低位直肠癌经括约肌间切除术后吻合口瘘对患者近远期肛门功能影响的临床分析

Clinical analysis of impact of anastomotic leakage on short-and long-term anal function in patients after intersphincteric resection for low rectal cancer

背景与目的:经括约肌间切除术(ISR)作为超低位直肠癌的极限保肛手术,已被证实可获得良好的肿瘤学根治效果。因其能最大程度地保留患者肛门,避免永久性肠造口,已逐渐成为了低位直肠癌保肛手术的重要选择之一。然而,ISR手术由于切除了部分或全部内括约肌,不可避免地会导致术后肛门控便功能的下降。吻合口瘘是ISR手术后最常见的并发症之一,可能对患者术后肛门功能产生不良影响。目前关于吻合口瘘对ISR术后患者的肛门功能的具体影响尚未有深入的研究。因此,本研究探讨吻合口瘘对ISR术后患者短期及长期肛门功能的影响。方法:回顾性收集中国人民解放军火箭军特色医学中心肛肠外科于2011年6月—2022年1月行ISR及预防性末端回肠造口术的236例患者临床及随访资料,比较发生与未发生吻合口瘘患者的一般临床资料、回肠造口还纳后6个月和2年Wexner失禁评分(WIS)与低位前切除综合征(LARS)评分以及肛门直肠测压各参数的差异。结果:236例患者中有41例(17.4%)发生吻合口瘘,23例(9.7%)最终未还纳回肠造口。与未发生吻合口瘘患者的一般临床资料比较结果显示,发生吻合口瘘患者BMI较高(27 kg/m^(2)vs.25 kg/m^(2))、合并糖尿病者较多(29.3%vs.15.9%)、手术时间较长(222 min vs.200 min),且造口未还纳比例明显升高(34.1%vs.4.6%),差异均有统计学意义(均P<0.05)。在回肠造口还纳后6个月和2年均完成了肛门功能问卷随访的共有149例患者,其中20例(13.4%)有吻合口瘘,129例(86.6%)无吻合口瘘。还纳后6个月,吻合口瘘组肛门功能WIS评分(12 vs.9)和LARS评分(34 vs.29)均高于无吻合口瘘组(均P<0.05);还纳后2年,两组患者肛门功能WIS评分(8.5 vs.8)和LARS评分(28.5 vs.32)差异均无统计学意义(均P>0.05)。在回肠造口还纳后6个月和2年均完成直肠肛管测压检查的共有53例患者,其中11例(20.8%)有吻合口瘘,42例(79.2%)无吻合口瘘。还纳后6个月,吻合口瘘患者的肛管最大收缩压高于无吻合口瘘患者(P<0.05),其余参数包括肛管静息压、肛管高压区长度和最大耐受容量差异均无统计学意义(均P>0.05);还纳后2年,两组的肛门直肠测压各参数差异均无统计学意义(均P>0.05)。结论:吻合口瘘的发生增加了ISR术后永久性造口的风险。对恢复肠道连续性的患者,吻合口瘘对早期肛门功能有负面影响,但对远期肛门功能可能无明显影响。

Background and Aims:Intersphincteric resection(ISR) has been proven to achieve good oncological outcomes as an ultimate sphincter-preserving surgery for ultra-low rectal cancer.Due to its maximal preservation of the anus and avoidance of permanent stoma,ISR has gradually become an important option for sphincter-preserving surgery for low rectal cancer.However,ISR involves partial or complete resection of the internal anal sphincter,inevitably leading to a decrease in postoperative anal function.Anastomotic leakage is one of the most common complications after ISR and may have an adverse effect on postoperative anal function.However,there is no thorough study on the specific effect of anastomotic leakage on anal function in patients after ISR.Therefore,this study was performed to investigate the impact of anastomotic leakage on short-and long-term anal function in patients after ISR.Methods:The clinical and follow-up data of 236 patients undergoing ISR with a diverting loop ileostomy from June 2011 to January 2022 in the PLA Rocket Force Characteristic Medical Center were retrospectively collected.The general clinical data between patients who developed anastomotic leakage and those who did not were compared.Differences in the Wexner incontinence score(WIS) and low anterior resection syndrome(LARS) score,as well as differences in various parameters of anorectal manometry at 6 months and 2 years after ileostomy reversal,were compared between patients with and without anastomotic leakage.Results:Among the 236 patients,41 cases(17.4%) developed anastomotic leakage,and 23(9.7%)ultimately did not undergo ileostomy reversal.Comparison of general clinical data between patients with and without anastomotic leakage showed that patients with anastomotic fistula had a higher BMI(27 kg/m^(2) vs.25 kg/m^(2)),a higher incidence of diabetes(29.3%vs.15.9%),longer operative time(222 min vs.200 min),and a significantly higher proportion of ileostomy non-reversal(34.1%vs.4.6%),all of which were statistically significant(all P<0.05).A total of 149 patients completed anal function questionnaires at 6 months and 2 years after ileostomy reversal,of whom 20(13.4%) had anastomotic leakage and 129(86.6%) did not.At 6 months after closure,the WIS score(12 vs.9) and LARS score(34 vs.29) of patients with anastomotic leakage were higher than those without(both P<0.05);however,at 2 years after closure,there were no statistically significant differences in WIS score(8.5 vs.8) and LARS score(28.5 vs.32) between the two groups of patients(both P>0.05).A total of 53 patients completed rectal manometry examinations at 6 months and 2 years after ileostomy closure,of whom11(20.8%) had anastomotic leakage and 42(79.2%) did not.At 6 months after closure,the maximum squeeze pressure of the anal canal in patients with anastomotic leakage was higher than that in patients without(P<0.05),while other parameters including resting pressure of the anal canal,length of the highpressure zone of the anal canal,and maximum tolerable volume showed no statistical differences between the two groups of patients(all P>0.05);at 2 years after closure,there were no statistical differences in all parameters of anorectal manometry between the two groups of patients(all P>0.05).Conclusion:The occurrence of anastomotic leakage increases the risk of permanent stoma after ISR.For patients who have restored intestinal continuity,anastomotic leakage has a negative impact on early anal function,but may not have a significant impact on long-term anal function.