作者：李嘉玲1，陈志锋2，刁德昌3，易小江3

单位：1.毕节市中医医院 肛肠科，贵州 毕节 551700;  2.梅州市中医医院 肝胆胃肠甲状腺外科，广东 梅州 514000;  3.广州中医药大学第二附属医院/广东省中医院 胃肠肿瘤中心结直肠外科，广东 广州 510120

Authors: Li Jialing1, Chen Zhifeng2, Diao Dechang3, Yi Xiaojiang3

Unit:  1. Department of Proctology, Bijie Hospital of Traditional Chinese Medicine, Bijie 551700, Guizhou, China;  2. Department of Hepatobiliary Gastrointestinal Thyroid Surgery, Meizhou Hospital of Traditional Chinese Medicine, Meizhou 514000, Guangdong, China;  3. Department of Colorectal (Tumor) Surgery/ Gastrointestinal Cancer Center, Guangdong Provincial Hospital of Chinese Medicine, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, Guangdong, China

摘要：

目的  探讨直肠癌术后行预防性回肠造口的决策因素，并分析预防性回肠造口对围手术期预后的影响。方法  采用回顾性病例对照研究方法，纳入2013年1月至2021年12月广东省中医院胃肠肿瘤中心行前切除术的直肠癌患者751例，其中229例患者术后行预防性回肠造口（预防性回肠造口组），522例未行预防性回肠造口（非预防性回肠造口组），比较两组患者的术前、术中和肿瘤相关资料，并对比两组患者围手术期预后的差异。结果  术前影响因素方面，预防性回肠造口组中，男性、既往使用激素或免疫抑制剂、术前行放化疗和既往有吸烟史的患者比例多于非预防性回肠造口组(均P<0.05)；术中影响因素方面，预防性回肠造口组中，离断肿瘤远端直肠肠管时使用的直线切割闭合器钉仓数目≥2个、吻合口与肛缘距离≤5 cm 和手术时间＞180 min 的患者比例多于非预防性回肠造口组(均P<0.05)；肿瘤影响因素方面，预防性回肠造口组的T分期晚于未行造口组(P=0.001)，肿瘤位置低于非预防性回肠造口组(P=0.001)。多因素Logistic回归分析提示，男性患者、伴有术前肠梗阻、术前进行放化疗、吻合口与肛缘距离≤5 cm、使用超过1个直线切割闭合器离断肠管、中低位和超低位肿瘤和手术时间＞180 min为预防性回肠造口的独立危险因素。围手术期预后方面，预防性回肠造口未能降低吻合口漏的发生[4.37%（10/229）比5.17%（27/522）]，差异无统计学意义（P＞0.05），同时增加住院费用(P=0.001)；但可缩短总住院、术后住院和盆腔引流管拔除时间(均P<0.05)，降低术后肛管放置率(23.14%比62.84%) (P<0.001)。结论  术前、术中和肿瘤相关诸多因素可影响预防性回肠造口决策的判断，预防性回肠造口可改善围手术期的短期预后。

关键词： 直肠癌；预防性回肠造口；决策因素；围手术期

Abstract：

Objective  To explore the decision-making factors of preventive ileostomy (PI) after rectal cancer surgery, and analyze the impact of PI on perioperative prognosis. Method  A retrospective case-control study was used to include 751 rectal cancer patients who underwent anterior resection at the Gastrointestinal Cancer Center of Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2013 to December 2021. Among them, 229 patients underwent PI after surgery (PI group), and 522 patients did not undergo PI (non-PI group). The preoperative, intraoperative, tumor related data and the differences in perioperative prognosis of these two groups were compared. Result  In terms of preoperative factors, the proportion of male patient in the PI group, the history of hormone or immunosuppressive drug use before operation, preoperative radiotherapy and chemotherapy, and smoking history were higher than non-PI group (all P<0.05). In terms of intraoperative factors, the proportion of patients in the PI group who used linear cutting closure device with nail number ≥2, distance between the anastomotic site and anal margin ≤5 cm, and surgical time >180 minutes were higher than non-PI group (all P<0.05). In terms of tumor factors, the T staging of the PI group was more advanced than that of the non-PI group (P=0.001), and the tumor location was lower than that of the non-PI group (P <0.001). Multivariate Logistic regression analysis suggested that male patients, preoperative intestinal obstruction, preoperative radiotherapy and chemotherapy, the distance between anastomotic site and anal margin ≤5 cm, linear cutting closure device with nail number ≥1, middle, low and ultralow level tumors, and surgical time >180 minutes are independent risk factors for PI. In terms of perioperative prognosis, PI did not reduce the incidence of anastomotic leakage[4.37% (10/229) vs. 5.17% (27/522)], without statistical difference (P>0.05), and increased hospitalization costs (P=0.001). But it can shorten the total hospitalization, postoperative hospitalization, and pelvic drainage tube removal time (all P<0.05), and reduce the postoperative anal tube placement rate (23.14% vs. 62.84%) (P<0.001). Conclusion  Preoperative, intraoperative, and tumor related factors can affect the judgment of PI decisions, and PI can improve shortterm prognosis during the perioperative period.

Key Words:  Rectal cancer; Preventive ileostomy; Decision-making factors; Perioperative period