腹腔镜直肠前切除术后吻合口漏发生的危险因素及其防治措施

Risk factors,prevention and treatment of anastomotic leakage after laparoscopic anterior resection of rectum

目的通过对结直肠漏评分(CLS)系统在腹腔镜直肠前切除术中的运用来探讨发生吻合口漏(AL)的相关因素及吻合口漏防治的经验分享。方法纳入2014年1月至2017年6月期间于四川省肿瘤医院行腹腔镜直肠前切除术的患者,采用CLS评分系统来分析术后发生吻合口漏的危险因素,总结腹腔镜直肠前切除术并发AL的防治经验。结果共582例患者纳入本研究,术后发生吻合口漏43例(7.3%),其中有症状吻合口漏29例(4.9%)。单因素分析显示:性别、ASA麻醉分级、不健康个人史、新辅助治疗、吻合口距肛缘距离、附加的手术程序、术中失血与输血及手术时间与腹腔镜直肠前切除术后吻合口漏的发生相关(均P<0.05)。多因素回归分析显示:术前麻醉分级ASA(OR 3.173,95%CI:1.848~5.448)、不健康生活行为(OR 3.898,95%CI:2.144~7.085)、吻合口与肛缘的距离(OR 1.718,95%CI:1.3605~2.262)、附加的手术程序(OR 11.353,95%CI:3.387~38.058)、手术时间(OR 1.622,95%CI:1.144~2.301)、术中保护性造口(OR 0.024,95%CI:0.005~0.123)、改良技术的运用与否(OR 0.271,95%CI:0.091~0.803)是影响术后吻合口漏发生的独立危险因素(均P<0.05)。CLS评分系统对腹腔镜直肠前切除术后吻合口漏的发生有良好的预测作用,CLS 12分可以作为腹腔镜直肠前切除术后吻合口漏发生的高风险临界预测值。结论对于腹腔镜直肠前切除术后CLS评分>12分,应警惕术后吻合口漏的发生,运用相关腹腔镜改良技术可以有效防治AL的发生。

Objective To explore the related factors about the occurrence of anastomotic leakage by Colorectal Leakage Scoring System(CLS)in laparoscopic anterior resection and share the experience on the prevention and treatment of anastomotic leakage in our department.Methods Clinical data of 582 rectal cancer patients who underwent elective laparoscopic anterior resection from January 2014 to June 2017 at Affiliated Sichuan Tumor Hospital of Electronic Science and Technology University were retrieved.Demographic data were collected in CLS to evaluate the risk of anastomotic leakage.Results Of all the 582 enrolled patients,the cases of anastomotic leakage and symptomatic anastomotic leakage were 43(7.3%)and 29(4.9%)respectively.In univariate analysis,gender,American Society of Anesthesiologists(ASA),intoxication,neoadjuvant therapy,distance between anastomosis and anal verge,additional procedures,blood loss(mL)and blood transfusion,duration of operation were significantly associated with postoperative anastomotic leak(P<0.05).Multivariate analysis showed that ASA(OR 3.173,95%CI:1.848~5.448),intoxication(OR 3.898,95%CI:2.144~7.085),distance between anastomosis and anal verge(OR 1.718,95%CI:1.3605~2.262),additional procedures(OR 11.353,95%CI:3.387~38.058),duration of operation(OR 1.622,95%CI:1.144~2.301),protective enterostomy(OR 0.024,95%CI:0.005~0.123)and the application of modified pelvic reconstruction or not(OR 0.271,95%CI:0.091~0.803)were the independent risk factors of anastomotic leak following laparoscopic anterior resection for the rectal cancer.The CLS has a good value of predicting anastomotic leakage after laparoscopic anterior resection of rectal cancer.CLS scored 12 could be considered as a high critical risk predictive value of anastomotic leakage after laparoscopic anterior resection.Conclusion For patients with the CLS score of more than 12 after laparoscopic anterior resection,the occurrence of postoperative anastomotic leakage should be monitored.Modified laparoscopic technique can effectively prevent the occurrence of AL.