重视极限保肛术后吻合口的全程管理

Importance of comprehensive management of anastomotic site after ultra-low anal sphincter-preservation surgery

低位直肠癌患者采取经括约肌间切除术(ISR)可提高其保肛率。然而,ISR手术吻合口面临吻合口漏、吻合口分离、继发吻合口狭窄、慢性骶前窦道、直肠阴道瘘和直肠尿道瘘等吻合口结构性愈合不良的并发症,进而引起预防性造口不能回纳或二次永久性造口,从而不能保肛而丧失“经肛排便”的机会。本文对ISR术后吻合口结构性愈合不良的术前高危因素及其特点以及患者住院期间、出院至术后1个月、术后1个月至预防性造口回纳前后等各个阶段吻合口的管理进行系统阐述,以期对ISR吻合口在整个愈合过程中不同阶段的风险有较清晰的认识,从而及时发现并积极处理相关并发症,有针对性地对吻合口进行全程管理,从而降低永久性造口的比例,真正实现ISR手术“生命延长”与“生活质量改善”的双生愿望。

Intersphincteric resection(ISR)surgery increases the rate of anal sphincter preservation in patients with ultra-low rectal cancers.However,the anastomotic site of ISR surgery is at risk for structural healing complications such as anastomotic leakage,anastomotic dehiscence,secondary anastomotic stenosis,chronic presacral sinus,rectovaginal fistula,and rectourethral fistula,which can lead to a persistent defunctioning ostomy or a secondary permanent colostomy.This article systematically describes the preoperative high-risk factors and characteristics of anastomotic site structural healing complications after ISR surgery,as well as the management of the anastomotic site during various stages including hospitalization,from discharge to one month after surgery,from one month after surgery to before stoma reversal,and after stoma reversal.This is to provide a clearer understanding of the risks associated with the anastomotic site at different stages of the healing process and to timely detect and actively manage related complications,thereby reducing the rate of permanent colostomy and truly achieving the dual goals of"survival benefit"and"quality of life improvement"in ISR surgery.