直肠癌术后吻合口瘘

Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery. 2010 Mar;147(3):339-51.
1233
9
no difference in the leakage rate.
732
prospective, multicenter, randomized study
stapled anastomoses are as safe as manually constructed anastomoses
Lopez-Kostner F Vignali
leakage rate
漏24例（11%），吻合口均低于6cm
吻合口高于15cm为0.14%,10-15cm为5.4%，低于10cm为 8.4% 高位前切除为1%，低于7cm为7.7%，多因素分析唯一危 险因素是低于7cm
219
819 1014
• These data provide substantial evidence that lower anastomoses are prone to leakage.
术前放疗(Preoperative Radiation Therapy)
• These conclusions must be interpreted with caution since the absence of concomitant chemotherapy and the liberal use of a protective stoma in that study may have obscured the data
吻合口瘘定义
• AL was defined as follows: peritonitis and a defect in the anastomosis, discharge of pus from the anus, and recto-vaginal fistula or faeces or gas from the abdominal drain. • The time limit for AL was set at 30 days after surgery for patients discharged from the hospital within this time. There was no time limit for inhospital patients. • Leakage was confirmed by digital rectal examination, CT scan, endoscopy, contrast enema, reoperation.
危险因素(The Patient)
• 病人---男性 • 可能是男性狭窄的骨盆，在切除时视野不佳导致手术操作 更困难. • 吸烟和酗酒在多因素分析中也被证实是危险因素，主要通 过影响小血管，导致组织缺氧，影响组织愈合.
吻合口高度(Height of the Anastomosis)
n
Karanjia
吻合器vs手缝(Stapled VS Handsewn)
n MacRae HM(1998) Meta(RCT) 13 结论 no difference in the leakage rate between the two groups.
Neutzling CB(2012)
Docherty JG(1995)
To be well perfused
• Sheridan et al. reported that oxygen tension(氧 分压) on the anastomosis is a predictive factor for leakage. • In a recent prospective study, Hirano et al. found by using near-infrared spectroscopy (近红外光谱 学)that patients with leakage had lower tissue oxygen saturation(氧饱和度) at the anastomosis site than patients without anastomotic leakage.
直肠癌低位前切除术后吻合口瘘
Anastomotic Leakage After Low Anterior Resection For Rectal Cancer
山东大学齐鲁医院
Introduction
• Anastomotic leakage (AL) after anterior resection of the rectum is a serious cause of morbidity and mortality , with the risk of a permanent stoma . • It may also be associated with an increased risk of local recurrence . • The incidence of clinically significant leakage after LAR varies between 3% and 21%, but is thought to average 10%. Subclinical anastomotic failure may occur in up to 51% of patients. • Anastomotic leakage is a feared complication, resulting in a postoperative mortality rate of 6–9 percent, depending on whether a diverting stoma is created
High ligation
• may severely compromise the blood supply of the sigmoid colon • As the marginal artery of the descending colon is a more reliable vessel for the blood supply, the descending colon is preferred for the anastomosis. • A surgical advantage of high tie is that it renders the left colon more mobile, which might facilitate construction of the coloanal anastomosis. • It should be noted, however, that many surgeons adopt a more selective approach towards mobilization of the splenic flexure.
Omentoplasty AND extraperitoneal anastomosis
• There is no prospective evidence that omentoplasty reduces the leakage rate and that it should not be routinely used. • The peritonealization of the pelvis and the extraperitoneal positioning of the anastomosis have been evaluated with conflicting results. Some believe that this technique reduces the occurrence of peritonitis after anastomotic leakage, but others disagree. • While it seems possible that the above maneuvers may mitigate(减轻) the consequences of anastomotic leakage, we do not think that there is a proven mechanism to reduce the rate of this complication.
Without tension
• To create a well-perfused anastomosis without tension, routine mobilization of the splenic flexure has been proposed. • Karanjia et al. reported that if the sigmoid colon was used for the anastomosis without full mobilization of the splenic flexure the leakage rate was 22%, compared with 9% if full mobilization was done. • Another important reason for mobilizing the splenic flexure is that the adequately mobilized descending colon can occupy the pelvis, reducing the dead space and diminishing the risk of abscess or pelvic collection formation.