切换至 "中华医学电子期刊资源库"
高级检索
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
全文 ( ) 下载PDF ( ) 导出引用
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]. 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]. 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
[1]
Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015[J]. CA: a Cancer Journal for Clinicians, 2016, 66(2): 115-132.
[2]
Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017[J]. CA: A Cancer Journal for Clinicians, 2017, 67(3): 177-193.
[3]
Sung JJY, Lau JYW, Goh KL, et al. Increasing incidence of colorectal cancer in Asia: implications for screening[J]. The Lancet Oncology, 2005, 6(11): 871-876.
[4]
Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer[J]. Surgical Endoscopy, 2004, 18(8): 1211-1215.
[5]
Lujan J, Valero G, Hernandez Q, et al. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer[J]. The British Journal of Surgery, 2009, 96(9): 982-989.
[6]
JW M, dOO, KI T, et al. Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer[J]. Diseases of the Colon and Rectum, 2009, 52(7): 1215-1222.
[7]
van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial[J]. The Lancet Oncology, 2013, 14(3): 210-218.
[8]
Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial[J]. Lancet (London, England), 2005, 365(9472): 1718-1726.
[9]
Boccola MA, Buettner PG, Rozen WM, et al. Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1 576 patients[J]. World Journal of Surgery, 2011, 35(1): 186-195.
[10]
Akiyoshi T, Ueno M, Fukunaga Y, et al. Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer[J]. American Journal of Surgery, 2011, 202(3): 259-264.
[11]
Alves A, Panis Y, Trancart D, et al. Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients[J]. World Journal of Surgery, 2002, 26(4): 499-502.
[12]
Jung SH, Yu CS, Choi PW, et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery[J]. Diseases of the Colon and Rectum, 2008, 51(6): 902-908.
[13]
Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer[J]. British Journal of Surgery, 2001, 88(3): 400-404.
[14]
Furnée EJB, Aukema TS, Oosterling SJ, et al. Influence of conversion and anastomotic leakage on survival in rectal cancer surgery; retrospective cross-sectional study[J]. Journal of Gastrointestinal Surgery: Official Journal of the Society for Surgery of the Alimentary Tract, 2019, 23(10): 2007-2018.
[15]
Matthiessen P, Hallbook O, Andersson M, et al. Risk factors for anastomotic leakage after anterior resection of the rectum[J]. Colorectal Disease: the Official Journal of the Association of Coloproctology of Great Britain and Ireland, 2004, 6(6): 462-469.
[16]
Maeda K, Nagahara H, Shibutani M, et al. Efficacy of intracorporeal reinforcing sutures for anastomotic leakage after laparoscopic surgery for rectal cancer[J]. Surgical Endoscopy, 2015, 29(12): 3535-3542.
[17]
Kwon YJ, Ahn BK, Park HK, et al. One layer end-to-side pancreaticojejunostomy using reinforcing suture on the pancreatic stump[J]. Hepato-gastroenterology, 2013, 60(126): 1488-1491.
[18]
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.
[19]
Mirnezami A, Mirnezami R, Chandrakumaran K, et al. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis[J]. Annals of Surgery, 2011, 253(5): 890-899.
[20]
Cong ZJ, Hu LH, Bian ZQ, et al. Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer[J]. PloS One, 2013, 8(9): e75519.
[21]
Taflampas P, Christodoulakis M, Tsiftsis DD. Anastomotic leakage after low anterior resection for rectal cancer: facts, obscurity, and fiction[J]. Surgery Today, 2009, 39(3): 183-188.
[22]
Trencheva K, Morrissey KP, Wells M, et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients[J]. Annals of Surgery, 2013, 257(1): 108-113.
[23]
Caulfield H, Hyman NH. Anastomotic leak after low anterior resection: a spectrum of clinical entities[J]. JAMA Surg, 2013, 148(2): 177-182.
[24]
Peeters KC, Tollenaar RA, Marijnen CA, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer[J]. The British Journal of Surgery, 2005, 92(2): 211-216.
[25]
Alberts JC, Parvaiz A, Moran BJ. Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection[J]. Colorectal Disease: the Official Journal of the Association of Coloproctology of Great Britain and Ireland, 2003, 5(5): 478-482.
[26]
Schilt PN, Musunuru S, Kokoska M, et al. The effect of cartilaginous reinforcing sutures on initial tracheal anastomotic strength: a cadaver study[J]. Otolaryngol Head Neck Surg, 2012, 147(4): 722-725.
[27]
Park JS, Choi GS, Kim SH, et al. Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group[J]. Ann Surg, 2013, 257(4): 665-671.
[28]
Tan WS, Tang CL, Shi L, et al. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer[J]. The British Journal of Surgery, 2009, 96(5): 462-472.
[29]
Xiao L, Zhang WB, Jiang PC, et al. Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study[J]. World Journal of Surgery, 2011, 35(6): 1367-1377.
[30]
Zhao WT, Hu FL, Li YY, et al. Use of a transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer[J]. World Journal of Surgery, 2013, 37(1): 227-232.
[31]
Nishigori H, Ito M, Nishizawa Y, et al. Effectiveness of a transanal tube for the prevention of anastomotic leakage after rectal cancer surgery[J]. World Journal of Surgery, 2014, 38(7): 1843-1851.
[32]
Ito M, Sugito M, Kobayashi A, et al. Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection[J]. International Journal of Colorectal Disease, 2008, 23(7): 703-707.
[33]
Gadiot RP, Dunker MS, Mearadji A, et al. Reduction of anastomotic failure in laparoscopic colorectal surgery using antitraction sutures[J]. Surgical Endoscopy, 2011, 25(1): 68-71.
[34]
Li TF, Duan XH, Li Z, et al. Endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis[J]. Acta Radiol, 2015, 56(11): 1368-1372.
[35]
Lee S, Ahn JY, Na S, et al. Clinical features of postoperative anastomotic bleeding after gastrectomy and efficacy of endoscopic hemostasis: a case-control study[J]. Surgical Endoscopy, 2017, 31(8): 3210-3218.
[36]
Mukai M, Fukasawa M, Kishima K, et al. Trans-anal reinforcing sutures after double stapling for lower rectal cancer: Report of two cases[J]. Oncol Rep, 2009, 21(2): 335-339.
[37]
Baek SJ, Kim J, Kwak J, Kim SH. Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?[J]. World Journal of Gastroenterology, 2013, 19(32): 5309-5313.
[1] 康夏, 田浩, 钱进, 高源, 缪洪明, 齐晓伟. 骨织素抑制破骨细胞分化改善肿瘤骨转移中骨溶解的机制研究[J]. 中华乳腺病杂志(电子版), 2023, 17(06): 329-339.
[2] 唐旭, 韩冰, 刘威, 陈茹星. 结直肠癌根治术后隐匿性肝转移危险因素分析及预测模型构建[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 16-20.
[3] 张生军, 赵阿静, 李守博, 郝祥宏, 刘敏丽. 高糖通过HGF/c-met通路促进结直肠癌侵袭和迁移的实验研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 21-24.
[4] 张焱辉, 张蛟, 朱志贤. 留置肛管在中低位直肠癌新辅助放化疗后腹腔镜TME术中的临床研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 25-28.
[5] 李婷, 张琳. 血清脂肪酸代谢物及维生素D水平与结直肠癌发生的关系研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 661-665.
[6] 付振保, 曹万龙, 刘富红. 腹腔镜直肠癌低位前切除术中不同缝合方法的回肠双腔造口术临床效果研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 684-687.
[7] 贺亮, 王松林, 周业江. 两种预防性回肠造口在腹腔镜ISR术治疗超低位直肠癌的效果对比研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 697-700.
[8] 中国医师协会结直肠肿瘤专业委员会, 中国抗癌协会大肠癌专业委员会, 北京整合医学学会结直肠肿瘤分会. 吲哚菁绿近红外荧光血管成像技术应用于腹腔镜结直肠手术中吻合口血供判断中国专家共识（2023版）[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 441-447.
[9] 关旭, 王锡山. 基于外科与免疫视角思考结直肠癌区域淋巴结处理的功与过[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 448-452.
[10] 顾睿祈, 方洪生, 蔡国响. 循环肿瘤DNA检测在结直肠癌诊治中的应用与进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 453-459.
[11] 卢艳军, 马健, 白鹏宇, 郭凌宏, 刘海义, 江波, 白文启, 张毅勋. 纳米碳在腹腔镜直肠癌根治术中253组淋巴结清扫的临床效果[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 473-477.
[12] 倪文凯, 齐翀, 许小丹, 周燮程, 殷庆章, 蔡元坤. 结直肠癌患者术后发生延迟性肠麻痹的影响因素分析[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 484-489.
[13] 范小彧, 孙司正, 鄂一民, 喻春钊. 梗阻性左半结肠癌不同手术治疗方案的选择应用[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 500-504.
[14] 杨红杰, 张智春, 孙轶. 直肠癌淋巴结转移诊断研究进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 512-518.
[15] 马慧颖, 凡新苓, 覃仕瑞, 陈佳赟, 曹莹, 徐源, 金晶, 唐源. 磁共振加速器治疗局部晚期直肠癌的初步经验[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 519-523.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号