直肠癌术后直肠阴道瘘的危险因素及诊治体会

Risk factors of rectovaginal fistula after rectal cancer surgery and experience in treatment

目的分析中低位直肠癌直肠前切除术后直肠阴道瘘的危险因素,探讨治疗直肠阴道瘘的优先干预措施。方法回顾性分析2011年1月至2019年12月就诊于福建医科大学附属协和医院结直肠外科的960例中低位直肠癌女性病人的临床资料,计量资料采用t检验或秩和检验,计数资料采用χ^2检验或Fisher精确概率法,采用Logistic回归模型进行直肠阴道瘘相关危险因素的单因素和多因素分析。结果中低位直肠癌直肠前切除术后直肠阴道瘘的发生率为3.4%,多因素分析结果提示:术前血清血红蛋白水平(P=0.008)、肿瘤与肛缘距离(P=0.032)、手术术式(P=0.025)及联合盆腔脏器切除(P=0.001)是发生直肠阴道瘘的独立危险因素。单纯转流性肠造口或保守治疗的治愈率为42.4%(14/33),但治疗周期较长。在造口基础上接受推移皮瓣修补术8例,治愈6例。结论直肠癌病人术前贫血(<90 g/L)、肿瘤位置低(≤5 cm)、联合盆腔脏器切除、接受经括约肌间切除手术者,术后应警惕直肠阴道瘘的发生,推荐行转流性肠造口术以促进炎症反应和感染消退,积极的外科治疗可使多数病人治愈。

Objective To analyze the risk factors of rectovaginal fistula after anterior rectal resection for middle and low rectal cancer and to explore the priority interventions for the treatment of rectovaginal fistula.Methods The clinical data of 960 female patients with low rectal cancer who visited the Department of Colorectal Surgery,Fujian Medical University Union Hospital from January 2011 to December 2019 were retrospectively analyzed.The measurement data were analyzed by t test or rank sum test.The enumeration data were analyzed byχ^2 test or Fisher exact probability method.The univariate and multivariate analysis of risk factors related to rectovaginal fistula was performed by logistic regression model.P<0.05 was considered statistically significant.Results The incidence of rectovaginal fistula after anterior proctectomy for middle and low rectal cancer was 3.4%.The results of multivariate analysis suggested that preoperative serum hemoglobin level(P=0.008),distance between tumor and anal verge(P=0.032),surgery(P=0.025)and combined pelvic exenteration(P=0.001)were independent risk factors for rectovaginal fistula.The cure rate of simple bypass enterostomy or conservative treatment was 42.4%(14/33),but the treatment cycle was long.The cure rate of flap repair on the basis of stoma was 75%(6/8).Conclusion Patients with rectal cancer who have preoperative anemia(<90 g/L),low location of tumor(≤5 cm),combined pelvic exenteration and intersphincteric resection should be alert to the occurrence of rectovaginal fistula after operation.Bypass enterostomy is recommended to promote inflammatory response and infection subsidence.Active surgical treatment can cure most patients.