作者：陈育洪，程黎阳，陈战，雷德桥

单位：中国人民解放军南部战区总医: 普通外科，广东 广州 510010

Authors: Chen Yuhong，Cheng Liyang，Chen Zhan，Lei Deqiao

Unit: Departments of General Surgery，General Hospital of Southern Theater Command，PLA，Guangzhou 510010, Guangdong，China

摘要：

目的 探讨中低位直肠癌前切除(low anterior resection,LAR)术后发生吻合口漏的危险因素。方法 回顾性对照研究方法,分析中国人民解放军南部战区总医:普通外科2015—2019年行LAR术505例患者的临床资料,按照国际直肠癌研究小组(International Study Group of Rectal Cancer,ISREC)对术后吻合口漏(anastomotic leakage,AL)进行确诊。观察指标有性别、年龄、糖尿病、高血压、吸烟史、体质量指数(body mass index,BMI)、肠梗阻、新辅助治疗、肿瘤直径、手术方式、术中出血量、手术时间、吻合口与肛缘距离、预防性肠造口、术后白蛋白及血红蛋白。采用X2检验对吻合口漏的影响因素进行单因素分析,对比组间差异具有统计学意义的变量纳入多因素Logistic回归分析,确定吻合口漏发生的独立危险因素。结果 男309例,女196例,平均年龄61(36～73)岁。吻合口漏43例(8.5%),A/B级漏37例(86.0%),C级漏6例(14.0%)。单因素分析显示,性别(P=0.029)、糖尿病(P=0.002)、吸烟史(P=0.027)、BMI≥28 kg/m2(P=0.002)、肠梗阻(P=0.004)、新辅助治疗(P=0.002)、肿瘤直径≥5 cm(P=0.017)、吻合口与肛缘距离≤5 cm(P=0.021)、预防性肠造口(P=0.020)、术后白蛋白<35 g/L (P=0.030)、术后血红蛋白<100 g/L (P=0.029)在观察组与对照组的差异具有统计学意义(P<0.05)。多因素Logistic回归分析显示,性别(OR=0.217,95%CI:0.070～0.669,P=0.008)、糖尿病(OR=4.617,95%CI:1.391～15.332,P=0.012)、BMI≥28 kg/m2(OR=1.292, 95%CI:1.036～1.612,P=0.023)、肠梗阻(OR=8.588, 95%CI:1.432～51.511,P=0.019)、新辅助治疗(OR=13.971,95%CI:2.974～65.624,P=0.001)、肿瘤直径≥5 cm(OR=2.46,95%CI:1.377～4.393,P=0.002)、吻合口与肛缘距离≤5 cm(OR=0.171,95%CI:0.100～0.294,P<0.001)、术后血红蛋白<100 g/L (OR=0.91,95%CI:0.875～0.947,P<0.001)是吻合口漏发生的独立危险因素,而预防性肠造口(OR=0.001,95%CI:0.001～0.011,P<0.001)是吻合口漏发生的保护因素。结论 吻合口漏病理是多因素共同作用的结果。了解吻合口漏危险因素,在于采取更好的防治措施。

关键词：直肠肿瘤；吻合口漏；危险因素

Abstract：

Objective To investigate the risk factors of anastomotic leakage (AL) after low anterior resection (LAR) for the middle and low rectal carcinoma. Methods The clinical data of 505 patients undergoing LAR in the Departments of General Surgery, the General Hospital of Southern Theater Command, PLA from 2015 to 2019 were analyzed retrospectively. AL in these patients was diagnosed according to the criteria of International Study Group of Rectal Cancer. Indexes including gender, age, diabetes mellitus, hypertension, smoking history, BMI, intestinal obstruction, neoadjuvant therapy, tumor diameter, operative type, intraoperative blood loss, operation time, distance between anastomotic stoma and anal margin, prophylactic intestinal stoma, postoperative albumin and hemoglobin were observed. Univariate analysis of the influencing factors of AL was carried out using the Chi-square test, and variables showing statistically significant differences between groups were subjected to multivariate logistic regression analysis for the determination of the independent risk factors of AL. Results A total of 505 patients were enrolled in this study, including 309 males and 196 females, with an average age of 61 (36~73) years. Forty-three cases (8.5%) had AL. Among them, 37 cases (86.0%) were of Grade A/B and 6 cases (14.0%) were of Grade C. Univariate analysis revealed that gender (P=0.029), diabetes mellitus (P=0.002), smoking history (P=0.027), BMI≥28 kg/m2 (P=0.002), intestinal obstruction (P=0.004), neoadjuvant therapy (P=0.002), tumor diameter≥5 cm (P=0.017), distance between anastomotic stoma and anal margin≤5 cm (P=0.021), the prophylactic intestinal stoma (P=0.020), postoperative albumin约35 g/L(P=0.030) and postoperative hemoglobin约100 g/L(P=0.029) have significant difference in observe group and control group (P<0.05). Multivariate logistic regression analysis indicated that gender (OR =0.217, 95%CI:0.070-0.669, P=0.008), diabetes mellitus (OR =4.617, 95%CI:1.391-15.332, P=0.012), BMI≥28 kg/m2 (OR=1.292, 95%CI:1.036-1.612, P=0.023), intestinal obstruction (OR=8.588, 95%CI:1.432-51.511, P=0.019), neoadjuvant therapy (OR=13.971, 95%CI:2.974-65.624, P=0.001), tumor diameter≥5 cm (OR=2.46, 95%CI:1.377-4.393, P=0.002), distance between anastomotic stoma and anal margin≤5 cm (OR=0.171, 95%CI:0.100-0.294, P<0.001) and postoperative hemoglobin< 100 g/L (OR=0.91, 95%CI: 0.875-0.947, P<0.001) were independent risk factors of AL. The prophylactic intestinal stoma (OR=0.001, 95%CI:0.001-0.011, P<0.001) was a protective factor of AL. Conclusion AL is a synergistical result of multiple factors, with an unidentified pathophysiological mechanism. A good understanding of the risk factors of AL can help us to take better preventive measures.

Key Words: Rectal cancer；Anastomotic leakage；Risk factors