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腹腔镜直肠癌保肛手术后吻合口瘘的危险因素分析及对策
张展志
2016-05-11
导师张能维
专业外科学
授予单位北京大学
授予地点北京大学第九临床医学院
学位博士
关键词腹腔镜 直肠癌 吻合口瘘 危险因素 对策
其他题名Analysis of risk factors of anastomotic fistula after laparoscopic rectal cancer anus-preserving operation and countermeasures
分类号R735.3
摘要

 

目的

    吻合口瘘为直肠癌保肛手术后最严重的并发症之一,其增加了患者的痛苦和经济负担。腹腔镜直肠癌根治术已经发展为主流术式,因此研究此术式下吻合口瘘的危险因素便显得尤为重要。研究腹腔镜直肠癌保肛手术后发生吻合口瘘的危险因素及吻合口瘘的防治办法,以期提高腹腔镜直肠癌保肛手术的综合效果,降低吻合口瘘的发生率。

   

方法

回顾性分析2010-1-1至2015-06-30北京大学第九临床医学院行腹腔镜直肠癌保肛手术患者160例的性别、年龄、伴有糖尿病、体重指数、肿瘤最大直径、术前血红蛋白、术前血白蛋白、病理结果、术中出血量、手术时间、离断血管水平、预防性造口、手术方式、肿瘤下极距齿状线距离、病理TNM分期和新辅助放化疗的情况,统计吻合口瘘的发生情况,并进行单因素和logistic多因素回归分析。总结吻合口瘘的相关危险因素及处理措施和效果。

 

结果

本研究中吻合口瘘发生率为8.75%(14/160)。单因素分析显示,腹腔镜直肠癌保肛手术后发生吻合口瘘组与未发生瘘组在患者体重指数(χ2=4.974,P=0.026)、术前白蛋白水平(χ2=5.749,P=0.016)、肿瘤下极距齿状线距离(χ2=14.84,P=0.002)、手术方式(χ2=10.27,P=0.001)、病理TNM分期(χ2=6.877, P=0.032)、新辅助放化疗(χ2=7.540, P=0.006)方面差异有统计学意义。Logistic 多因素回归分析结果显示,体重指数(OR=11.56)、肿瘤下极距齿状线距离(OR=9.753)、手术方式(OR=4.731)、新辅助放化疗(OR=16.61)被认为是腹腔镜直肠癌保肛手术后发生吻合口瘘发生的独立危险因子。经采取充分引流、静脉使用生长抑素、双套管冲洗、回肠或横结肠造口等方法进行处理后,吻合口瘘均痊愈。

 

结论

体重指数、肿瘤下极距齿状线距离、手术方式、新辅助放化疗等被认为是腹腔镜直肠癌保肛手术后发生吻合口瘘发生的独立危险因子。对伴肿瘤下极距齿状线距离<2cm、ISR手术方式和新辅助放化疗的病例采取预防性造口,可以降低非计划二次手术的概率,减轻瘘的严重程度,缩短瘘的治愈时间。围手术期采取适当措施,可有效降低吻合口瘘的发生率。

英文摘要

 

Objective

Anastomotic fistula is one of the most serious complications after rectal cancer anus-preserving operation,and it increases the patient’s  pain and economic burden .It becomes very important to research the risk factors of anastomotic fistula after laparoscopic rectal cancer anus-preserving operation which has been developed into the mainstream surgical procedure.To study the risk factors of anastomotic leakage after laparoscopic resection of rectal cancer and the methods of prevention and treatment on anastomotic leakage. So as to improve the comprehensive effect of laparoscopic operation for rectal cancer, and reduce the incidence of anastomotic leakage.

 

Methods

Between January 1, 2010 and June 30 ,2015, a retrospective analysis of 160 cases of laparoscopic anus-preserving rectal cancer resection was performed in Peking University Ninth School of Clinical Medicine. The data of gender, age, diabetes, body mass index, maximum tumor diameter, preoperative hemoglobin, preoperative serum albumin, pathological findings, intraoperative bleeding, operation time, severed vascular level and a defunctioning stoma, operation method, distance from tumor inferior edge to dentate line, pTNM staging and neoadjuvant chemoradiation, and anastomotic leakage was recorded. Single factor and logistic multivariate regression analysis was performed. Treatment measures and effects of anastomotic leakage was summarized.

 

Results

The incidence of anastomotic leakage was 8.75% (14/160) in this study. The single factor analysis showed that the difference between anastomotic leakage group and non anastomotic leakage group was statistically significant in the patients' body mass index(χ2=4.974,P=0.026), preoperative serum albumin level(χ2=5.749,P=0.016), distance from tumor inferior edge to dentate line (χ2=8.270,P=0.004), operation method (χ2=10.27,P=0.001), pTNM staging(χ2=6.725, P=0.015)and neoadjuvant chemoradiation(χ2=7.540,P=0.006). Logistic multiple regression analysis showed that the body mass index(OR=11.56), distance from tumor inferior edge to dentate line(OR=9.753), the operation method(OR=4.731), and the new adjuvant chemoradiation(OR=16.61) were considered as the independent risk factors for the  occurrence of anastomotic leakage after laparoscopic surgery for rectal cancer. After the adoption of adequate drainage and intravenous somatostatin,  double cannula douche, ileum or colon stoma , anastomotic fistulas were cured.

 

Conclusions

The body mass index,distance from tumor inferior edge to dentate line, operation mode, and new adjuvant chemoradiation were considered as the independent risk factors for the occurrence of anastomotic leakage after laparoscopic surgery for rectal cancer. The probability of non planned second operations can be reduced by taking preventive stoma in patients with distance from tumor inferior edge to dentate line less than 2cm、ISR operation mode and new adjuvant chemoradiation. The preventive stoma can also reduce the degree of fistula, and shorten the healing time of fistula. Appropriate measures can be taken to reduce the incidence of anastomotic leakage.

语种中文
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文献类型学位论文
条目标识符http://ir.bjmu.edu.cn/handle/400002259/124811
专题北京大学第九临床医学院
作者单位北京大学第九临床医学院
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张展志. 腹腔镜直肠癌保肛手术后吻合口瘘的危险因素分析及对策[D]. 北京大学第九临床医学院. 北京大学,2016.
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