直肠癌术后吻合口漏的早期诊断与治疗  

Early diagnosis and treatment of anastomotic leak after rectal cancer surgery

作　　者：杨廷翰[1] 王自强[1] Yang Tinghan, Wang Ziqiang(Department of Gastrointestinal Surgery, West China hospital, Sichuan University, Chengdu 610041, Chin)

机构地区：[1]四川大学华西医院胃肠外科,成都610041

出　　处：《中华胃肠外科杂志》2018年第4期388-394,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：四川省科技支撑计划（2016SZ0043）;四川省卫生和计划生育委员会普及应用项目（17PJ101）

摘　　要：中低位直肠癌术后吻合口漏是最常见的严重并发症。由于对其发生机制缺乏真正的了解。目前尚缺乏确实有效的防控措施。本文主要就直肠癌术后吻合口漏的关键预防措施、早期诊断及治疗措施等方面的进展做一讨论。对于具有吻合口漏高危因素，如吻合口距肛〈4cm、男性、肥胖患者、吻合口血供相对不足、新辅助放化疗及严重全身合并症的患者，应积极采取预防措施。目前预防性造口、术前肠道准备以及肛管减压对预防吻合口漏是否有利，尚存有争议；对肠道血供的荧光监测及选择性保留左结肠动脉的联合应用是今后在术中预防吻合口漏发生的研究方向。而随着新辅助放疗及预防性造口的广泛应用，更多的患者呈现非典型临床表现，如麻痹性或炎性肠梗阻、腹泻、肠道脓性分泌物、低热、心率、呼吸增快及少尿等，外科医生对这些非典型表现应有更充分的认识，及时的CT及内镜检查有利于早期确定吻合口漏的诊断、感染范围及吻合口缺损大小。对合并弥漫性腹膜炎的患者，应在积极液体复苏的情况下紧急手术，而对于感染相对局限的吻合口漏，则应综合感染范围、感染来源是否能有效控制、肿瘤后续治疗策略以及肠道延续性恢复的可能性与必要性等多个因素决策治疗方案。Anastomotic leakage is the most common major complication after mid-low rectal cancer surgery. Due to lack of knowledge regarding the virtual mechanisms of anastomotic leakage, not much can be done to prevent its development. The aim of the present review was to discuss the prevention, early diagnosis, and treatment of anastomotic leakage after rectal cancer surgery. For patients with risk factors, such as anastomotic site within 4 cm from anus, obese men, lack of blood supply of the anastomotic site, neoadjuvant chcmo radiotherapy, or patients with severe co- morbidity, aggressive preventive strategy should be adopted. The effectiveness of diverting stoma, preoperative bowel preparation, and transanal decompression are still in debate. The combination of fluorescence imaging to assess anastomotic perfusion and selective preservation of the left colic artery can be used in the future to prevent anastomotic leakage intraoperatively. With increasing use of neoadjuvant chemo radiotherapy and diverting stoma, more than half of the leaks present in a more subtle and insidious manner, including ileus, diarrhea, anal discharge of pus, mild fever, accelerated heart rate, tachypnea, and oliguria. Surgeons should be more cautious regarding these insidious clinical presentations. Computed tomography scan and endoscopy are among the most important diagnostic workups that can early diagnose leakage and indicate the size of the defect and extent of infection. For patients presenting with diffuse peritonitis, emergency surgical exploration is mandatory along with fluid resuscitation. For those with limited infection, appropriate treatment plan should be made after consideration of the extent of infection, methods to eradicate the infectious source, strategies following adjuvant therapy, and the possibility and necessity of re-establishing bowel continuity.

关 键 词：直肠肿瘤 低位前切除术 吻合口漏 早期诊断 治疗 

分 类 号：R735.37[医药卫生—肿瘤]