直肠癌低位前切除术双吻合器致吻合口瘘原因分析及预防

为研究直肠癌低位前切除术中双吻合器致吻合口瘘的原因，并探讨其预防方法，3年中共应用双吻合器实施直肠癌低位前切除术70例，对发生吻合口瘘者进行分析和总结。结果示，发生吻合口瘘4例，发生率为5.71％(4／70)。初步研究结果提示，直肠癌低位前切除术双吻合器吻合安全可靠。吻合口瘘的发生原因主要是术中止血不彻底及吻合操作不规范所致。     

吻合口减张法预防低位直肠癌保肛术后吻合口瘘

 【摘要】　目的　对照研究双吻合器联合双侧减张法在预防低位直肠癌保肛术后吻合口瘘的效果。方法　将2008年1月至2010年6月河南省肿瘤医院普外科214例行直肠癌低位前切除患者随机分为双吻合器联合双侧减张组105例和单纯双吻合器吻合组109例,对比研究两组吻合口瘘的发生率。结果　双吻合器联合双侧减张组发生吻合口瘘1例,单纯双吻合器吻合组发生8例,两组差异有统计学意义（χ2＝5.415,P＝0.02）。结论　双吻合器吻合是安全而有效的手术方法,联合吻合口双侧减张法可进一步降低术后吻合口瘘的发生。     

双吻合器技术在41例低位直肠癌保肛术中的应用

[目的]探讨直肠癌低位前切除术中应用双吻合器技术的经验及临床价值。[方法]应用双吻合器技术对41例低位直肠癌患者行低位前切除术,并对患者术后的并发症和排便功能进行分析。[结果]41例直肠癌患者中除1例因吻合口出血而改行Miles术,其余均一期吻合成功。术后吻合口瘘2例(4%),术后排便次数增多34例(85%),吻合口狭窄3例(7%),局部复发2例(5%),盆腔内复发2例(5%),无手术死亡病例。[结论]应用双吻合器技术完成低位直肠癌保肛手术,是治疗低位直肠癌患者较有效方法。     

双吻合器在中低位直肠癌前切除术中的应用

[目的]评价双吻合器技术在中低位直肠癌前切除术中的应用价值。[方法]回顾分析2004年1月～2006年1月32例中低位直肠癌根治术中行双吻合器吻合的病例。[结果]32例应用双吻合器的手术中直肠闭合及吻合顺利，术后切口感染3例，吻合口狭窄1例，吻合口瘘1例，尿潴留2例，性功能障碍3例，无手术死亡病例。[结论]双吻合器吻合法可作为中低位直肠癌保肛手术的安全可靠的术式选择，从而提高中低位直肠癌患者生存质量。     

直肠癌超低位前切除术

目的探讨经过选择的低位直肠癌患者中施行前切除术的效果和适应证。方法对距肛缘4～6cm的隆起型或溃疡型直肠癌，肿瘤直径在3cm以内的低位直肠癌患者63例行超低位前切除术。结果全组无手术死亡，术后发生吻合口瘘4例(6．3％)，吻合口狭窄16例(25．4％)；术后局部复发6例，其中2例为吻合口复发，4例为盆腔复发，总局部复发率为9．5％。全组5年生存率为74％。结论直肠癌超低位前切除术因双吻合器的熟练使用而得以实施，使部分低位直肠癌患者避免了人工肛门所带来的不便和痛苦，改善了生活质量。若适应证选择得当，可部分替代腹会阴联合切除术而不降低疗效。     

双吻合器技术在直肠癌保肛手术中吻合口瘘的危险因素分析

背景与目的：直肠癌术后吻合口瘘是严重的并发症之一,降低吻合口瘘发生率是临床亟待进一步解决的问题,本研究探讨使用双吻合器进行直肠前切除术(Dixon术)后吻合口瘘的发生及原因分析。方法：回顾性分析150例使用双吻合器进行直肠前切除术的患者,对术后发生吻合口瘘的患者进行性别、年龄、身体质量指数(body mass index,BMI)、细胞分化程度、吻合口部位、TNM分期、是否合并糖尿病、是否合并术前贫血及是否进行术前新辅助放疗的单因素分析,旨在进一步判断直肠前切除术后吻合口瘘的风险。结果：150例患者中共7例发生吻合口瘘,其中3例行二次手术回肠造瘘,4例保守治疗后愈合。单因素分析及多因素分析证实,吻合口距肛距离、术前新辅助放疗是影响直肠癌术后吻合口瘘的独立危险因素。结论：使用双吻合器技术进行直肠前切除的吻合其术后吻合口瘘发生率相对较低,吻合口距肛距离、术前新辅助放疗是影响直肠癌术后吻合口瘘的独立危险因素,对于吻合口瘘的高危患者可以考虑选择性的进行保护性小肠造口。     

直肠癌全直肠系膜超低位前切除术的并发症及防治

目的:探讨低位直肠癌超低位前切除术的主要并发症及防治措施。方法:回顾性分析152例直肠癌全直肠系膜切除超低位前切除术的主要并发症、可能原因及防治措施。其中28例低位人工端端吻合;113例采用单吻合器,双荷包吻合;11例采用双吻合器吻合。结果:术中并发症,阴道静脉丛出血1例,吻合口出血1例,吻合器吻合手术124例中直肠残端闭合失败1.6%(2/124),吻合器切割不全1.6%(2/124)。术后吻合口瘘10.5%(16/152),吻合口狭窄19.1%(29/152),吻合口出血1例。60岁以下,男性性功能障碍占16.1%(10/62);女性10.9%性兴奋能力障碍。排便功能,除2例高龄患者差外,余均良好。局部复发率8.6%(13/152)。结论:直肠癌超低位前切除术避免了永久性结肠造瘘,提高了患者的生活质量,但仍有较多的并发症,注意在术中和术后防治。     

直肠癌全直肠系膜超低位前切除术的并发症及防治

目的:探讨低位直肠癌超低位前切除术的主要并发症及防治措施.方法:回顾性分析152例直肠癌全直肠系膜切除超低位前切除术的主要并发症、可能原因及防治措施.其中28例低位人工端端吻合;113例采用单吻合器,双荷包吻合;11例采用双吻合器吻合.结果:术中并发症,阴道静脉丛出血1例,吻合口出血1例,吻合器吻合手术124例中直肠残端闭合失败1.6%(2/124),吻合器切割不全1.6%(2/124).术后吻合口瘘10.5%(16/152),吻合口狭窄19.1%(29/152),吻合口出血1例.60岁以下,男性性功能障碍占16.1%(10/62);女性10.9%性兴奋能力障碍.排便功能,除2例高龄患者差外,余均良好.局部复发率8.6%(13/152).结论:直肠癌超低位前切除术避免了永久性结肠造瘘,提高了患者的生活质量,但仍有较多的并发症,注意在术中和术后防治.     

双吻合器在直肠癌前切除术中的应用

目的研究分析双吻合器在直肠癌前切除术的临床效果。方法回顾性分析使用双吻合器行103例直肠癌前切除术的临床资料。结果103例使用双吻合器行直肠癌前切除术后发生吻合口瘘2例（1．9％），吻合口狭窄2例（1．9％），切口感染6例（5．8％），吻合口复发1例（1．0％），与同期52例手工缝合患者比较差异无显著性。结论使用双吻合器行直肠癌前切除术省时、安全，对预后无不良影响，并可明显增加保肛机会。     

直肠癌根治术中双吻合器的应用分析

:[目的]介绍和评价双吻合器在直肠癌低位前切除术中的应用。[方法]对90例直肠癌根治术中行双吻合器吻合的病例进行回顾性分析。[结果]行传统根治术75例 ,扩大根治术7例 ,直肠全系膜切除术(TME)者8例 ,吻合过程顺利。术后切口感染3例(3.33 %) ,吻合口狭窄5例(5.56 %) ,吻合口瘘3例(3.33%)。无手术死亡病例。术后吻合口复发2例 ,腹腔淋巴结转移3例 ,随访期间肝转移5例。全部病例中83例获得随访 ,5年生存率58.6%。[结论]双吻合器应用于直肠癌前切除术中的结直肠吻合具有操作简单 ,节约手术时间和安全等优点 ,并可适当提高低位直肠癌保肛率。     

双吻合器在直肠癌保肛手术中的实用价值

目的：探讨双吻合器在直肠癌保肛手术中的实用性和安全性。方法：回顾性分析1997年1月－2000年12月应用双吻合器进行直肠癌保肛手术60例，结果；全组手术过程顺利，术后发生吻合口瘘1例，吻合口出血1例，无吻合口狭窄，切口感染5例，术后粘连性肠梗阻2例，结论：应用双吻合器进行直肠癌的保肛手术是安全可行的。     

全直肠系膜切除加双吻合器法在低位直肠癌保肛根治手术中的应用(附65例分析)

目的:总结全直肠系膜切除(TME)加双吻合器(DST)在低位直肠癌保肛手术应用中的经验。方法:对我院2000-2010年间65例直肠癌应用全直肠系膜切除加双吻合器法行低位直肠癌保肛根治术的临床及随访资料进行回顾性分析。结果:术后发生吻合口瘘2例,吻合口狭窄3例,局部复发7例,性功能障碍1例,无大便失禁及排尿困难。结论:全直肠系膜切除加双吻合器应用可有效保护盆腔脏器的功能,使一部分超低位直肠癌保肛成为可能,适于在低位直肠癌中应用。     

Risk Assessment on Anastomotic Leakage after Rectal Cancer Surgery: An Analysis of 753 Patients

Purpose: To investigate the risk factors for anastomotic leakage (AL) after anterior resection for rectalcancer with a double stapling technique. Patients and Methods: Between January 2004 and December 2011,753 consecutive patients in Jiangsu Cancer Hospital and Research Institute diagnosed with rectal cancer andundergoing anterior resection with a double stapling technique were recruited. All patients experienced atotal mesorectal excision (TME) operation. Additionally, decrease of postoperative tumor supplied group offactors (TSGF), which have not been reported before, was proposed as a new indicator for AL. Univariate andmultivariate analysis were performed to determine risk factors for AL. Results: AL was detected in 57 (7.6%) of753 patients with rectal cancer. The diagnosis of anastomotic leakage was confirmed between the 6th and 12thpostoperative day (POD; mean 8th POD). After univariate analysis and multivariate analysis, age (p<0.001),gender (p=0.002), level of anastomosis (p < 0.001), preoperative body mass index (BMI) (p = 0.001) and reductionof TSGF in 5th POD was less than 10 m/ml (p < 0.001) were selected as 5 independent risk factors for AL. It wasalso indicated that a temporary defunctioning transverse ileostomy (p = 0.04) would decrease the occurrence ofAL. Conclusion: AL after anterior resection for rectal carcinoma is related to elderly status, low level site of thetumor (below the peritoneal reflection), being male, preoperative BMI and the decrease of TSGF in 5th POD isless than 10 m/ml. Preventive ileostomy is advisable after TME for low rectal tumors to prevent AL.     

全直肠系膜切除加双吻合器法在低位直肠癌保肛根治手术中的应用（附65例分析）

目的：总结全直肠系膜切除（TME）加双吻合器（DST）在低位直肠癌保肛手术应用中的经验。方法：对我院2000-2010年间65例直肠癌应用全直肠系膜切除加双吻合器法行低位直肠癌保肛根治术的临床及随访资料进行回顾性分析。结果：术后发生吻合口瘘2例,吻合口狭窄3例,局部复发7例,性功能障碍1例,无大便失禁及排尿困难。结论：全直肠系膜切除加双吻合器应用可有效保护盆腔脏器的功能,使一部分超低位直肠癌保肛成为可能,适于在低位直肠癌中应用。     

低位直肠癌保肛手术后吻合口瘘防治

回顾性分析我院1997年1月~2005年10月行低位直肠癌(距肛缘≤7cm)保肛手术155例患者临床资料,其中17例术后发生吻合口瘘,发生率为10·09%(17/155),经非手术治疗治愈10例,暂时性横结肠造口术7例。结果提示,吻合口瘘是低位直肠癌保肛手术后一种常见并发症,非手术综合治疗多可治愈。     

双吻合器在直肠癌保肛手术中的应用

目的：探讨双吻合器在直肠癌保肛手术中的应用价值。方法：回顾性分析我院外科自１９９７年１月至１９９９年６月收治的３５例采用双吻合器行直肠癌保肛手术的病例。结果：全组吻合满意,切缘无癌残留,术后吻合口出血１例,直肠－阴道瘘１例,粘连性肠梗阻２例,切口感染４例,无吻合口狭窄。结论：双吻合的应用明显提高低位直肠癌保肛手术成功率,同时也是一种安全可靠的手术方式。     

Evaluation of Stapled versus Hand-Sewn Techniques for Colo-Rectal Anastomosis after Low Anterior Resection of Mid-Rectal Carcinoma: a Study on 50 Patients

Aim: To evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection of mid-rectal carcinoma. Patients and Methods: A prospective study of fifty patients who underwent colo-rectal anastomosis following low anterior resection (LAR) of T2 mid-rectal cancers at the Egyptian National Cancer Institute during the time period from June 2010 to June 2013 was conducted. Classification was into two groups; a stapled anastomosis group I (25 patients) and a hand-sewn anastomosis group II (25 patients). All operationsare evaluated regarding intra-operative complications such as anastomotic line bleeding, visceral injuries or major blood loss. The anastomotic time and operative time are documented for each operation. All patients are evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus. Results: The distance of the tumor from the anal verge was 9.6±2.0 cm in group I and 9.9±2.4 cm in group II. The mean operative time was 191.5±16.2 min in the stapled group and 208±18.6 min in the sutured group (p=0.002). The mean anastomotic times were 9.0±1.9 min and 19.7±12.2 min (p=0.001). Anastomotic leakage developed in three (12.0%) patients in the stapled group and in four (16.0%) patients in the sutured group (p=1.000). Post-operative ileus was observed in 3 patients in group I and one patient in group II. Wound infection developed in three (12.0%) patients in the stapled group and four (16.0%) patients in the sutured group (p=1.000). Conclusion: Colo-rectal anastomosis after low anterior resection for mid rectal carcinoma can be conducted safely either by stapling or hand-sewn techniques; however the stapling technique showed shorter anastomotic and operative times with no significant advantages regarding intra- or post-operative complications or hospital stay.     

Acidic Pelvic Drainage as a Predictive Factor For Anastomotic Leakage after Surgery for Patients with Rectal Cancer

Purpose: To demonstrate the value of sequential determinations of pelvic drainage in the identification ofincreased risk of anastomotic leakage (AL) after anterior resection for rectal cancer with a double staplingtechnique. Patients and Methods: Between January 2004 and December 2011, data for the daily postoperativepH of pelvic drainage fluid in 753 consecutive patients with rectal cancer who initially underwent anteriorresection with a double stapling technique were reviewed. All patients experienced a total mesorectal excision.Patients with anastomotic leakage (Group AL, n=57) were compared to patients without leakage (Group nAL,n=696). Patients with perioperatively abdominopelvic implants that were likely to affect pH value (determinedat 25 ℃) other than leakage were excluded. Mean postoperative values were compared. Results: Anastomoticleakage was noted in 57 (7.6%) of 753 patients with rectal cancer. The diagnosis of anastomotic leakage wasmade between the 6th and 12th postoperative day (POD; mean 8th POD). There was no significance of the dailyaverage values of pH on POD1 & 2 in group AL while a significantly sharp declining mean pH value reachedits diagnostic point of AL (p<0.001) on POD3. A cut-off value of 6.978 on the 3rd POD maximized the sensitivity(98.7.0%) and specificity (94.7%) in assessing the risk of leakage. Conclusion: According to these results, anearly and persistent declining of pH value of pelvic drainage fluid after rectal surgery with anastomosis, is amarker of AL. A cut-off value of 6.798 on POD3 maximizes sensitivity and specificity.     

留置肛管与保护性造口预防直肠癌术后吻合口瘘的现状与进展

随着全直肠系膜切除术的概念普及以及手术器械的改进，保肛手术越来越多。目前吻合口瘘依然是直肠癌前切除术后最严重的并发症。吻合口瘘的发生与代谢性疾病、术前新辅助治疗、吻合口距肛缘距离、血供、张力等因素相关。大多数文献认为留置肛管对于预防吻合口瘘有积极作用，但因为纳入标准的不同，导致研究结果存在偏差。目前公认的预防吻合口瘘的方法是留置肛管和保护性造口，但是二者比较研究尚存争议。因此，期待未来开展更多的前瞻性与回顾性实验来比较研究留置肛管与保护性造口对直肠癌特别是低位直肠癌前切除术后吻合口瘘的预防作用。