直肠癌术后吻合口狭窄的临床分析

Clinical analysis of anastomotic stenosis after laparoscopic total mesorectal excision for rectal cancer

目的探讨腹腔镜下直肠癌全直肠系膜切除术(total mesorectal excision,TME)术后吻合口狭窄的原因和防治方法。方法回顾性分析三峡大学第一临床医学院2010～2014年收治的486例行腹腔镜下直肠癌TME术病人的临床资料,将病人分为吻合口狭窄及无吻合口狭窄两组。采用χ~2检验,对各影响因素进行Logistic回归分析。结果共发生吻合口狭窄27例,发生率为5.6%。多因素分析表明,男性、吻合口漏、术前新辅助放疗、肿瘤下缘距肛缘距离<5 cm为术后吻合口狭窄的独立危险因素(P<0.05)。27例吻合口狭窄中1例为肿瘤局部复发并肝转移,行永久降结肠双腔造口。26例吻合口瘢痕狭窄病人中,行剖腹切除狭窄吻合口后一期吻合4例;经肛门完整切除膜状狭窄环7例;6例经肛门放射状切开狭窄环,并于术后4d经肛门每日人工扩张吻合口2～3次,共扩张3个月;9例未行手术,每日经肛门行人工扩张吻合口1次,共扩张3个月。吻合口狭窄病人再次术中未发生肠管损伤、输尿管损伤、骶前大出血等并发症。吻合口狭窄病人中位随访时间为20个月。27例病人均获得随访,2例随访期间死亡,余25例吻合口通畅。结论男性、吻合口漏、术前新辅助放疗、肿瘤下缘距肛缘距离<5 cm为直肠癌术后吻合口狭窄的危险因素;直肠癌术后吻合口狭窄重在预防,应根据吻合口不同狭窄原因及程度采取不同方法解除梗阻。

Objective To analyze the reasons and prevention strategies of anastomotic stenosis after laparoscopic total mesorectal excision（TME）for rectal cancer.Methods We retrospectively analyzed the clinical data of 486 patients undergoing laparoscopic TME surgery from 2010 to 2014 at the First Clinical Medical College of the Three Gorges University.The patients were divided into two groups：anastomotic stenosis and anastomotic non-stenosis.The χ~2 test was used to analyze the influencing factors.Results Anastomotic stenosis occurred in27 cases,and the incidence was 5.6%.Multivariate analysis showed that male,anastomotic leakage,preoperative neoadjuvant radiotherapy,the lower edge of the tumor from the anal margin distance〈5 cm were postoperative anastomotic stenosis independent risk factors（P〈0.05）.Of 27 cases of anastomotic stenosis,1 case had local recurrence and liver metastasis,and was given permanent descending colon double-chamber stoma.Of the 26 patients with anastomotic scar stenosis,4 patients underwent anastomosis following the anastomotic stenosis resection;7 cases had complete dissection of the membranous stenosis ring through the anus;6 cases were treated by anus radial incision of the stenosis ring,and the anus was given artificial expansion of anastomosis 4 days after operation,2-3 times every day for 3 months;9 cases were given no surgery,and accepted the artificial expansion of the anastomosis through the anus,once every day for 3 months.During the re-operation of the patients with anastomotic stenosis,no intestinal injury,ureteral injury,sacral hemorrhage and other complications occurred.The median follow-up time was 20 months for patients with anastomotic stenosis.Twenty-seven patients were followed up,2 died during the follow-up period,and the rest 25 patients had unobstructed anastomoses.Conclusions Male,anastomotic leakage,preoperative neoadjuvant radiotherapy,and the lower edge of the tumor from the anal margin 〈5 cm were the risk factors of anastomotic stenosis following rectal cancer operation.The anastomotic stenosis after rectal cancer operation should be prevented,and different procedures are chosen to remove the anastomotic stenosis in terms of the causes of anastomotic stenosis.