保护性横结肠襻式造口对腹腔镜直肠癌前切除术后吻合口漏及狭窄的影响

Effects of protective transverse colostomy on the incidence of postoperative anastomotic leakage and stricture after laparoscopic resection for rectal cancer

目的 探讨保护性横结肠襻式造口术对减少腹腔镜直肠癌前切除术后吻合口漏及狭窄的价值.方法 回顾性分析2008年3月至2012年2月浙江大学金华医院收治的128例中低位直肠癌患者的临床资料.所有患者接受新辅助治疗后行腹腔镜直肠癌前切除术,其中61例采用保护性横结肠襻式造口（造口组）,67例未采用保护性横结肠襻式造口（未造口组）.比较两组患者吻合口漏及吻合口狭窄的发生率、病情程度和治疗转归.患者术后采用门诊复诊、入院化疗就诊及电话等方式随访.随访时间截至2013年5月.计量资料采用-x±s表示,组间比较采用t检验;计数资料采用率或构成比表示,组间比较采用x2检验或Fisher确切概率法.结果 128例直肠癌患者术后总体吻合口漏发生率为7.03％（9/128）,其中造口组发生为率6.56％ （4/61）,未造口组发生率为7.46％ （5/67）,两组比较差异无统计学意义（x2=0.000,P＞0.05）.造口组患者中4例发生吻合口漏患者全身反应轻,均经保守治疗后痊愈,未行再次手术治疗;未造口组患者中5例发生吻合口漏患者全身症状重,其中4例行再次手术治疗,再次手术率为4/5,1例经保守治愈,两组再次手术率比较,差异有统计学意义（P＜0.05）.128例直肠癌患者术后总体吻合口狭窄发生率为13.28％ （17/128）.造口组患者吻合口狭窄发生率为19.67％（12/61）,其中重度吻合口狭窄发生率为8.20（5/61）;未造口组患者吻合口狭窄发生率为7.46％ （5/67）,其中重度吻合口狭窄发生率为0,两组比较,差异有统计学意义（x2=4.133,P＜0.05）.结论 保护性横结肠襻式造口术不能降低腹腔镜直肠癌前切除术后吻合口漏的发生率,可减轻吻合口漏的相关症状,能降低再次手术率.但保护性横结肠襻式造口术可增加术后吻合口狭窄发生率,因此应慎重选用该术式.

Objective To investigate the value of protective transverse colostomy in decreasing postoperative anastomotic leakage and stricture after laparoscopic resection for rectal cancer.Methods The clinical data of 128 patients with rectal cancer who were admitted to the Jinhua Hospital of Zhejiang University from March 2008 to February 2012 were retrospectively analyzed.All the patients received laparoscopic anterior resection of rectal cancer after neoadjuvant chemoradiotherapy.Sixty-one patients received protective transverse colostomy （colostomy group） and 67 patients did not receive protective transverse colostomy （non-colostomy group）.The incidences of postoperative anastomotic leakage and stricture,condition of the patients and the prognosis of the patients in the 2 groups were compared.Patients were followed up via out-patient examination,in-patient chemotherapy or phone call till May 2013.All data were analyzed using the t test,chi-square test or Fisher exact probability.Results The overall incidence of postoperative anastomotic leakage was 7.03％ （9/128）.The incidences of postoperative anastomotic leakage in the colostomy group and non-colostomy group were 6.56％ （4/61） and 7.46％ （5/67）,with no significant difference between the 2 groups （x2 =0.000,P ＞ 0.05）.The systemic condition of 4 patients who were complicated with anastomotic leakage in the colostomy group was comparatively better,and all of them were cured by conservative treatment.The condition of 5 patients who were complicated with anastomotic leakage in the non-colostomy group was severe,and 4 of them received reoperation,with the reoperation rate of 4/5 ; the other patient received conservative treatment.There was significant difference in the reoperation rate between the 2 groups （P ＜0.05）.The overall incidence of postoperative anastomotic stricture was 13.28％ （17/128）.The incidences of postoperative anastomotic stricture in the colostomy group and the non-colostomy group were 19.67％ （12/61） and 7.46％ （5/67）,with significant difference between the 2 groups （x2=4.133,P ＜ 0.05）.The incidences of severe anastomotic stricture of the colostomy group and the non-colostomy group were 8.20 （5/61） and 0,respectively.Conclusion Protective transverse colostomy could not reduce the incidence of postoperative anastomotic leakage,but could mitigate the symptoms followed anastomotic leakage and reduce the reoperation rate.Protective transverse colostomy may improve the incidence of anastomotic stricture,therefore it should be applied cautiously.