手术质量控制下中低位直肠癌一期吻合与预防性造口的对比研究

Comparative study between one-stage anastomosis of rectal carcinoma under surgical quality control and defunctioning stoma

目的:探讨手术质量控制下腹腔镜中低位直肠前切除术行一期吻合与预防性造口的利弊和留置肛管的优势。方法:选取某院行腹腔镜下中低位直肠前切除术的59例患者的临床资料,根据是否行预防性造口分为预防性造口组(30例)和一期吻合组(29例)。比较2组手术时间、术后较术前白蛋白下降值、排气排便时间、进食时间、拔管时间、出院时间、总治疗费用、吻合口漏(AL)发生率等。同时在一期吻合患者中根据是否留置肛管分为留置肛管组(16例)和未留置肛管组(13例),比较留置肛管对术后恢复的影响。结果:预防性造口组的手术时间[(4.14±1.02)h]长于一期吻合组[(3.66±0.86)h],排气排便时间、进食时间、拔管时间、出院时间[(3.00±1.41)d、(5.50±2.79)d、(10.59±3.60)d、(13.47±4.59)d]均短于一期吻合组[(5.24±1.46)d、(8.59±4.47)d、(14.03±5.70)d、(16.07±6.19)d],住院总费用[(101 696.12±8 985.97)元]多于一期吻合组[(72 777.31±15785.84)元],术后较术前白蛋白下降值[(13.74±5.09)g/L]多于一期吻合组[(11.81±4.85)g/L],差异均有统计学意义(P<0.05);预防性造口组AL发生率(3.33%)与一期吻合组AL发生率(13.79%)比较,差异无统计学意义(P>0.05)。留置肛管组排气排便时间[(4.69±1.20)d]短于未留置肛管组[(5.92±1.50)d](P<0.05),进食时间[(7.88±5.05)d]与未留置肛管组[(9.46±3.64)d]比较,差异无统计学意义(P>0.05)。结论:一期吻合与预防性造口AL发生率相当,但手术时间更短,费用更少,且避免了二次手术,因此不建议常规行预防性造口。留置肛管可以加速消化道功能的恢复,值得推广。

Objective:To compare the advantages and disadvantages between the one-stage anastomosis in laparoscopic middle and lower rectal anterior resection under surgical quality control and defunctioning stoma and to explore the merits of preservation of anal canal.Methods:Clinical data of 59 patients undergoing laparoscopic middle and lower rectal anterior resection were selected and were divided, according to whether to undergo defunctioning stoma, into a defunctioning stoma group(n=30)and a one-stage anastomosis group(n=29).Operation time, postoperative albumin decrease value, exhaust and defecation time, time of taking food, extubation time, discharge time, total treatment cost, and incidence of anastomotic leakage(AL) were compared between the two groups.Meanwhile, the 29 patients in the one-stage anastomosis group were, according to whether to preserve anal canal, re-divided into a preservation group(n=16) and a non-preservation group(n=13)and the effect of anal canal preservation on postoperative recovery was compared and assessed.Results:The operation time of the defunctioning stoma group[(4.14±1.02)h]was longer than that of the one-stage anastomosis group[(3.66±0.86)h];the exhaust and defecation time, time of taking food, extubation time, and discharge time[(3.00±1.41)d,(5.50±2.79)d,(10.59±3.60)d,(13.47±4.59)d]were earlier than those of the one-stage anastomosis group[(5.24±1.46)d、(8.59±4.47)d、(14.03±5.70)d、(16.07±6.19)d];the total treatment cost[(101 696.12±8 985.97) RMB yuan]was higher than that of the one-stage anastomosis group[(72 777.31±15 785.84) RMB yuan],the differences being statistically significant(all P<0.05).The postoperative albumin decrease value of the defunctioning stoma group[(13.74±5.09)g/L]was higher than that of the one-stage anastomosis group[(11.81±4.85)g/L](P<0.05).The incidence of AL in the defunctioning stoma group was 3.33%(1/30), while the incidence in the one-stage anastomosis group was 13.79%(4/29)(P>0.05).The exhaust and defecation time of the anal canal preservation group[(4.69±1.20)d]was earlier than that of the non-preservation group[(5.92±1.50)d](P<0.05), and the time of taking food[(7.88±5.05)d]was earlier than that of the non-preservation group[(9.46±3.64)d](P>0.05).Conclusion:The incidences of AL are not of much difference between one-stage anastomosis and defunctioning stoma, but the former uses shorter time and less treatment cost and can avoid the second operation, so the routine defunctioning stoma is not recommended.The preservation of anal canal can accelerate the recovery of digestive function and is worth to be recommened.