比较分析腹腔镜与开腹直肠癌根治术后吻合口出血的影响因素

Comparing the influencing factors of anastomotic bleeding in rectal carcinoma resection between laparoscopic and open radical approaches

目的研究腹腔镜与开腹直肠癌根治术后吻合口出血发生率的差异及其影响因素。方法直肠癌根治术263例，其中腹腔镜组（LS组）86例，开腹组（OS组）177例。根据吻合口位置分布情况及是否行预防性结肠造口，再分为AR组（直肠前切除术，180例）与LAR（低位直肠前切除术）或UAR（超低位直肠前切除）组（83例），造口组（62例）与非造口组（201例）。通过观察各组内吻合口出血发生率，建立吻合口出血危险因素Logistic回归模型，从而判定吻合口出血与手术方式（LS与OS）、吻合口位置（AR与LAR或UAR）及预防性结肠造口等影响因素之间的关系。结果全组患者术后发生吻合口出血16例（6．1％）。LS组与OS组术后吻合口出血发生率分别为9．3％与4．5％。造口组与非造口组分别为8．1％和5．5％，AR组与LAR或UAR组则分别为3．3％和12．1％；差异均无统计学意义（P〉0．05）。手术方式因素中，LS与OS比较，LS因素的回归系数b1=1．319，优势比OR1=3．741，标准回归系数b1’=0．342。吻合口位置因素中，AR与LAR或UAR比较，LAR或UAR因素的回归系数b2=2．460，优势比OR2=11．704，标准回归系数b2＇=0．632。预防性结肠造口因素中，造口与非造口比较，预防性结肠造口因素的回归系数b3=-1．394，优势比OR3=0．248，标准回归系数b3＇=-0．327。结论直肠癌根治术后，腹腔镜手术、低位或超低位直肠前切除术是吻合口出血的危险因素；预防性结肠造口是吻合口出血的保护因素。三者之中，吻合口位置影响最大．手术方式次之，预防性结肠造口影响最小。

Objective To observe the occurrence of anastomotic bleeding following laparoscopic and open radical resection for rectal carcinoma, and to explore its contributing factors. Methods Two hundred and sixty-three cases of rectal carcinoma undergone radical resection were divided into 2 groups, laparoscopic surgery（LS） group（n=86） and open surgery（OS） group （n=177）. According to the different locations of anastomotic stoma and with or without preventive colostomy, the two groups were divided into AR sub-group and LAR/UAR sub-group, colostomy sub-group and non-colostomy sub-group. After analyzing the incidence of anastomotic bleeding in each sub-group, a logistic regression model was establisbed to determine the relationships between anastomotic bleeding and three contributing factors including surgical approaches （LS or OS）, location of stoma （AR or LAR/ UAR） and preventive colostomy. Results Anastomotic bleeding occurred on 16 out of 263 patients with radical resection of rectal cancer（6.1%）. The rates of anastomofic bleeding in LS group and OS group were 9.3% and 4.5%, in colostomy and non-colostomy were 8.1% and 5.5%, and in AR group and LAR/UAR group were 3.3% and 12.1% respectively, there were no significant differences between them （P〉0.05）. Comparing the two different surgical approaches（LS vs OS）, the coefficient of regression, odd ratio and standard coefficient of regression for LS were 1.319, 3.741 and 0.342 respectively. In comparison of the locations of anastomosis （AR vs LAR/UAR）, the three index for LAR/UAR were 2.460, 11.704, and 0.632 respectively. Comparing colostomy with non-colostomy, the three index for colostomy were -1.394, 0.248, and -0.327 respectively. Conclusions Anastomotic bleeding after radical rectectomy is related to the choice of surgical approach, location of anastomosis and with or without preventive colostomy. Both LS and LAR/UAR are risk factors, and preventive colostomy is a protective factor. Regarding to the significance of three factors, location of anastomosis takes the first place, following by surgical method and with or without preventive colostomy.