腹腔镜下直肠低位双吻合术的改良及效果观察

Modification and efficacy observation of laparoscopic dual anastomosis for mid-low rectal cancer

目的：探讨降低直肠低位双吻合术后并发症的手术方法。方法回顾分析2010年2月至2014年6月在苏州大学附属第一医院普通外科行腹腔镜下直肠癌根治术时作改良直肠低位双吻合的56例中低位直肠癌患者（改良吻合组）的临床资料，与同期常规直肠低位双吻合的64例中低位直肠癌患者（常规吻合组）的临床资料进行对比研究。改良吻合组进行直肠低位双吻合时，将直肠远侧端切割闭合由水平方向改成垂直方向，以“端-角”方式进行肠-肠吻合以去除直肠远侧端闭合线上角部，以血管夹夹闭的方法去除该闭合端下角部，用可吸收线加强缝合直肠双吻合后仅形成的一处钉合线“T”形交汇处（“危险三角”）。结果两组患者术中出血量、术后引流量、术后吻合口出血、肛门排气时间和住院时间差异无统计学意义（P＞0．05）。与常规吻合组相比，改良吻合组手术耗时较长[（211±91） min比（174±57） min，P＜0．05]、术后吻合口瘘的发生率[1．8％（1／56）比12．5％（8／64），P＝0．030]、里急后重感发生率[3．6％（2／56）比14．1％（9／64），P＜0．05]和再次手术造瘘率[改良吻合组0，常规吻合组9．4％（6／64），P＜0．05]均低于常规吻合组。两组均无死亡病例。结论改良的直肠低位双吻合可有效降低术后吻合口瘘等术后并发症的发生率。

Objective To explore a new procedure of laparoscopic dual anastomosis for mid-low rectal cancer to reduce postoperative complications. Methods Clinical data of 56 patients with mid-low rectal cancer undergoing laparoscopic rectal cancer resection （modified double-stapling technique, MDST, modification group） in the Department of General Surgery, the First Affiliated Hospital of Soochow University from February 2010 to June 2014 were compared with the data of 64 patients with mid-low rectal cancer （conventional double-stapling technique, DST, convention group） in the same period based on gender, age, tumor size, the distance from lower edge to the dentate line and tumor staging, etc. Patients in the modification group received operation as follows： （1） the rectum distal end was closed vertically instead of horizontally. （2） the anastomosis was conducted in an “end-corner”approach. （3） upper corner of the closed line in the distal end of rectum was removed. （4） the lower corner of closed line in the distal end of rectum was removed using vascular occlusion clamp method. （5） two T-shaped interchanges （“dangerous triangle”） of stapled sutures formed after anastomosis were strengthened with absorbable suture. Patients in the convention group received laparoscopic dual anastomosis using conventional method： two corners and “dangerous triangles” were kept without any treatment. The clinical outcomes of two groups were analyzed retrospectively. Results The intraoperational blood loss, postoperative drainage volume, postoperative anastomotic stoma bleeding, bowel function return and hospital stay were not significantly different between the two groups （all P〉0.05）. As compared to the convention group, the modification group had longer operation time [（211± 91） min vs. （174±57） min, P〈0.05], lower incidence of postoperative anastomotic leakage [1.8%（1/56） vs. 12.5%（8/64）, P=0.030], lower tenesmus rate [3.6%（2/56） vs. 14.1%（9/64）, P〈0.05], less postoperative stoma re-creation [0 vs. 9.4%（6/64）, P〈0.05]. Conclusion Modified laparoscopic dual anastomosis for mid-low rectal cancer can significantly reduce the incidence of post-surgical complications such as anastomotic leakage.