腹腔镜右半结肠癌根治术后吻合口瘘的原因分析及对策

Anastomotic leakage after laparoscopic-assisted radical right hemicolectomy： reason analysis and management

目的 分析腹腔镜右半结肠癌根治术后吻合口瘘病例的临床特点、可能原因和处理对策。方法 回顾性分析2010年10月至2016年9月间在北京协和医院接受腹腔镜右半结肠癌根治术的546例患者的临床资料，评估其术后吻合口瘘的发生情况及处理方法。结果 546例患者中有8例（1.5%）术后发生吻合口瘘，其中男性7例，女性1例，年龄（54.3 ± 10.3）岁。8例患者术后证实升结肠癌6例，升结肠炎性包块1例，动静脉畸形1例。行D3清扫术和D2清扫术病例术后吻合口瘘发生率分别2.1%（6/290）和0.8%（2/256）。吻合口瘘诊断距手术的时间为（6.6 ± 3.6）d；吻合口瘘表现为引流液呈粪水样7例，发热4例，腹痛3例。4例患者行引流液的淀粉酶和胆红素检查，均明显升高。8例患者均行二次回肠袢式造口术，腹腔镜和开腹各4例。二次手术后1例患者因腹腔感染较重出现呼吸衰竭，经呼吸机支持治疗后好转；1例患者出现盆腔包裹性积液，经穿刺引流后好转。所有患者在回肠造口后均顺利出院。结论 吻合口瘘是腹腔镜右半结肠癌根治术后少见但严重的并发症，可能与过于激进的淋巴脂肪组织清扫有关。发现吻合口瘘之后，首选末端回肠袢式造口术，手术效果满意。

Objective To analyze the clinical features, possible reasons and management of anastomotic leakage after laparoscopic-assisted radical right hemicolectomy.Methods Clinical data of 546 patients undergoing laparoscopic-assisted radical right hemicolectomy in Peking Union Medical College Hospital from October 2010 to September 2016 were retrospectively analyzed. The occurrence of anastomotic leakage and its countermeasures were evaluated.Results Among 546 patients, 8 （1.5%） cases developed anastomotic leakage, including 7 males and 1 female with mean age of （54.3±10.3） years. Six cases of ascending colon cancer, 1 case of phlegmon and 1 case of arterior-venous malformation were confirmed after operation. The incidence of anastomotic leakage after D3 and D2 lymphadenectomy was 2.1% （6/290） and 0.8% （2/256） . The time from operation to the diagnosis of anastomotic leakage was （6.6 ± 3.6） days. The clinical manifestation of anastomotic leakage were stool-like drainage in 7 patients, fever in 4 and abdominal pain in 3. Amylase and bilirubin in drainage of 4 patients increased obviously. All the 8 patients underwent secondary ileostomy, including 4 with laparoscopy and 4 with laparotomy. One patient suffered from respiratory failure after re-operation because of severe abdominal infection and was cured by ventilator support treatment. Another one had pelvic encapsulated effusion and was treated by puncture drainage. All the patients discharged from hospital smoothly.Conclusions Anastomotic leakage after laparoscopic-assisted right hemicolectomy is a quite rare but serious complication, which may be associated with over-cleaning of lymph fatty tissues. Ileostomy should be the first choice of anastomotic leakage after laparoscopy-assisted right hemicolectomy and its efficacy is satisfactory.