经肛全直肠系膜切除治疗中低位直肠癌术后吻合口失败的发生及危险因素分析

Incidence and risk factors of anastomotic failure after transanal total mesorectal resection for mid-low rectal cancer

目的探究经肛全直肠系膜切除(transanal total mesorectal excision,taTME)术后吻合口失败的发生率,并确定其危险因素。方法分析首都医科大学附属北京友谊医院2016年11月至2021年10月期间前瞻性收集的88例连续性接受taTME手术并行一期吻合的直肠癌病人的临床资料。主要研究终点为吻合口失败,包括早期和晚期吻合口漏、盆腔脓肿、吻合口瘘管形成、慢性窦道形成及吻合口狭窄。计数资料比较采用χ^(2)检验或Fisher确切概率法来探究组间基线差异,计量资料比较采用Mann-Whitney U检验来探究组间基线差异。使用二元Logistic模型确定吻合口失败的独立危险因素。结果88例接受taTME手术的病人中发生吻合口失败19例(21.6%)。总的吻合口漏发生率为18.2%(16/88),A级7例,B级8例,C级1例。早期(术后≤30 d)吻合漏13例(14.8%),其中3例(3.4%)病人出院后被诊断;晚期(术后>30 d)吻合口漏3例(3.4%)。5例病人因吻合口漏再次入院治疗,4例病人形成慢性盆腔脓肿。吻合口狭窄的发生率为11.4%(10/88),其中7例病人同时被诊断为吻合口漏。未发现病人有吻合口瘘管及慢性窦道形成。单因素分析结果显示,吸烟、美国麻醉医师协会分级≥Ⅲ级和低位肿瘤与taTME术后吻合口失败的发生显著相关;多因素分析显示,糖尿病是吻合口失败的独立危险因素。结论根据吻合失败危险因素,对于高风险病人个体化制定前期管理、术中决策以及术后治疗方案,以减少和减轻吻合口相关并发症的发生。

Objective To determine the incidence of anastomotic failure after transanal total mesorectal excision(taTME)and identify its risk factors.Methods Between November 2016 and October 2021,clinical data were collected prospectively from 88 consecutive patients undergoing taTME with primary anastomosis at a single center.The primary endpoint of anastomotic failure was defined as a composite endpoint of early and delayed anastomotic leakage(AL),pelvic abscess,anastomotic fistula formation,chronic sinus formation and anastomotic stricture.χ^(2) test or Fisher′s exact probability test was employed for intergroup variations of categorical or dichotomous outcomes.And Mann-Whitney U test was utilized for intergroup variation.Univariable and multivariable Logistic regression analyses were performed with a binary Logistic model for identifying predictors for anastomotic failure.Results Anastomotic failure occurred in 19/88 taTME patients(21.6%).The overall rate of AL was 18.2%(16/88).Clinical grades were A(n=7),B(n=8)and C(n=1).Among 13 cases(14.8%)of early anastomotic leak(≤30 d),3 patients(3.4%)were diagnosed after discharge and 3 cases(3.4%)developed delayed AL(>30 d).Five patients were readmitted for AL and four cases developed chronic pelvic abscess.Anastomotic stricture rate was 11.4%(10/88)and AL was diagnosed in 7 patients.There was no occurrence of anastomotic fistula or chronic sinus formation.Univariate analysis revealed that smoking,American Society of Anesthesiologists(ASA)grade≥Ⅲand low rectal cancer were significantly associated with anastomotic failure after taTME.And multivariate analysis indicated that diabetes mellitus was an independent risk factor for anastomotic failure.Conclusion Based upon anastomotic failure risk factors,preoperative management,intraoperative decision-making and postoperative treatment protocol should be individualized for high-risk patients for minimizing the occurrence of anastomotic-related complications.