腹腔镜低位直肠癌前切除术吻合口漏的预防和治疗

doi:10.16139/j.1007-9610.2023.03.008

摘要/Abstract

摘要：

吻合口漏是腹腔镜辅助低位直肠癌前切除术后不可避免的严重并发症之一。随着手术技术和认知理念的提高，直肠癌的吻合口越来越低，吻合口漏的问题比较棘手。预防性造口是目前临床上应对吻合口漏的常用方法，但由此带来的过度依赖造口、造口相关并发症等问题也困扰着临床医师。笔者结合多年的实践经验就如何通过吻合口漏风险评估量表避免不必要的造口，以及如何在腹腔镜辅助低位直肠癌前切除术早期发现和处理吻合口漏进行归纳和总结。

关键词: 腹腔镜, 低位直肠癌前切除术, 吻合口漏, 预防性造口, 风险评估量表

Abstract:

Anastomotic leakage (AL) is one of the inevitable and severe complications after laparoscopic-assisted anterior resection of low rectal cancer. With the improvement of surgical technology and cognitive concept, the position of sigmoid-rectal anastomosis is becoming lower and lower, and the problem of AL is more challenging. Preventive stoma is currently a common method to deal with AL, but over-reliance on stoma and the stoma-related complications have also troubled surgeons. Based on years of practical experience, we summarized how to avoid unnecessary stoma through the risk assessment scale, and how to detect and deal with AL in the early stage of laparoscopic-assisted anterior resection of low rectal cancer.

Key words: Laparoscopy, Anterior resection of low rectal cancer, Anastomotic leakage, Preventive stoma, Risk assessment scale

中图分类号:

R735.37

骆洋, 钟鸣. 腹腔镜低位直肠癌前切除术吻合口漏的预防和治疗[J]. 外科理论与实践, 2023, 28(03): 220-225.

LUO Yang, ZHONG Ming. Prevention and treatment of anastomotic leakage after laparoscopic anterior resection of low rectal cancer[J]. Journal of Surgery Concepts & Practice, 2023, 28(03): 220-225.

图/表 6

表1

图1

图2

表2

图3

图4

参考文献 33

[1]	SUN R, DAI Z, ZHANG Y, et al. The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a syste-matic review and meta-analysis[J]. Support Care Cancer, 2021, 29(12):7249-7258. doi: 10.1007/s00520-021-06326-2
[2]	FRANCHINI MELANI A G, CAPOCHIN ROMAGNOLO L G. Management of postoperative complications during laparoscopic anterior rectal resection[J]. Minerva Surg, 2021, 76(4):324-331.
[3]	GARG P K, GOEL A, SHARMA S, et al. Protective diversion stoma in low anterior resection for rectal cancer: a meta-analysis of randomized controlled trials[J]. Visc Med, 2019, 35(3):156-160. doi: 10.1159/000497168 URL
[4]	PHAN K, OH L, CTERCTEKO G, et al. Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials[J]. J Gastrointest Oncol, 2019, 10(2):179-187. doi: 10.21037/jgo URL
[5]	NAGAOKA T, FUKUNAGA Y, MUKAI T, et al. Risk factors for anastomotic leakage after laparoscopic low anterior resection: a single-center retrospective study[J]. Asian J Endosc Surg, 2021, 14(3):478-488. doi: 10.1111/ases.v14.3 URL
[6]	PEEL A L, TAYLOR E W. Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group[J]. Ann R Coll Surg Engl, 1991, 73(6):385-388.
[7]	BRUCE J, KRUKOWSKI Z H, AL-KHAIRY G, et al. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery[J]. Br J Surg, 2001, 88(9):1157-1168. doi: 10.1046/j.0007-1323.2001.01829.x URL
[8]	RAHBARI N N, WEITZ J, HOHENBERGER W, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer[J]. Surgery, 2010, 147(3):339-351. doi: 10.1016/j.surg.2009.10.012 URL
[9]	FOPPA C, NG S C, MONTORSI M, et al. Anastomotic leak in colorectal cancer patients: new insights and perspectives[J]. Eur J Surg Oncol, 2020, 46(6):943-954. doi: 10.1016/j.ejso.2020.02.027 URL
[10]	YE L, HUANG M, HUANG Y, et al. Risk factors of postoperative low anterior resection syndrome for colorectal cancer: a meta-analysis[J]. Asian J Surg, 2022, 45(1):39-50. doi: 10.1016/j.asjsur.2021.05.016 URL
[11]	SCIUTO A, MEROLA G, DE PALMA G D, et al. Predictive factors for anastomotic leakage after laparoscopic colorectal surgery[J]. World J Gastroenterol, 2018, 24(21):2247-2260. doi: 10.3748/wjg.v24.i21.2247 URL
[12]	骆洋, 俞旻皓, 陈建军, 等. 倒刺缝线在腹腔镜直肠癌根治术中加固吻合口的应用价值[J]. 中华消化外科杂志, 2020, 19(11):1205-1210.
	LUO Y, YU M H, CHEN J J, et al. Application value of barbed suture in reinforcing anastomosis during laparoscopic radical resection of rectal cancer[J]. Chin J Dig Surg, 2020, 19(11):1205-1210.
[13]	骆洋, 秦骏, 陈建军, 等. 腹腔镜直肠癌手术中保留左结肠动脉与否疗效对比研究[J]. 中国实用外科杂志, 2017, 37(6):660-664.
	LUO Y, QIN J, CHEN J J, et al. Laparoscopic radical resection of rectal cancer with and without preservation of the left colonic artery: a comparative study[J]. Chin J Pract Surg, 2017, 37(6):660-664.
[14]	骆洋, 俞旻皓, 樊钊强, 等. 结直肠外科专业化程度对腹腔镜低位直肠癌手术预防性造口的影响[J]. 腹腔镜外科杂志, 2021, 26(2):112-116.
	LUO Y, YU M H, FAN Z Q, et al. The effect of colorectal surgery specialization on preventive stoma during laparoscopic surgery for lower rectal cancer[J]. J Laparosc Surg, 2021, 26(2):112-116.
[15]	LIN H, YU M, YE G, et al. Intracorporeal reinforcement with barbed suture is associated with low anastomotic leakage rates after laparoscopic low anterior resection for rectal cancer: a retrospective study[J]. BMC Surg, 2022, 22(1):335. doi: 10.1186/s12893-022-01782-x
[16]	LUO Y, YU M H, HUANG Y Z, et al. Lymphadenectomy around inferior mesenteric artery in low-tie vs. high-tie laparoscopic anterior resection: short- and long-term outcome of a cohort of 614 rectal cancers[J]. Cancer Manag Res, 2021, 13:3963-3971. doi: 10.2147/CMAR.S282986 URL
[17]	CONG Z J, HU L H, ZHONG M, et al. Diverting stoma with anterior resection for rectal cancer: does it reduce overall anastomotic leakage and leaks requiring laparotomy?[J]. Int J Clin Exp Med, 2015, 8(8):13045-13055.
[18]	AHMAD N Z, ABBAS M H, KHAN S U, et al. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery[J]. Int J Colorectal Dis, 2021, 36(3):445-455. doi: 10.1007/s00384-020-03771-z
[19]	SCHLESINGER N H, SMITH H. The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study[J]. Int J Colorectal Dis, 2020, 35(10):1903-1910. doi: 10.1007/s00384-020-03625-8
[20]	ZEMAN M, CZARNECKI M, CHMIELARZ A, et al. Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients[J]. World J Surg Oncol, 2020, 18(1):207. doi: 10.1186/s12957-020-01979-5
[21]	EMILE S H, KHAN S M, GAROUFALIA Z, et al. When is a diverting stoma indicated after low anterior resection? A meta-analysis of randomized trials and meta-regression of the risk factors of leakage and complications in non-diverted patients[J]. J Gastrointest Surg, 2022, 26(11):2368-2379. doi: 10.1007/s11605-022-05427-5
[22]	MYRSETH E, NYMO L S, GJESSING P F, et al. Diverting stomas reduce reoperation rates for anastomotic leak but not overall reoperation rates within 30 days after anterior rectal resection: a national cohort study[J]. Int J Colorectal Dis, 2022, 37(7):1681-1688. doi: 10.1007/s00384-022-04205-8
[23]	中华医学会外科学分会结直肠外科学组. 中国直肠癌手术吻合口漏诊断、预防及处理专家共识(2019版)[J]. 中华胃肠外科杂志, 2019, 22(3):201-206.
	Chinese Society of Colorectal Surgery, Chinese Society of Surgery, Chinese Medical Association. Expert consensus on diagnosis, prevention, and management of anastomotic leakage in rectal cancer surgery in China(2019 edition)[J]. Chin J Gastrointest Surg, 2019, 22(3):201-206.
[24]	骆洋, 俞旻皓, 敬然, 等. 腹腔镜低位直肠癌前切除术后吻合口漏危险因素分析及其风险评估量表应用价值的多中心回顾性研究[J]. 中华消化外科杂志, 2021, 20(12):1342-1350.
	LUO Y, YU M H, JING R, et al. Risk factors for anastomotic leakage after laparoscopic lower anterior resection of rectal cancer and application value of risk assessment scoring model: a multicenter retrospective study[J]. Chin J Dig Surg, 2021, 20(12):1342-1350.
[25]	FUKADA M, MATSUHASHI N, TAKAHASHI T, et al. Risk and early predictive factors of anastomotic leakage in laparoscopic low anterior resection for rectal cancer[J]. World J Surg Oncol, 2019, 17(1):178. doi: 10.1186/s12957-019-1716-3
[26]	LI T, HUANG J, LEI P, et al. A novel nomogram for anastomotic leakage after surgery for rectal cancer: a retrospective study[J]. Peer J, 2022, 10:e14437. doi: 10.7717/peerj.14437 URL
[27]	YEUNG D E, PETERKNECHT E, HAJIBANDEH S, et al. C-reactive protein can predict anastomotic leak in colorectal surgery: a systematic review and meta-analysis[J]. Int J Colorectal Dis, 2021, 36(6):1147-1162. doi: 10.1007/s00384-021-03854-5
[28]	SINGH P P, ZENG I S, SRINIVASA S, et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery[J]. Br J Surg, 2014, 101(4):339-346. doi: 10.1002/bjs.9354 URL
[29]	KORNMANN V N, TRESKES N, HOONHOUT L H, et al. Systematic review on the value of CT scanning in the diagnosis of anastomotic leakage after colorectal surgery[J]. Int J Colorectal Dis, 2013, 28(4):437-445. doi: 10.1007/s00384-012-1623-3 URL
[30]	DOEKSEN A, TANIS P J, VROUENRAETS B C, et al. Factors determining delay in relaparotomy for anastomotic leakage after colorectal resection[J]. World J Gastroenterol, 2007, 13(27):3721-3725. doi: 10.3748/wjg.v13.i27.3721 URL
[31]	颜登国, 张汝一, 甄运寰, 等. 结直肠癌切除术后吻合口瘘的治疗[J]. 中华胃肠外科杂志, 2006, 9(5):408.
	YAN D G, ZHANG R Y, ZHENG Y H, et al. Treatment of anastomotic fistula after resection of colorectal cancer[J]. Chin J Gastrointest Surg, 2006, 9(5):408.
[32]	ERIKSEN J D, EMMERTSEN K J, MADSEN A H, et al. Anastomotic leakage following restorative rectal cancer resection: treatment and impact on stoma presence 1 year after surgery-a population-based study[J]. Int J Colorectal Dis, 2022, 37(5):1161-1172. doi: 10.1007/s00384-022-04164-0
[33]	VAN WORKUM F, TALBOOM K, HANNINK G, et al. Treatment of anastomotic leakage after rectal cancer resection: the TENTACLE-Rectum study[J]. Colorectal Dis, 2021, 23(4):982-988. doi: 10.1111/codi.v23.4 URL

Definition	Grade	Clinical manifestation
Subclinical leakage or imaging leakage	A	No special clinical symptoms or signs, only leakage may be detected before stoma closure, which may lead to delayed stoma closure and have hardly impact on recovery
Clinical leakage or significant leakage	B	The peritonitis is not typical or limited, which requires anti-infection and local drainage treatment
Clinical leakage or significant leakage	C	There are clinical manifestations of peritoneal irritation sign and other abdominal infections，requiring emergency surgical intervention

1 point	2 points	3 points
Age≥70 years	Male	Diabetes
BMI≥28 kg/m²	Tumor diameter≥ 3.5 cm	Haemoglobin<90 g/L
Chronic smocking and (or) alcohol abuse	Anastomosis without reinforcement	Albumin<30 g/L
Non-preservation of left colonic artery	Numbers of staplers≥3	Neoadjuvant chemoradiotherapy
Operation time≥ 180 min	Bleeding≥100 mL	Distance from the anastomosis to the dentate line< 1cm
Non-specialized team	Without anal tube	ASA system grading ≥Ⅲ