经腹经肛全直肠系膜切除术后吻合口漏影响因素分析

Analysis of influencing factors for anastomotic leakage after transabdominal transanal total mesorectal excision

目的探讨经腹经肛全直肠系膜切除术后吻合口漏的影响因素。方法采用回顾性病例对照研究方法。收集2017年12月至2018年11月上海交通大学医学院附属仁济医院收治的50例直肠癌患者的临床病理资料;男34例,女16例;年龄为(60±11)岁,年龄范围为31~84岁。患者均行经腹经肛全直肠系膜切除术。观察指标:(1)经腹经肛全直肠系膜切除术后吻合口漏情况。(2)经腹经肛全直肠系膜切除术后吻合口漏影响因素分析。(3)学习曲线对经腹经肛全直肠系膜切除术后吻合口漏的影响。正态分布的计量资料以±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。单因素分析采用χ^2检验,多因素分析采用Logistic回归模型。结果(1)经腹经肛全直肠系膜切除术后吻合口漏情况:50例患者中,术后发生吻合口漏9例,其中A级吻合口漏6例(2例术中行保护性造口),B级吻合口漏2例,C级吻合口漏1例。9例发生吻合口漏患者中,男5例,女4例;年龄为62岁(40~75岁);体质量指数为27 kg/m^2(21~31 kg/m^2);吻合口距肛缘距离为30 mm(5~40 mm)。(2)经腹经肛全直肠系膜切除术后吻合口漏影响因素分析。单因素分析结果显示:吻合方式和保护性造口是影响经腹经肛全直肠系膜切除术后吻合口漏的相关因素(χ^2=5.490,5.456,P<0.05)。多因素分析结果显示:吻合方式和保护性造口均不是影响经腹经肛全直肠系膜切除术后吻合口漏的独立因素(优势比=0.062,0.460,95%可信区间为0.009~1.119,0.102~2.809,P>0.05)。(3)学习曲线对经腹经肛全直肠系膜切除术后吻合口漏的影响:随着学习曲线的度过及保护性造口的使用,学习曲线前25例患者中,术中行保护性造口11例,术后发生吻合口漏6例;学习曲线后25例患者中,术中行保护性造口20例,术后发生吻合口漏3例。学习曲线前、后术后吻合口漏比较,差异无统计学意义(χ^2=1.220,P>0.05)。结论吻合方式和保护性造口是影响经腹经肛全直肠系膜切除术后吻合口漏的相关因素。

Objective To investigate the influencing factors for anastomotic leakage after transabdominal transanal total mesorectal excision.Methods The retrospective case-control study was conducted.The clinicopathological data of 50 patients with rectal cancer who were admitted to the Renji Hospital of Shanghai Jiaotong University School of Medicine from December 2017 to November 2018 were collected.There were 34 males and 16 females,aged(60±11)years,with a range from 31 to 84 years.All the patients underwent transabdominal transanal total mesorectal excision.Observation indicators:(1)anastomotic leakage after transabdominal transanal total mesorectal excision;(2)analysis of influencing factors for anastomotic leakage after transabdominal transanal total mesorectal excision;(3)effects of learning curve on anastomotic leakage after transabdominal transanal total mesorectal excision.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers or percentages.Univariate analysis was conducted using the chi-square test,and multivariate analysis was conducted using the Logistic regression model.Results (1)Anastomotic leakage after transabdominal transanal total mesorectal excision:of the 50 patients,9 had postoperative anastomotic leakage,including 6 of grade A anastomotic leakage(2 patients receiving protective enterostomy),2 of grade B anastomotic leakage,and 1 of grade C anastomotic leakage.Of the 9 patients with anastomotic leakage,there were 5 males and 4 females,aged 62 years(range,40-75 years).The 9 patients had a body mass index of 27 kg/m^2(range,21-31 kg/m^2),and a distance from anastomosis to anal edge of 30 mm(range,5-40 mm).(2)Analysis of influencing factors for anastomotic leakage after transabdominal transanal total mesorectal excision:results of univariate analysis showed that anastomotic method and protective stoma were related factors for anastomotic leakage after transabdominal transanal total mesorectal excision(χ^2=5.490,5.456,P<0.05).Results of multivariate analysis showed that anastomotic method and protective stoma were not independent factors for anastomotic leakage after transabdominal transanal total mesorectal excision(odds ratio=0.062,0.460,95%confidence interval:0.009-1.119,0.102-2.809,P>0.05).(3)Effects of learning curve on anastomotic leakage after transabdominal transanal total mesorectal excision:with the passing of learning curve and the use of protective stoma,11 of the first 25 patients of learning cure underwent protective stoma and 6 had postoperative anastomotic leakage,while 20 of the last 25 patients of learning cure underwent protective stoma and 3 had postoperative anastomotic leakage.There was no significant difference in the postoperative anastomotic leakage between them(χ^2=1.220,P>0.05).Conclusion Anastomotic method and protective stoma are related factors influencing anastomotic leakage after transabdominal transanal total mesorectal excision.