直肠癌低位前切除术后吻合口漏的危险因素分析

Risk factors analysis of anastomotic leakage after low anterior resection of rectal cancer

目的探究直肠癌低位前切除(LAR)术后吻合口漏的影响因素,为临床诊疗提供依据。方法回顾性收集南京医科大学第一附属医院结直肠外科2013年1月—2017年12月期间完成的1 336例直肠癌LAR手术患者的临床资料,进行数据整理分析。其中男性838例,女性498例,中位年龄62(53,70)岁。观察指标包括:(1)手术情况,包括预防性造口、保留左结肠动脉、留置肛管等;(2)术后情况,包括临床症状体征、术后住院时间等。依据2010年国际直肠癌研究小组(ISREC)吻合口漏的分级方法进行分级。偏态分布的计量资料以中位数表示,组间比较采用Mann-Whitney U检验。等级资料以频数和率表示,组间比较采用秩和检验。计数资料以频数和率表示,组间比较采用χ^2检验或Fisher确切概率法。单因素分析选出的潜在影响因素纳入多因素非条件logistic回归,分析吻合口漏发生的独立危险因素。结果吻合口漏发病率为10.4%(139/1 336),其中B级漏为7.0%(93例),C级漏为3.4%(46例)。C级漏发生时间早于B级漏,分别为3(2,6) d和5(3,7)d(Z=2.746,P=0.006)。单因素分析表明,吻合口漏在性别、体重指数、放置肛管、肿瘤部位的不同分组中存在差异(χ^2=10.897、9.033、6.343、6.34,Z=-2.380, P<0.05)。进一步的多因素logistic回归分析显示,男性(OR=1.840,95%CI:1.210~2.799,P=0.004)、体重指数≥24 kg/m^2(OR=1.573,95%CI:1.088~2.274,P=0.016)、放置肛管(OR=2.418,95%CI:1.196~4.888,P=0.014)、中段肿瘤(OR=1.536,95%CI:0.836~2.822,P=0.167)、下段肿瘤(OR=1.989,95%CI:1.068~2.822,P=0.03)、超低位肿瘤(OR=2.908,95%CI:1.289~6.560,P=0.01)是发生吻合口漏的独立危险因素。结论男性、高体重指数、放置肛管、低位肿瘤患者发生吻合口漏的危险性增加,是吻合口漏的独立危险因素。

Objective To analyze the risk factors for anastomotic leakage after low anterior resection(LAR) for rectal cancer. Methods The retrospective study of 1 336 patients with rectal cancer who underwent LAR from Jan. 2013 to Dec. 2017 in the Department of Colorectal Surgery, First Affiliated Hospital of Nanjing Medical University was conducted. There were 838 male and 498 female patients. The median age was 62 (53, 70) years. Observation indicators:①intraoperative conditions, including the performance of preventive enterostomy, the preservation of left colic artery, the placement of transanal decompression tube;②postoperative conditions, for example, postoperative clinical symptoms and physical examination, postoperative hospital stay. Anastomotic leakage patients were graded according to the grading system of anastomotic leakage following anterior resection of the rectum proposed by the International Study Group of Rectal Cancer in 2010. Measurement data with non-normal distribution were described as median, and comparison between groups was done using Mann-Whitney U test. Ranked data were compared with rank sum test. Comparison of count data between groups were analyzed using the Chi-square test or Fisher exact test. Potential risk factors for anastomotic leakage were further analyzed with multiple logistic regression. Results Anastomotic leakage was noted in 138(10.4%) of 1 336 patients with 93 patients (7.0%) of Grade B and 46 patients (3.4%) of Grade C respectively.The occurrence of Grade C anastomotic leakage was on the 3th day postoperatively, which was earlier than Grade B anastomotic leakage [5(3, 7) d, Z=2.746, P=0.006]. There were significant differences in sex, BMI, placement of transanal decompression tube and tumor location between anastomotic leakage cases and non-anastomotic leakage cases by Chi-squared test(χ^2=10.897, 9.033, 6.343, 6.34, Z=-2.380, P<0.05). On multiple logistic regression analysis, male sex(OR=1.840, 95%CI: 1.210-2.799, P=0.004), BMI≥24 kg/m^2(OR=1.573, 95%CI: 1.088-2.274, P=0.016), placement of transanal decompression tube(OR=2.418, 95%CI: 1.196-4.888, P=0.014), middle rectal cancer(OR=1.536, 95%CI: 0.836-2.822, P=0.167), low rectal cancer(OR=1.989, 95%CI: 1.068-2.822, P=0.03), ultralow rectal cancer (OR=2.908, 95%CI: 1.289-6.560, P=0.01) were independent risk factors of anastomotic leakage. Conclusion Male sex, high BMI, placement of transanal decompression tube and low rectal tumor were independent risk factors of anastomotic leakage for patients receiving LAR.