0.002
表5 高、低危险组吻合口加强与吻合口漏的相关性研究
吻合口漏 χ2值 P值
有 无
高风险 5.10 0.024*
是 6 45
否 15 35
低风险 - 0.681
是 3 65
否 2 67
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