腹腔镜直肠癌全直肠系膜切除术预防性末端回肠造瘘后相关并发症危险因素和造瘘还纳时机分析

Risk factor analysis on postoperative complications after laparoscopic total mesorectal excision with preventive terminal ileostomy and timing of stoma closure in rectal cancer

目的：总结预防性末端回肠造瘘在腹腔镜直肠癌全直肠系膜切除术（TME）中的应用情况，探讨术后并发症发生的危险因素和造瘘还纳时机。方法回顾分析北京大学第三医院普通外科2007年1月至2013年12月对中低位直肠癌患者施行腹腔镜直肠癌全直肠系膜切除术并行预防性末端回肠造瘘77例患者的临床资料，通过Logistic回归分析找出术后发生造瘘相关并发症的独立危险因素；同时分析末端回肠造瘘还纳时间。结果全组患者术后总并发症发生率为57．1％（44／77）。出现水电解质紊乱39例（50．6％，39／77，其中1例出现低血容量性晕厥）；造瘘口旁疝9例（11．7％，9／77）；造瘘口周围皮炎合并皮下脓肿1例（1．3％，1／77）。术后出现水电解质紊乱的单因素分析结果中，P＜0．2的危险因素有新辅助放化疗（P＝0．094）、癌胚抗原（P＝0．086）及TNM分期（P＝0．026）；术后出现造瘘口旁疝的单因素分析结果中，P＜0．2的危险因素有使用降糖药（P＝0．172）、ASA麻醉分级（P＝0．168）及TNM分期（P＝0．161）；但多因素分析显示，上述危险因素皆不是术后水电解质紊乱和造瘘口旁疝发生的独立危险因素（均P＞0．05）。随访期内造瘘还纳65例，其中术后90 d以内还纳者2例（3．1％），90～180 d还纳者20例（30．8％），超过180 d还纳者43例（66．2％）。结论腹腔镜直肠癌TME预防性末端回肠造瘘术后的主要并发症为水电解质紊乱及造口旁疝，未发现引起上述两种并发症的独立危险因素。造瘘还纳时间多需术后6月以上。

Objective To summarize the application of protective terminal ileostomy in laparoscopic total mesorectal excision for rectal cancer patients , and explore the risk factors associated with postoperative complications and timing of stoma closure. Methods Clinical data of 77 patients with middle or low rectal cancer undergoing laparoscopic total mesorectal excision （TME） with preventive terminal ileostomy in our department from January 2007 to December 2013 were retrospectively analyzed . Independent risk factors associated to postoperative complications of terminal ileostomy were examined by logistic regression and timing of stoma closure was investigated . Result The total postoperative complication morbidity was 57.1%（44/77）. Electrolyte disturbance was found in 39 cases （50.6%, 39/77）, including 1 case of hypovolemic syncope. Parastomal hernia occurred in 9 cases （11.7%, 9/77）. Peristomal dermatitis and subcutaneous abscess was observed in 1 case （1.3%, 1/77）. The result of the single factor analysis of the water electrolyte disturbance after＆nbsp;operation, the risk factors of P0.05）. Sixty-five patients underwent stoma closure during follow-up, including 2 cases （3.1%） within 90 days, 20 cases （30.8%） from 90 to 180 days, and 43 cases （66.2%） more than 180 days. Conclusions No risk factors were found to be associated with main postoperative complications of protective terminal ileostomy after laparoscopic TME for rectal cancer patients, such as electrolytes imbalance and parastomal hernia. The timing of stoma closure should be longer than 180 days.