医学课件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
• Leakage was confirmed by digital rectal examination, CT scan, endoscopy, contrast enema, reoperation.
吻合口瘘发生率能降低吗？
• 检索 Medline 和 PubMed databases • Keywords: “leakage,” “low anterior resection,”“rectal
Mar;147(3):339-51.
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.
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直肠癌前切除后吻合口瘘定义和分级
• 直肠癌前切除后吻合口瘘定义和严重度分级建议
定义 分级
结直肠或结肠肛管吻合区（包括直肠储袋的缝合和吻合 线）肠壁完整性缺损，导致肠管内外区交通；靠近吻合 口的盆腔脓肿也认定为吻合口漏。
A 不需要积极的治疗干预
B 需要积极的治疗干预，但不需要再次剖腹手术
C 需要再次剖腹手术
cancer,” “risk factors.”
– 可以确定(evidence suggests):吻合口越低更容易漏. – 其他(well-documented)是男性,吸烟,术前营养不良 – 常规游离脾曲和使用J-pouch 似乎能降低吻合口漏率 – 术前放化疗对吻合口的影响正在严格审查中 – 保护性造口的指征还有争论 – 大网膜成形术,肠道准备,使用引流,肿瘤分期似乎不能影响吻合口
n
Karanjia
219
Lopez-Kostner F 819
Vignali
1014
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
Neutzling 1233 9 CB(2012)
no difference in the leakage rate.
Docherty 732 JG(1995)
prospective, multicenter, randomized study
stapled anastomoses are as safe as manually constructed anastomoses
• 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.
• These data provide substantial evidence that lower anastomoses are prone to leakage.
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.
• Anastomotic leakage is a feared complication, resulting in a postoperative mortality rate of 6–9 percent, depending on whether a diverting stoma is created
• 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.
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 .
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
漏率 – 手术类型(开放或腔镜) 和吻合方法(手缝或吻合器) 也不是关键
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)