确定性手术治疗慢性放射性肠损伤的安全性分析

Safety analysis of definitive surgery for chronic radiation intestinal injury

目的探讨确定性手术治疗慢性放射性肠损伤的安全性。方法采用描述性病例系列研究方法,回顾性分析北京清华长庚医院胃肠外科2016年6月至2020年5月期间收治的105例慢性放射性肠损伤病例;男性30例(28.6%),女性75例(71.4%);中位年龄58(P25,P75:52,64)岁。纳入标准:临床诊断为慢性放射性肠损伤且接受确定性手术治疗(即切除放射性损伤肠管+一期消化道重建)、资料完整的病例,排除肿瘤复发或拒绝手术的患者。根据术前评估结果和临床表现,选择最佳切除部位。观察指标:(1)术前评估情况(包括营养风险筛查评分、术前梗阻或瘘的情况);(2)临床表现和治疗策略;(3)确定性手术情况;(4)术后并发症情况,Clavien-Dindo分级为Ⅲ~Ⅴ级定义为中-重度并发症。结果(1)术前评估情况:88例(83.8%)患者在放疗结束超过1年出现慢性放射性肠损伤症状。98例(93.3%)患者术前营养风险筛查评分≥3分,74例(70.5%)患者接受术前肠外营养支持,中位营养支持时间为10.5(7.0,16.0)d。16例(15.2%)患者术前因严重梗阻接受小肠减压管置入。(2)临床表现和治疗策略:全部患者中,有87例(82.9%)临床表现为肠梗阻,均接受放射性损伤肠管确定性切除+一期消化道重建;18例(17.1%)患者临床表现为肠瘘,均接受放射性损伤肠段、肠瘘确定性切除+一期消化道重建,其中3例回肠直肠残端瘘患者同时接受带蒂大网膜盆腔封闭术;4例回肠膀胱瘘患者中,2例患者因术前已行肾造口减压而接受膀胱瘘切除和膀胱修补术,另2例患者在瘘口近远端离断小肠并关闭肠袢,不行瘘口切除及肠瘘和膀胱瘘修补术。(3)确定性手术情况:中位确定性手术时间和中位术中失血量分别为230(180,300)min和50(20,50)ml。105例患者中,92例(87.6%)患者吻合部位为回肠-结肠吻合,其中回肠-结肠肝曲和回肠-结肠脾曲吻合分别为88例(83.8%)和4例(3.8%);13例(12.4%)患者为回肠-回肠吻合。92例(87.6%)患者吻合部位严格位于放射野的对侧象限,13例(12.4%)患者吻合部位远离放射野。105例患者中,9例(8.6%)吻合口>1个,5例(4.8%)剩余小肠长度<180 cm,7例(6.7%)行小肠逆行排列术,4例(3.8%)因腹壁缺损接受同期腹壁重建手术,87例(82.9%)腹盆腔严重粘连(3~4级粘连)。术中3例(2.9%)出现并发症,均及时发现并妥善处理。术后中位住院时间为13.0(12.0,24.5)d,所有患者出院时均已恢复经口进食。(4)术后并发症情况:术后共14例(13.3%)患者共发生18例次中-重度并发症。术后吻合口漏发生率为5.7%(6/105),其中回肠-结肠吻合和回肠-回肠吻合的吻合口漏发生率分别为2.2%(2/92)和4/13(χ^(2)=17.29,P<0.001);临床表现为肠瘘和肠梗阻的术后吻合口漏的发生率分别为3/18和3.4%(3/87)(χ^(2)=4.84,P=0.028),差异均具有统计学意义。术后30 d病死率为1.0%(1/105),为术后吻合口漏引起腹腔感染、感染性休克,最终导致多器官功能衰竭而死亡。结论确定性手术治疗慢性放射性肠损伤是安全可行的。

Objective To investigate the safety of definitive surgery for chronic radiation intestinal injury.Methods A descriptive case series study was performed.Clinical data of 105 patients who were diagnosed as chronic radiation intestinal injury,had complete data and received definitive surgery(the radiation-induced intestinal segment and digestive tract reconstruction)at Department of Gastrointestinal Surgery of Beijing Tsinghua Changgung Hospital from June 2016 to May 2020 were retrospectively analyzed.There were 30 males(28.6%)and 75 females(71.4%)with the median age of 58 years(P25,P75:52,64 years).Patients who had tumor recurrence or refused surgical treatment were excluded.According to the preoperative evaluation and clinical manifestations,to select the resection range.Outcome parameters:(1)preoperative evaluation(nutrition risk assessment and status of obstruction or fistula);(2)clinical manifestations and treatment strategies;(3)details of surgical parameters;(4)postoperative complications,and Clavien-Dindo classification III to V was defined as main moderate-severe complication.Results(1)Preoperative evaluation:Eighty-eight patients(83.8%)developed symptoms of chronic radiation intestinal injury more than 1 year after the end of radiotherapy.Ninety-eight patients(93.3%)had preoperative NRS-2002 score≥3,74 patients(70.5%)received preoperative parenteral nutritional support,and the median time of nutritional support was 10.5(7.0,16.0)days.Sixteen patients(15.2%)received small intestinal decompression tube implantation due to severe obstruction.(2)Clinical manifestations and treatment strategies:Among 105 patients,87(82.9%)presented with obstruction and received definitive resection of the radiation-induced intestinal segment plus one-stage digestive tract reconstruction;18(17.1%)presented with intestinal fistula and all of them received definitive resection of the radiation-induced intestinal segment,intestinal fistula plus one-stage digestive tract reconstruction.Among above 18 patients with fistula,3 patients with ileorectal stump fistula received pedicled pelvic closure of greater omentum at the same time;4 patients had ileal vesical fistula,of whom 2 patients received cystectomy and bladder repair due to preoperative nephrostomy decompression,and the other 2 patients received transection of the small intestine proximal and distal to the fistula and anastomosis of the intestinal loop without fistula resection,intestinal fistula or bladder fistula repair.(3)The details of surgical parameters:Median operative time and intraoperative blood loss was 230(180,300)minutes and 50(20,50)ml respectively.Ninety-two patients(92/105,87.6%)underwent ileocolonic anastomosis,and anastomosis on the hepatic flexure or splenic flexure colon were performed in 88(83.8%)and 4(3.8%)patients respectively.Ileoileal anastomosis was performed in 13 patients(12.4%).The anastomotic site of 92 patients(87.6%)was strictly located in the contralateral quadrant of the radiation field,and the anastomotic site of 13 patients(12.4%)was far from the radiation field.Nine patients(8.6%)had more than one anastomosis,5 patients(4.8%)had less than 180 cm of residual small intestine,7 patients(6.7%)underwent retrograde intestinal permutation,4 patients(3.8%)underwent abdominal wall reconstruction surgery due to abdominal wall defects,and 87 patients(82.9%)had severe abdominal pelvic adhesions(grade 3-4 adhesions).Intraoperative complications occurred in 3 patients(2.9%),which were found in time and handled properly.The median postoperative hospital stay was 13.0(12.0,24.5)days,and all the patients had resumed oral feeding upon discharge.(4)Postoperative complications:Fourteen patients(13.3%)had 18 major complications(grade III to V).The incidence of postoperative anastomotic leakage was 5.7%(6/105),and the incidence of anastomotic leakage for ileocolon anastomosis and ileoileal anastomosis was 2.2%(2/92)and 4/13,respectively(χ^(2)=17.29,P<0.001).The incidence of postoperative anastomotic leakage of intestinal fistula and intestinal obstruction was 3/18 and 3.4%(3/87),respectively(χ^(2)=4.84,P=0.028).The mortality at 30 days after operation was 1.0%(1/105),after abdominal infection and septic shock caused by postoperative anastomotic leakage resulting in multiple organ failure.Conclusion For chronic radiation intestinal injury patients with obstruction or fistula,definitive surgical treatment is feasible and safe with acceptable major complications.