直肠癌术后吻合口漏的早期诊断和预防研究进展

Research progress on early diagnosis and prevention of anastomotic leak after rectal cancer surgery

吻合口漏是直肠前切除术后常见且严重的并发症,尽管吻合器械及外科手术技术不断进步,但吻合口漏发生率并无显著下降。随着更多关于吻合口漏早期诊断的研究发表,吻合口漏的危险因素如发热、首次排粪时间、腹部CT、C-反应蛋白(CRP)水平、降钙素原(PCT)水平、基质金属蛋白酶-9、其他细胞因子和生物标志物(IL-6、TNF-α、乳酸、pH值、尿新蝶呤/肌酐比率)等为外科医生评估吻合口漏发生风险提供了参考,增加了吻合口漏早期诊断的可能。尽管如此,预防吻合口漏的发生仍然是最终目标。对于吻合口漏的预防,术中吲哚菁绿(ICG)荧光显影技术为医生评估吻合口灌注提供了一种简单且安全的客观手段;转流性造口的应用可能降低吻合口漏发生率;越来越多的证据表明,经肛管引流可以减少直肠癌术后吻合口漏发生率。但是对于不同类型的引流管是否均可以明确降低吻合口漏发生率,还需要更多的循证医学证据。此外,对于经肛引流管留置时间,放置的位置尚未形成统一意见。目前对于吻合口漏的研究仍未采用统一的定义,相关研究之间的异质性大,仍然期待更多高质量、多中心、大型前瞻性及随机对照研究来明确直肠癌吻合口漏的早期诊断和预防措施。

Anastomotic leak is a common and serious complication after anterior rectal resection.Despite the continuous advancement of anastomotic instruments and surgical techniques,the incidence of anastomotic leak has not decreased significantly compared with the past.As more studies on the early diagnosis of anastomotic leak are published,postoperative risk factors of anastomotic leak,such as fever,time to first bowel movement,CT,C-reactive protein(CRP)and procalcitonin(PCT),matrix metalloproteinase-9,and other cytokines and biomarkers(IL-6,TNF-α,lactate,pH,urinary neopterin/creatinine ratio),provide a reference for surgeons to assess the risk and increase the possibility of early diagnosis of anastomotic leak.Nevertheless,preventing the occurrence of anastomotic leak is still the ultimate goal.For the prevention of anastomotic leak,intraoperative ICG fluorescence imaging technology provides a simple and safe objective method for surgeons to evaluate anastomotic perfusion.The diversion stoma may reduce the incidence of anastomotic leak.More and more evidence shows that drainage through the anal canal can reduce the incidence of anastomotic leak after rectal cancer,but whether different types of drainage catheters can clearly reduce the incidence of anastomotic leak still needs more evidence.In addition,there has not yet been a unified opinion on the retention time and location of the drainage catheter.At present,the research of anastomotic leak has not adopted a unified definition and the heterogeneity among related studies is still great.We still look forward to more high-quality multi-center large prospective and randomized controlled studies.