Risk factors for anastomotic leakage after low anterior resection without diversional stomas

Objective The most important complication after low anterior resection(LAR) for mid-low rectal cancer is symptomatic anastomotic leakage(AL). More than one-third of patients with rectal cancer who underwent LAR will have functional stomas during primary operation. The aim of this retrospective study was to evaluate the risk factors associated with clinical AL following LAR without diversional stomas.Methods Between 2012 and 2017, information about 578 consecutive patients with rectal tumors less than 12 cm from the anal verge who underwent LAR without diversional stomas by the same surgical team was collected retrospectively. A standardized extraperitonealized anastomosis and pelvic drainage were conducted for all patients during primary operations, and the outcome of interest was clinical AL. The associations between AL and 14 patient-related and surgical variables were examined by both univariate chi-square test and multivariate logistic regression analysis.Results The AL rate was 7.27%(42 of 578). Univariate and multivariate analyses showed that male sex(P = 0.018), mid-low rectal cancer(located 10 cm or less above the anal verge)(P = 0.041), presence of diabetes(odds ratio = 2.117), longer duration of operation(odds ratio = 1.890), and intraoperative contamination(odds ratio = 2.163) were risk factors of AL for LAR without diversional stoma and independently predictive of clinical AL. Nearly 83.3%(35 of 42) of leakage could be cured by persistent pelvic irrigation-suction-drainage without surgical intervention. Only 7 patients(16.7%) with severe complications, such as peritonitis, and fistula, required reoperation, and functional stoma was used as a salvage treatment.Conclusion From the findings of this retrospective survey, we identified that mid-low rectal cancer and male sex were independent risk factors for developing clinical AL after LAR without diversional stomas, as well as longer duration of operation, presence of diabetes, and contamination of the operative field. Moreover, we deemed that LAR without diversional stomas for mid-low rectal cancers was safe, effective, and feasible. Extraperitonealized anastomosis and pelvic drainage obtained a relatively low rate of AL and avoided unnecessary functional stomas. Pelvic irrigation-suction-drainage was an effective procedure to resolve AL, and functional stoma was potentially used as a salvage modality for serious leakage.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage(AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Risk factors causing structural sequelae after anastomotic leakage in mid to low rectal cancer

AIM: To investigate the risk factors causing structural sequelae after anastomotic leakage in patients with mid to low rectal cancer.METHODS: Prospectively collected data of consecutive subjects who had anastomotic leakage after surgical resection for rectal cancer from March 2006 to May 2013 at Korea University Anam Hospital were retrospectively analyzed. Two subgroup analyses were performed. The patients were initially divided into the sequelae(stricture, fistula, or sinus) and no sequelae groups and then divided into the permanent stoma(PS)and no PS groups. Univariate and multivariate analyses were performed to identify the risk factors of structural sequelae after anastomotic leakage.RESULTS: Structural sequelae after anastomotic leakage were identified in 29 patients(39.7%).Multivariate analysis revealed that diversion ileostomy at the first operation increases the risk of structural sequelae [odds ratio(OR) = 6.741; P = 0.017].Fourteen patients(17.7%) had permanent stoma during the follow-up period(median, 37 mo). Multivariate analysis showed that the tumor level from the dentate line was associated with the risk of permanent stoma(OR = 0.751; P = 0.045).CONCLUSION: Diversion ileostomy at the first operation increased the risk of structural sequelae of the anastomosis, while lower tumor location was associated with the risk of permanent stoma in the management of anastomotic leakage.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients

Objective Anastomotic leakage(AL)is one of the serious complications after anterior resection for rectal cancer.Defunctioning stoma(DS)is one of the most widely used approaches to prevent it;however,the effect of DS on the occurrence of AL remains controversial.This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients.Methods A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019.Results The results showed the overall AL incidence was 7.5%.Multivariate analyses revealed that males[odds ratio(OR)1.562]and T3–T4 stage(OR 1.729)were independent risk factors for all patients.After propensity score matching analysis,the AL incidence was 14.1%in the group with no DS and 6.4%in the DS group(P<0.001).The clinical AL(grade B+grade C)incidence was 12.4%in no DS group and 4.6%in the DS group(P<0.001).Conclusion The study suggested that males and T3–T4 stage were independent risk factors of AL.In addition,DS could reduce the rate of symptomatic AL.

Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess:A case report and review of literature

BACKGROUND Abscess formation is one of the complications after radical resection of rectal cancer;cases with delayed postoperative anastomotic abscess are rare.Here,we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery.Ultimately,the patient was diagnosed and treated by endoscopic fenestration.In addition,we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.CASE SUMMARY A 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma.Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria,and a submucosal tumor was suspected.The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography,which revealed no thickening or strengthening of the anastomotic wall.In order to clarify the origin of the lesion and obtain the pathology,endoscopic fenestration was performed.After endoscopic procedure,a definitive diagnosis of delayed anastomotic submucosal abscess was established.The patient achieved good recovery and prognosis after the complete clearance of abscess.CONCLUSION Endoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.

Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis

BACKGROUND Anastomotic leakage(AL)following rectal cancer surgery is an important cause of mortality and recurrence.Although transanal drainage tubes(TDTs)are expected to reduce the rate of AL,their preventive effects are controversial.AIM To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery.METHODS A systematic literature search was performed using the PubMed,Embase,and Cochrane Library databases.We included randomized controlled trials(RCTs)and prospective cohort studies(PCSs)in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated.The results of the studies were synthesized using the Mantel-Haenszel randomeffects model,and a two-tailed P value>0.05 was considered statistically significant.RESULTS Three RCTs and two PCSs were included in this study.Symptomatic AL was examined in all 1417 patients(712 with TDT),and TDTs did not reduce the symptomatic AL rate.In a subgroup analysis of 955 patients without a diverting stoma,TDT reduced the symptomatic AL rate(odds ratio=0.50,95%confidence interval:0.29–0.86,P=0.012).CONCLUSION TDT may not reduce AL overall among patients undergoing rectal cancer surgery.However,patients without a diverting stoma may benefit from TDT placement.

Smart responsive staple for dynamic promotion of anastomotic stoma healing

The precise combination of conflicting biological properties through sophisticated structural and functional design to meet all the requirements of anastomotic healing is of great demand but remains challenging.Here,we develop a smart responsive anastomotic staple(Ti–OH-MC)by integrating porous titanium anastomotic staple with multifunctional polytannic acid/tannic acid coating.This design achieves dynamic sequential regulation of antibacterial,anti-inflammatory,and cell proliferation properties.During the inflammatory phase of the anastomotic stoma,our Ti–OH-MC can release tannic acid to provide antibacterial and anti-inflammatory properties,together with immune microenvironment regulation function.At the same time,as the healing progresses,the multifunctional coating gradually falls off to expose the porous structure of the titanium anastomotic staple,which promotes cell adhesion and proliferation during the later proliferative and remodeling phases.As a result,our Ti–OH-MC exceeds the properties of clinically used titanium anastomotic staple,and can effectively promote the healing.The staple’s preparation strategy is simple and biocompatible,promising for industrialisation and clinical application.This work provides an effective anastomotic staple for anastomotic stoma healing and serve as a reference for the functional design and preparation of other types of titanium-based tissue repair materials.

可崩解支架联合薄膜套粪便隔绝术预防低位直肠癌术后吻合口漏的效果分析

目的探讨可崩解支架联合薄膜套粪便隔绝术在预防低位直肠癌术后吻合口漏的应用。方法回顾性分析2016年1月至2023年4月在重庆医科大学附属永川医院行腹腔镜下低位直肠癌根治术(Dixon术式)的72名患者,其中行预防性造口的35名患者为观察组,行可崩解支架联合薄膜套粪便隔绝术的37名患者为研究组。比较2组患者的一般资料、手术时间、住院时间、总体并发症、住院费用、吻合口漏等指标。结果2组患者的一般资料(年龄、性别、BMI、NRS-2002评分、ASA分级、肿瘤分期、肿瘤距肛缘的距离)和合并基础疾病(糖尿病、高血压、其他心血管疾病、慢性阻塞性肺疾病)的比较差异均无统计学意义(P>0.05)。研究组的手术时间(238.0 vs 314.1 min,P<0.001)、术后住院时间(11 vs 12 d,P=0.040)、总体并发症(18.9%vs 51.4%,P=0.004)及住院费用(48327 vs 53092元,P=0.012)显著低于观察组。研究组吻合口漏率略低于观察组,但差异无统计学意义(2.7%vs 8.6%,P=0.350)。结论可崩解支架联合薄膜套粪便隔绝术缩短手术时间和住院时间,降低住院费用和减少总体并发症,且吻合口漏的风险不高于传统手术,可作为预防性造口的替代手术方式。

食管、胃吻合术式与吻合口愈合的关系——分层吻合法与全层吻合法的比较研究

本文对食管、胃层—层吻合术和全层吻合术进行比较观察。通过实验动物和临床病例术后随访,X线食管造影和食管镜检查,前一术式的吻合瘘发生率为0.4％,吻合口狭窄为2％,吞咽不适为36％;后一术式依次分别为4.2％,16％,72％。两者比较3项均有显著性差异。作者认为,层-层吻合术能显著地减少吻合口瘘和狭窄的发生。

不同可吸收吻合口填充材料在鼻内镜下泪囊鼻腔吻合术中的应用疗效

目的:比较自交联透明质酸钠凝胶、纳吸棉、明胶海绵在鼻内镜下泪囊鼻腔吻合术(En-DCR)中的疗效。方法:回顾性分析2019-06/2020-06我院收治的慢性泪囊炎均行En-DCR患者72例90眼,按吻合口填充材料类型分为三组,使用自交联透明质酸钠凝胶组(A组)、纳吸棉组(B组)、明胶海绵组(C组),术后2wk,1、2、3、6mo定期随访,观察患者术后舒适度、渗血情况、瘢痕增生、肉芽组织形成、吻合口黏连以及溢泪、泪道冲洗情况,并统计治愈率和有效率。结果:术后随访6mo,A、B、C三组有效率为97%、89%、94%(P>0.05);治愈率为91%、56%、87%(P<0.05),A、C两组与B组治愈率比较有差异(P<0.0167),A、C两组之间无差异(P>0.0167)。A组患者术后舒适度较B组好(P<0.0167),术后渗血情况较B组严重(P<0.0167)。A组瘢痕增生率低于B组(P<0.0167),A、B组吻合口黏连率均高于C组(P<0.0167)。结论:En-DCR术中应用自交联透明质酸钠凝胶填充泪囊鼻腔吻合口术中操作简单,术后可有效抑制瘢痕增生、促进黏膜上皮化,提高En-DCR的治愈率及有效率,且患者舒适度高,是一种简便、安全、舒适、高效的可吸收吻合口填充材料。

外置支架防止胆肠吻合口狭窄动物实验研究

目的研究自行设计的外置支架对胆肠吻合口的影响。方法制作白兔胆总管空肠RouxenY吻合模型,在吻合口处放置自行设计的外置支架;并设不放支架组作对照。6个月后,将各组白兔处死,取胆肠吻合口处的组织进行病理组织学观察、超微结构观察和立体学分析,并同时测定血总胆红素和直接胆红素的值。结果短期内外置支架能够防止胆肠吻合口狭窄。结论外置支架支撑作用能防止胆肠吻合口瘢痕过度增生,避免产生向心挛缩。

消化道恶性肿瘤腹腔化疗的研究进展

消化道恶性肿瘤术后复发率较高,传统静脉化疗、肠腔内灌注化疗等效果不佳,且不良反应大。近年来国内外学者开始对腹腔化疗进行研究,并取得了一些进展,但对术后早期腹腔化疗是否影响吻合口愈合等问题,仍存在争议。对于腹腔化疗药联合哪些药物可使化疗效果更佳,仍无统一的标准。本研究对目前腹腔化疗的有关问题特别是腹腔化疗的有效性及安全性等进行综述。

预防性末段回肠造瘘术在保护结直肠高危吻合口中的应用

目的：探讨预防性末段回肠造瘘术在保护结直肠高危吻合口中的临床效果。方法：2014年2月—10月,对11例结直肠高危吻合口瘘的结直肠癌患者行Dixon手术＋预防性末段回肠造瘘术,观察手术后吻合口并发症的发生情况及预后。结果：11例患者均于术后7-10 d出院。术后发生吻合口瘘2例,均为轻微瘘,患者无自觉症状,无特别治疗;术后发生吻合口出血1例,经保守治疗出血停止,未发生吻合口瘘。结论：预防性末端回肠造瘘术能有效防治结直肠高危吻合口瘘,值得临床推广。

胆肠吻合术后吻合口狭窄45例临床分析和再处理

目的探讨胆肠吻合术后胆肠吻合口狭窄的原因,以提高外科治疗水平。方法回顾性分析2000～2006年收集的45例病人行胆肠内引流手术发生胆肠吻合口狭窄再手术的资料,总结临床经验教训。结果45例病人中41例再手术治疗,其中39例行胆管空肠端侧Roux-en-Y吻合,1例行带蒂空肠瓣胆道修补重建术,1例更换U管;3例采取非手术治疗(其中1例为肝移植术后),1例家属放弃治疗(肝门部胆管癌复发),随访0.5～5年,5例(5/41)病人出现胆道感染症状,其中1例(1/41)为右肝残余结石。结论胆肠吻合术后吻合口狭窄主要原因首先为吻合方式不当,其次是病灶未能很好清除、引流不畅,再者应为吻合技术欠佳及使用材料不当。

胰十二指肠切除术后并发症的观察与护理

[目的]总结胰、十二指肠切除术(Whipple术)后并发症的观察和护理措施。[方法]回顾性分析14例Whipple术病人的临床资料。[结果]本组病人术后发生胰肠吻合口瘘1例,给予及时处理后痊愈出院;无其他并发症发生,无一例死亡。[结论]对Whipple术后病人严密观察和预防性处理可减少并发症的发生。

301例自体动静脉内瘘吻合口径与动静脉内瘘通畅率的关系探讨

目的总结探讨进行长期维持性血透的终末期肾病患者自体动静脉内瘘吻合口径与动静脉内瘘通畅率的关系。方法分析自2012年4月至2014年3月桂林医学院第一附属医院收治的301例为行长期维持性血液透析而行手术创建动静脉内瘘的终末期肾病患者的资料,记录分析不同吻合口径患者内瘘成功率、术后通畅率、术后并发症等情况。结果 301例行自体动静脉内瘘血管转流术的患者,其中吻合口径5 mm 82例,吻合口径6 mm 81例,吻合口径7 mm 81例,吻合口径8 mm 57例,术后一期吻合成功率达100%,不同吻合口组术后通畅率:术后1个月,5、6、7、8 mm吻合口径内瘘通畅率分别为93.90%、97.53%、97.53%、98.25%(P术后1个月> 0. 05);术后半年,内瘘通畅率分别为85.37%、90.12%、90.12%、91.23%(P术后半年>0.05);术后1年,内瘘通畅率分别为75.61%、86.42%、83.95%、85.96%(P术后1年>0.05);术后2年,内瘘通畅率分别为62.20%、75.31%、77.77%、77.19%(P术后2年<0.05);术后3年,内瘘通畅率分别为54.88%、61.73%、71.60%、85.96%(P术后3年<0.05),术后并发症(1个月内):术后血栓形成9例,术后手部肿胀6例,术口切口渗血9例,肢端窃血综合征1例。结论 7～8 mm的吻合口径较适宜,恰当吻合口径选择是提高自体动静脉内瘘通畅率的关键。

丹参对消化道吻合口的愈合作用

目的：探讨使用丹参注射液对消化道吻合愈合的作用。方法：对２６０例消化道吻合术的病人，术后第１天起给予丹参注射液０．４ｍｌ／ｋｇ体重，静脉滴注，每日１次，连续用药１４天，观察吻合口瘘与狭窄的发生率、检查甲皱微循环。结果：吻合口瘘与狭窄的发生率明显降低。结论：丹参可通过增加吻合口局部毛细血管开放、扩张管径、增加血流速度、改善组织液循环的作用，促进吻合口愈合并抑制吻合口瘢痕的过度增生。

选择性肠造口在直肠癌低位前切除患者中作用的Meta分析

背景与目的:选择性肠造口是否能预防直肠癌低位前切除术后吻合口漏及减轻其影响各家报道不一,本研究利用Meta分析的方法探讨直肠癌低位前切除后是否需要选择性行预防性肠造口。方法:收集1990至2007年国内外公开发表的有关选择性肠造口在直肠癌低位前切除中作用的文献,将直肠癌前切除加选择性肠造口组与单纯直肠癌切除术组的吻合口漏发生率及需要再次手术的吻合口漏发生率进行综合比较。结果:符合要求的有7篇文章,7个对照临床试验研究,累计病例5040例。(1)选择性肠造口对直肠癌低位前切除术后发生吻合口漏的影响:合并OR值0.68(95%CI=0.45-1.02,P>0.05),差异没有统计学意义;选择性肠造口未显著降低直肠癌低位前切除后吻合口漏的发生。(2)选择性肠造口对直肠癌低位前切除术后发生需要再次手术的吻合口漏的影响:合并OR值0.33(95%CI=0.25-0.44),差异有统计学意义(P<0.001);选择性肠造口显著降低直肠癌低位前切除后需要再次手术的吻合口漏的发生率。结论:选择性肠造口未能降低直肠癌前切除术后吻合口漏的发生率,但能降低需要再次手术的吻合口漏的发生率,对具有发生吻合口漏危险因素者应同时行选择性肠造口。

选择性经盲肠末端回肠置管造瘘术在保护结肠直肠高危吻合口的临床应用

目的:探讨经盲肠末端回肠置管造瘘术(transcecum tube ileostomy,TTI)在保护结肠直肠高危吻合口的临床效果。方法:将我院63例有结肠直肠高危吻合口瘘因素的病人分为TTI组(32例)和造瘘组(31例),TTI组行结肠直肠原发病灶常规手术切除一期吻合后附加TTI,造瘘组行结肠直肠原发病灶常规手术切除附加预防性末端回肠造瘘,观察两组病人术后造瘘引流量、术后吻合口相关并发症发生率和造瘘相关并发症发生率、附加手术时间、再手术率、造瘘维持时间及治疗费用等,进行统计分析。结果:TTI组和造瘘组病人造瘘平均引流量分别为(520±60)mL/d和(630±80)mL/d;吻合口相关并发症发生率分别为15.6%(5/32)和45.2%(14/31);造瘘相关并发症发生率分别为12.5%(4/32)和38.7%(12/31);附加手术时间分别为(25±12)min和(40±24)min;再手术率分别为0和67.7%(21/31);造瘘维持时间分别为(17.6±3.4)d和(117.0±22.5)d;治疗费用分别为(31 500±3600)元和(40 300±3900)元,两组均具有统计学差异(P<0.05)。结论:附加TTI简单易行,转流肠内容物效果较好,对生活质量影响小,对结肠直肠高危吻合口有保护作用,且无需造瘘回纳,有一定的临床应用价值。

Whipple术后胆肠、胰肠吻合口出血的胆道镜治疗

目的： 探讨胆道镜治疗胰十二指肠切除术后胆肠、胰肠吻合口出血的疗效。方法 拔出胆肠吻合口内的引流管，经引流管窦道插入胆道镜确定出血部位，局部电凝、微波固化、喷洒复方五倍子液止血。结果４例胆肠、６例胰肠吻合口出血止血成功，１例胰肠吻合口反复出血止血失败。结论胆道镜是诊断治疗本病首选有效方法。