经括约肌间切除术治疗新辅助放化疗后低位直肠癌的近远期并发症研究

Clinical features and risk factors of surgical complications after intersphincteric resection for low rectal cancer following neoadjuvant chemoradiotherapy

目的探讨经括约肌间切除术(ISR)治疗新辅助放化疗后低位直肠癌的近远期并发症特点及预后因素。方法检索中山大学附属第六医院结直肠癌数据库,获得2010年9月至2017年6月接受新辅助长程放化疗及ISR根治手术的132例直肠癌患者资料,男性100例,女性32例,年龄(52.9±11.4)岁,肿瘤与肛门距离为(3.9±1.1)cm。围手术期并发症按照Clavien-Dindo分级系统记录;吻合口漏依据严重程度分为A、B、C三级,依据诊断时间(术后30d为界)分为早发型和迟发型;吻合口狭窄以直径12mm的纤维结肠镜无法通过为主要诊断标准,并根据形态分为单纯吻合口狭窄及吻合口并近端肠管狭窄。采用单因素X2检验和多因素Logistic回归筛选识别吻合口漏、吻合口狭窄的预后因素。结果在132例患者中,全量放疗和预防性造口的比例均为97.0%(128/132)。吻合口漏发生率为31.1%(41/132),其中B、C级临床漏32例(24.2%),中位诊断时间为术后37(65)d(范围:2~214d),术后30d以上确诊的迟发型吻合口漏25例(18.9%)。随访至术后1年以上,17.1%(22/129)的患者形成慢性骶前窦道。吻合口狭窄见于28.1%(36/128)的可评估患者,其中单纯吻合口狭窄24例,合并近端肠管狭窄12例。中位随访时间26个月,因吻合口漏或狭窄接受永久性结肠造口者7例,保留持续性回肠造口而无法回纳者20例。多因素分析结果显示,放射性肠炎是ISR术后吻合口漏的独立预后因素(OR=5.04,95%CI:2.05~12.43,P=0.000);男性(OR=5.19,95%CI:1.24~21.75,P=0.024)和吻合口漏(OR=8.49,95%CI:3.32~21.70,P=0.000)是吻合口狭窄的独立预后因素。结论直肠癌新辅助放化疗后实施ISR具有较高的围手术期风险,术后常发生吻合口漏且易于迁延,同时与慢性吻合口狭窄密切相关。对于男性、存在放射性肠炎的高危患者,术后应警惕吻合口并发症的发生。

Objective To explore clinical features and prognosis factors of surgical complications after intersphincteric resection (ISR) for low rectal cancer following neoadjuvant chemoradiotherapy.Methods The clinical data of 132 patients with low rectal cancer who underwent ISR following neoadjuvant chemoradiotherapy from September 2010 to June 2017 at Department of Colorectal Surgery,Sixth Affiliated Hospital,Sun Yat-sen University were retrospectively reviewed.There were 100 males and 32 females,with the age of (52.9±11.4) years and distance to anal verge of 3.9 cm.Records of perioperative complication (POC) within 30 days after surgery,anastomotic leakage (AL),and anastomotic stenosis (AS) were analyzed.POC was recorded according to the Clavien-Dindo classification.AL was graded by ISREC system and classified into the early AL within 30 days after surgery and delayed AL beyond 30 days.AS was defined as narrowing of the bowel lumen at the anastomosis that prevented passage through a colonoscope with a 12 mm diameter.According to the shape of narrowing,AS was recorded as the stenosis in situ or stenosis with long-segment bowel above.Univariate and multivariate analysis were used to identify risk factors of anastomotic complications.Results Among the 132 patients,full-dose radiotherapy and diverting stoma were performed in 128 (97.0%) patients,respectively.In entire cohort,AL was found in 41 (31.1%)patients,including 32 patients with clinical leakage (24.2%).The median time for diagnosis of AL was 37 days (2 to 214 days) after surgery.There were 25 patients (18.9%) who were diagnosed with delayed AL beyond 30 days.Chronic presacral sinus formation was detected in 22 of 129 (17.1%) patients at 12 months from surgery.Among the 128 eligible patients,36 (28.1%) were diagnosed as AS,including 24 (18.8%) patients with stenosis in situ and 12 (9.4%) patients with bowel stenosis above.After a median follow-up of 26 months,7(5.3%) patients received permanent colostomy and the other 20(15.2%)patients retained a persistent ileostomy,owing to anastomotic complications.Results of multivariate analysis showed that radiation colitis was an independent prognosis factor of AL after ISR (OR =5.04,95% CI:2.05 to 12.43,P=0.000);male gender (OR=5.19,95% CI:1.24 to 21.75,P=0.024) and AL (OR=8.49,95% CI:3.32 to 21.70,P=0.000) were independent prognosis factors of AS after ISR.Conclusions Surgical complications are common after ISR for low rectal cancer patients with neoadjuvant chemoradiotherapy.A high rate of AL is observed after long-term follow-up,which is associated with AS.Increasing awareness of anastomotic complications after ISR should be raised,especially for male patients with radiation colitis.