直肠中动脉解剖分型与中低位直肠癌腹腔镜前切除术后吻合口漏的相关性研究

Correlation between anatomy of middle rectal artery and anastomotic leakage after laparoscopic resection of mid-low rectal cancer

目的探讨直肠中动脉(MRA)不同解剖分型与中低位直肠癌腹腔镜直肠前切除术后发生吻合口漏的关系。方法回顾性分析同济大学附属东方医院胃肠肛肠外科2015年1月至2017年12月收治的187例行腹腔镜直肠前切除术的中低位直肠癌患者临床资料,根据术前腹盆腔增强CT血管造影(CTA)分析MRA的不同解剖分型,采用Logistic多因素回归分析探讨术后发生吻合口漏的危险因素,并分析MRA解剖分型与术后吻合口漏的相关性。结果 187例中低位直肠癌患者术前CTA检查出现MRA174例(93.05%),缺如13例(6.95%),MRA出现病例中Ⅰ型(侧方型) 34例(19.54%),Ⅱ型(前侧方型) 56例(32.18%),Ⅲ型(经盆底肌表面型) 84例(48.28%)。术后发生吻合口漏11例(5.88%),MRAⅠ型+Ⅱ型患者吻合口漏发生率高于Ⅲ型患者,差异有统计学意义(P=0.007)。Logistic多因素回归分析结果显示,MRAⅠ型+Ⅱ型(P=0.022)、肿瘤下缘距齿状线距离<5cm (P=0.042)和术中发生并发症(P=0.001)是术后吻合口漏的独立危险因素。结论在接受腹腔镜中低位直肠癌保肛手术的患者中,MRA的解剖分型与吻合口漏发生有关,MRAⅠ型+Ⅱ型吻合口漏发生率高于MRAⅢ型患者。对于MRAⅠ型和Ⅱ型患者,应行预防性回肠造口,以减少吻合口漏发生后的不良影响。对于MRAⅢ型患者,游离肠管至直肠肛提肌交界处时,应尽量避免损伤,减少吻合口漏的发生。此外,尽量减少术中并发症的发生,糖尿病患者控制好血糖,对降低术后吻合口漏的风险亦具有重要的意义。

Objectives To determine the relationship between middle rectal artery(MRA)anatomy and anastomotic leakage af⁃ter laparoscopic resection for mid-and low rectal cancer.Methods This was a retrospective analysis of 187 patients with midand low rectal cancer who received laparoscopic resection between January 2015 and December 2017 at the Department of Colorectal Surgery,Shanghai East Hospital,Affiliated Hospital of Tongji University School of Medicine.MRA anatomy was ana⁃lyzed by preoperative abdominal and pelvic enhanced CT angiography(CTA).Multivariate logistic regression was used to analyze risk factors for postoperative anastomotic leakage and the relationship with MRA anatomy and such risk.Results MRA was lo⁃cated by CTA in 174/187(93.05%)patients and absent in 13/187(6.95%)patients.Among the 174 patients,34 had typeⅠ(later⁃al type,19.54%),56 typeⅡ(anterolateral type,32.18%),and 84 typeⅢ(trans-pelvic floor,48.28%).11(5.88%)patients devel⁃oped postoperative anastomotic leakage.The incidence of anastomotic leakage was significantly higher in patients with typeⅠ+Ⅱthan in those with typeⅢMRA(P=0.007).Multivariate logistic regression showed that MAR typeⅠ+Ⅱ(P=0.022),dis⁃tance<5 cm from the lower margin of the tumor to the dentate line(P=0.042),and intraoperative complications(P=0.001)were in⁃dependent risk factors for anastomotic leakage.Conclusion MRA anatomy is associated with incidence of anastomotic leakage af⁃ter laparoscopic resection in patients with mid-low rectal cancer.The incidence of leakage is higher in MRA typeⅠ+Ⅱpa⁃tients.For these patients,preventative ileostomy should be considered.For patients with MRA typeⅢ,intestine should be isolat⁃ed to the junction between rectum and levator ani muscle in order to avoid damage and lower incidence of leakage.In addition,to minimize the occurrence of intraoperative complications,control the blood glucose of diabetic patients,are important to reduce the risk of postoperative anastomotic leakage.