保留左结肠动脉对接受新辅助治疗的直肠癌患者术后吻合口漏的影响

Effect of preservation of left colic artery on postoperative anastomotic leakage of patients with rectal cancer after neoadjuvant therapy

目的探讨保留左结肠动脉(LCA)对接受新辅助治疗的直肠癌患者术后吻合口漏的影响。方法采用回顾性队列研究方法。收集2014年9月至2017年8月期间,福建省肿瘤医院胃肠肿瘤外科收治的直肠癌患者临床资料。纳入标准:(1)年龄在18~79岁之间;(2)术后病理证实为直肠腺癌;(3)术前无严重心脑血管基础疾病,且均行术前新辅助放(化)疗;(4)行腹腔镜辅助直肠前切除手术同时行末端回肠造口术,且临床资料完整。排除术中探查发现腹腔广泛转移、远处脏器转移或行联合脏器切除者。根据术中是否保留LCA分为两组,比较两组患者术中及术后情况,并通过单因素分析和多因素logistic回归分析新辅助治疗后直肠癌患者术后发生吻合口漏的相关因素。结果本研究共纳入125例患者资料,其中保留LCA组56例,不保留LCA组69例。保留LCA组与不保留LCA组患者性别、年龄、糖尿病、体质指数、术前血红蛋白水平、肿瘤距肛缘距离、肿瘤最大直径、术前新辅助治疗方式、ypTNM分期等一般资料的比较,差异均无统计学意义(均P>0.05),具有可比性。两组患者在手术时间、术中出血量、淋巴结清扫总数、肠系膜下动脉根部淋巴结清扫数、环周切缘情况、游离脾区情况、吻合口出血情况及术后住院天数方面比较,差异均无统计学意义(均P>0.05)。不保留LCA组中有18.8%(13/69)患者出现术后吻合口漏,其中A级、B级、C级分别为7例、5例和1例;而保留LCA组术后出现吻合口漏者仅占5.4%(3/56),其中A级1例,B级2例,无C级漏,两组差异有统计学意义(U=1 674.500,P=0.028)。单因素分析显示,术前血红蛋白<120 g/L、不保留LCA与本组接受新辅助治疗直肠癌患者术后发生吻合口漏有关(均P<0.05)。进一步纳入多因素分析显示,术前血红蛋白<120 g/L(OR=3.508,95%CI:1.158~10.628,P=0.017)、不保留LCA(OR=4.065,95%CI:1.074~15.388,P=0.031)均为影响本组患者术后发生吻合口漏的独立危险因素。所有患者中位随访时间为31(16~51)个月,无远期并发症发生。保留LCA组局部复发1例(1.8%),7例(12.5%)出现远处转移,而不保留LCA组局部复发及远处转移分别为2例(2.9%)及5例(7.2%),两组差异无统计学意义(分别为P=1.000、P=0.321)。结论保留LCA可以在不增加手术时间及出血量的情况下,达到同样彻底的淋巴结清扫效果,而且还能有效降低新辅助治疗后直肠癌患者术后吻合口漏的发生。

Objective To evaluate the effect of preservation of left colic artery (LCA) on postoperative anastomotic leakage in patients with rectal cancer after neoadjuvant therapy. Methods A retrospective cohort study was conducted to collect data of rectal cancer patients at Department of Gastrointestinal Surgery of Fujian Cancer Hospital from September 2014 to August 2017. Inclusion criteria:(1) age of 18 to 79 years;(2) rectal adenocarcinoma confirmed by postoperative pathology;(3) patients without preoperative serious cardiovascular and cerebrovascular disease receiving preoperative neoadjuvant radiotherapy or chemoradiotherapy;(4) laparoscopic-assisted anterior rectal resection and distal ileostomy were performed simultaneously;(5) complete clinical data. Exclusion criteria: patients with extensive abdominal metastasis, or distant organ metastasis during operation, and combined organ resection. According to whether LCA was retained during operation, the patients were divided into two groups, then the intraoperative and postoperative clinical outcomes were compared. Moreover, univariate analysis and multivariate logistic regression were used to analyze risk factors of postoperative anastomotic leakage. Results A total of 125 patients were included in this study, including 56 patients in the retained LCA group and 69 patients in the non-retained LCA group. Differences in baseline data, such as gender, age, diabetes mellitus, body mass index, hemoglobin, distance between tumor and anal margin, maximum diameter of tumor, preoperative neoadjuvant therapy, and ypTNM stage, between retained LCA group and non-retained LCA group were not statistically significant (all P>0.05), indicating that two groups were comparable. Meanwhile there were no significant differences in operation time, intraoperative blood loss, total number of lymph node harvested, number of harvested lymph node at the root of inferior mesenteric artery, circumferential margin, anastomotic bleeding, or postoperative hospital stay between two groups (all P>0.05). Thirteen patients in the non-retained LCA group (18.8%) developed postoperative anastomotic leakage, including 7 cases of grade A, 5 cases of grade B and 1 case of grade C, while in the retained LCA group, only 5.4%(3/56) of patients developed postoperative anastomotic leakage, including 1 case of grade A and 2 cases of grade B without case of grade C, whose difference was statistically significant (U=1674.500, P=0.028). Univariate analysis showed that preoperative hemoglobin <120 g/L and non-retained LCA were associated with postoperative anastomotic leakage (both P<0.05). Multivariate analysis cofirmed that preoperative hemoglobin < 120 g/L (OR=3.508, 95% CI: 1.158 to 10.628, P=0.017) and non-retained LCA (OR=4.065, 95%CI: 1.074 to 15.388, P=0.031) were independent risk factors for postoperative anastomotic leakage. Median follow-up time was 31 months (16 to 51 months), and no long-term complication was found. Local recurrence and distant metastasis were found in 1 case (1.8%) and 7 case (12.5%) in the retained LCA group, while those were found in 2 cases (2.9%) and 5 cases (7.2%) respectively, in the non-retained LCA group, whose differences were not statistically significant (P=1.000, P=0.321 respectively). Conclusion Preservation of left colic artery not only can ensure radical lymph node dissection efficacy under the condition of similar operation time and blood loss, but also can effectively reduce the incidence of postoperative anastomotic leakage for rectal cancer patients after neoadjuvant therapy.