高位复杂性肛瘘术后复发危险因素分析

Risk factors of postoperative recurrence of high complex anal fistula

目的探讨高位复杂性肛瘘患者术后复发的危险因素。方法采用回顾性队列研究的方法,收集2016年12月—2019年9月在南京市中医院肛肠中心接受手术治疗的426例高位复杂性肛瘘患者的临床资料,其中男320例、女106例;年龄范围7~68岁,年龄为(36.65±12.94)岁。根据随访期间复发情况,将患者分为复发组(71例)和未复发组(355例)。比较两组患者的一般资料(包括年龄、性别构成、BMI、病程、手术方式、是否出院后定期至医院换药、有无糖尿病史、吸烟史、既往肛瘘手术史、内口是否明确),术后随访时记录复发终点事件(肛瘘复发)。采用单因素和多因素Cox回归分析术后复发的危险因素。采用Kaplan-Meier生存曲线比较有无定期至医院换药患者术后累积未复发率和3种手术方式患者术后累积未复发率。结果复发组患者年龄显著小于未复发组(P=0.017),性别构成比显著高于未复发组(P=0.021),BMI显著大于未复发组(P<0.001),出院后未定期至医院换药、有肛瘘手术史、内口不明确的患者比例均显著高于未复发组(P值均<0.001),行切开挂线术的患者比例显著低于未复发组(P<0.001),行直肠黏膜瓣推移术、括约肌间瘘管结扎术(LIFT)的患者比例均显著高于未复发组(P值均<0.001)。单因素Cox回归分析结果显示,性别、BMI、出院后未定期至医院换药、有肛瘘手术史、内口不明确和手术方式是患者术后复发的危险因素(P值均<0.05)。出院后未定期至医院换药的患者累积未复发率显著低于出院后定期至医院换药患者[风险比(HR)为3.813,95%CI为3.242~9.602,P<0.001],3种手术方式术后累积未复发率的差异有统计学意义(P值均为0.001)。多因素Cox回归分析结果显示,出院后未定期至医院换药(HR=2.380,95%CI为1.460~3.879,P=0.001)、既往肛瘘手术史(HR=6.896,95%CI为3.965~11.991,P<0.001)、直肠黏膜瓣推移术(HR=1.989,95%CI为1.020~3.879,P=0.044)、内口不明确(HR=3.218,95%CI为1.937~5.346,P<0.001)是术后复发的独立危险因素。结论出院后未定期至医院换药、既往肛瘘手术史、手术方式和内口不明确是高位复杂性肛瘘术后复发的独立危险因素,在临床实践中,肛肠外科医师应引起重视。

Objective To explore the risk factors of postoperative recurrence in patients with high complex anal fistula.Methods A restrospective cohort study was conducted to collect the clinical data of 426 patients with high complex anal fistula treated in the Anorectal Center of Nanjing Hospital of Traditional Chinese Medicine from December 2016 to September 2019.There were 320 males and 106 females,with a mean age of(36.65±12.94)years old(range,7-68 years old).They were divided into recurrence group(n=71)and non-recurrence group(n=355).The general information of the two groups were compared(including age,sex composition,body mass index[BMI],course of disease,mode of operation,regular dressing change after discharge,history of diabetes,history of smoking,operation history of anal fistula,and the condition of internal opening).Recurrence of anal fistula was recorded during follow-up.Univariate and multivariate Cox regression were used to analyze the risk factors of postoperative recurrence.Kaplan-Meier survival curve was used to evaluate the cumulative non-recurrence rate of patients who regularly went to hospital to change dressing and the cumulative non-recurrence rate of patients with three different surgical methods.Results The age of patients in the recurrence group was significantly lower than that in the non-recurrence group(P=0.017).The sex constituent ratio and BMI of the recurrence group were significantly higher than those in the non-recurrence group(P=0.021,P<0.001).The proportions of patients with irregular dressing change after discharge,operation history of anal fistula and unclear internal opening in the recurrence group were significantly higher than those in the non-recurrence group(all P<0.001).The recurrence group had lower proportion of patients who underwent cutting seton and higher proportion of patients who underwent endorectal advancement flap and ligation of the intersphincteric fistula tract(LIFT)than the non-recurrence group(all P<0.001).Univariate Cox regression analysis showed that gender,BMI,irregular dressing change after discharge,operation history of anal fistula,unclear internal opening and mode of operation were the risk factors of postoperative recurrence(all P<0.05).The cumulative non-recurrence rate of patients who received irregular dressing change was significantly lower than that of patients who received regular dressing change after discharge(hazard ratio[HR]=3.813,95%CI:3.242-9.602,P<0.001).There was significant difference in the cumulative non-recurrence rates among the three surgical methods(P=0.001).Multivariate Cox regression analysis showed that irregular dressing change after discharge(HR=2.380,95%CI:1.460-3.879,P=0.001),operation history of anal fistula(HR=6.896,95%CI:3.965-11.991,P<0.001),Endorectal Advancement Flap(HR=1.989,95%CI:1.020-3.879,P=0.044)and unclear internal opening(HR=3.218,95%CI:1.937-5.346,P<0.001)were independent risk factors of postoperative recurrence.Conclusion Irregular dressing change after discharge,operation history of anal fistula,mode of operation and unclear internal opening are independent risk factors of postoperative recurrence of high complex anal fistula,which deserves more attention in clinics.