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中华结直肠疾病电子杂志 ›› 2023, Vol. 12 ›› Issue (04) : 288 -295. doi: 10.3877/cma.j.issn.2095-3224.2023.04.004

论著

基于肠脂垂的近红外荧光血管造影技术在预防腹腔镜超低位直肠癌经括约肌间切除术后吻合口漏中的应用价值
邱文龙, 刘军广, 胡刚, 李博, 李月刚, 梅世文, 权继传, 庄孟, 迟崇巍, 王锡山, 汤坚强()   
  1. 100021 北京,国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院结直肠外科
    100034 北京大学第一医院普外科
    100190 北京,中国科学院自动化研究所 中国科学院分子影像重点实验室
  • 收稿日期:2023-06-29 出版日期:2023-08-25
  • 通信作者: 汤坚强
  • 基金资助:
    北京市自然科学基金(L222054,4232058); 吴阶平医学基金会临床科研专项资助基金(320.6750.2021-04-2); 中国医学科学院肿瘤医院“希望之星”人才项目

The value of near-infrared fluorescence angiography of epiploic appendages in preventing anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study

Wenlong Qiu, Junguang Liu, Gang Hu, Bo Li, Yuegang Li, Shiwen Mei, Jichuan Quan, Meng Zhuang, Chongwei Chi, Xishan Wang, Jianqiang Tang()   

  1. Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021 Beijing, China
    Department of General Surgery, Peking University First Hospital, 100034 Beijing, China
    Key Laboratory of Molecular Imaging Chinese Academy of Sciences, Beijing Key Laboratory of Molecular Imaging, 100190 Beijing, China
  • Received:2023-06-29 Published:2023-08-25
  • Corresponding author: Jianqiang Tang
引用本文:

邱文龙, 刘军广, 胡刚, 李博, 李月刚, 梅世文, 权继传, 庄孟, 迟崇巍, 王锡山, 汤坚强. 基于肠脂垂的近红外荧光血管造影技术在预防腹腔镜超低位直肠癌经括约肌间切除术后吻合口漏中的应用价值[J/OL]. 中华结直肠疾病电子杂志, 2023, 12(04): 288-295.

Wenlong Qiu, Junguang Liu, Gang Hu, Bo Li, Yuegang Li, Shiwen Mei, Jichuan Quan, Meng Zhuang, Chongwei Chi, Xishan Wang, Jianqiang Tang. The value of near-infrared fluorescence angiography of epiploic appendages in preventing anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2023, 12(04): 288-295.

目的

探讨基于肠脂垂的近红外荧光血管造影技术在预防腹腔镜超低位直肠癌经括约肌间切除术(ISR)后吻合口漏(AL)中的应用价值。

方法

回顾性收集505例于2012年1月至2022年5月在北京大学第一医院和中国医学科学院肿瘤医院行ISR手术的低位直肠癌患者的临床资料,其中90例采用了肠脂垂荧光血管造影(FAEA),在单色原始荧光模式下进行FAEA血供评价和肠管离断位置的判断。将FAEA患者(n=90)和非FAEA患者(n=415)按照1∶2配对后,FAEA组(n=73)与非FAEA组(n=135)各因素平衡良好。主要终点为6个月内AL发生率。

结果

FAEA组AL发生率显著低于非FAEA组(2.7% vs.11.1%,P=0.035)。Logistic回归分析显示男性(OR=2.650,95%CI=1.156~6.076,P=0.021)、接受新辅助放化疗(OR=6.795,95%CI=3.141~14.699,P<0.001)和肿瘤距肛缘距离≤4 cm(OR=4.754,95%CI=1.611~12.987,P=0.004)是AL的独立危险因素。保留LCA(OR=0.460,95%CI=0.227~0.929,P=0.030)、保护性回肠造口(OR=0.198,95%CI=0.083~0.474,P=0.004)和FAEA(OR=0.252,95%CI=0.071~0.900,P=0.034)是AL的独立保护因素。FAEA显著缩短术后住院时间[9(6~12)vs. 10(8~13),P=0.008]。

结论

FAEA血供评估方法可作为腹腔镜经括约肌间切除术后AL并发症的有效预防方式。

Objective

To investigate the application value of near-infrared fluorescence angiography based on epiplogram in the prevention of anastomotic leakage (AL) after laparoscopic intersphincteric resection (ISR) for ultra-low rectal cancer.

Methods

We retrospectively collected a total of 505 patients with ultra-low rectal cancer after ISR surgery, including 90 patients with fluorescence angiography of epiploic appendages (FAEA). Perfusion assessment and transection line of the bowel was analyzed by FAEA in the monochrome fluorescence mode. After matching with 1:2 ratio, the FAEA group (n=73) and control group (n=135) were well balanced. The primary endpoint was the incidence of anastomotic leak within 6 months.

Results

The incidence of anastomotic leakage in FAEA group was lower (2.7% vs. 11.1%, P=0.035) than control group. Logistic regression analysis showed that male (OR=2.650, 95%CI=1.156~6.076, P=0.021), neoadjuvant chemoradiotherapy (OR=6.795, 95%CI=3.141~14.699, P<0.001) and tumor distance to the anus ≤4 cm (OR=4.754, 95%CI=1.611~12.987, P=0.004) were independent risk factors of AL. LCA retention (OR=0.460, 95%CI=0.227~0.929, P=0.030), ileostomy (OR=0.198, 95%CI=0.083~0.474, P=0.004) and FAEA (OR=0.252, 95%CI=0.071~0.900,P=0.034) were independent protective factors for AL. FAEA significantly shortened postoperative hospital stay [9(6~12) vs. 10 (8~13), P=0.008].

Conclusion

Perfusion assessment by FAEA can be used as an effective way to prevent the complications of anastomotic leakage after laparoscopic intersphincteric resection.

图1 数据筛选流程图
图2 不同近红外模式下缺血线的临床判断。切断直肠肛侧后,经切口取出标本。2A:分离肠系膜后,采用彩色可视模式观察缺血线(白线);2B:静脉注射ICG后,采用单色原始荧光模式动态观察肠脂垂微动脉,记录该模式下基于微动脉末端的缺血线(红线);2C:小静脉和肠壁逐渐可见;2D:改变成像模式为融合荧光模式,并以肠脂垂微动脉为基准,在离预切线(原始荧光模式下标记的红线)远1 cm~2 cm处标记融合模式的缺血线(黄线)
表1 PSM前后基线资料数据
变量 FAEA 组(n=73) 非FAEA组(n=135) 检验值 P
年龄(岁) 61(55~68) 62(55~68) 0.556 0.456
<60 32(43.8) 52(38.5)
≥60 41(56.2) 83(61.5)
性别 0.407 0.524
女性 27(63.0) 44(67.4)
男性 46(37.0) 91(32.6)
BMI(kg/m2 24.0(22.1~26.0) 23.7(22.0~25.6) 0.559 0.455
<25 46(63.0) 92(68.1)
≥25 27(37.0) 43(31.9)
ASA 0.588 0.629
1~2 64(87.7) 113(83.7)
3 9(12.3) 22(16.3)
糖尿病 3.283 0.070
68(93.2) 114(84.4)
5(6.8) 21(15.6)
血红蛋白(g/L) 0.171 0.680
≥120 67(91.8) 126(93.3)
<120 6(8.2) 9(6.7)
CEA(g/L) 0.975 0.323
≤5 20(27.4) 46(34.1)
>5 53(72.6) 89(65.9)
CA19-9(kU/L) 0.234 0.629
≤37 65(89.0) 123(91.1)
>37 8(11.0) 12(8.9)
肿瘤最大径(M,IQR)(mm) 40(27~50) 35(25~47) 28.918 0.256
肿瘤最大径(mm) 32.925 0.316
≤35 32(43.8) 69(51.1)
>35 41(56.2) 66(48.9)
肿瘤距离肛缘距离(M,IQR)(cm) 4.0(3.5~4.0) 4.0(3.5~4.0) 13.632 0.809
T分期 0.287 0.592
0-2 32(43.8) 54(40.0)
3-4 41(56.2) 81(60.0)
N分期 0.003 0.959
0 50(68.5) 92(68.1)
1-2 23(31.5) 43(31.9)
M分期 0.513 0.474
M0 72(98.6) 131(97.0)
M1 1(1.4) 4(3.0)
TNM分期 0.141 0.707
Ⅰ/Ⅱ 23(31.5) 46(34.1)
Ⅲ/Ⅳ 50(68.5) 89(65.9)
组织学分化程度 1.452 0.228
高-中分化 58(79.5) 116(85.9)
低分化 15(20.5) 19(14.1)
术前治疗 0.077 0.781
13(17.8) 22(16.3)
60(82.2) 113(83.7)
保护性造口 1.243 0.265
59(80.8) 117(86.7)
14(19.2) 18(13.3)
吻合口距肛缘距离(M,IQR)(cm) 2.0(2.0~3.0) 2.0(2.0~3.0) 5.259 0.742
LCA保留 0.132 0.716
22(30.1) 44(32.6)
51(69.9) 91(67.4)
表2 PSM后FAEA组患者和非FAEA组患者的围手术期事件结果[例(%)]
表3 吻合口漏的单因素和多因素分析
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