经肛手工加固低位吻合口在直肠癌经肛全直肠系膜切除术后预防吻合口漏中的作用  

Efficacy of transanal hand-sewn reinforcement in low rectal stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision

作　　者：揭海清 李泽 罗双灵[1] 刘占振 张兴伟[1] 阮蕾[1] 梁文锋 胡焕新[1] 康亮[1] Jie Haiqing;Li Ze;Luo Shuangling;Liu Zhanzhen;Zhang Xingwei;Luan Lei;Liang Wenfeng;Hu Huanxin;Kang Liang(Department of Colorectal Surgery,Institute of Gastroenterology,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China)

机构地区：[1]中山大学附属第六医院结直肠肛门外科,广州510655

出　　处：《中华胃肠外科杂志》2021年第6期530-535,共6页Chinese Journal of Gastrointestinal Surgery

基　　金：中山大学临床医学研究5010计划项目(2016005)。

摘　　要：目的探讨经肛手工加固吻合口在经肛全直肠系膜切除(taTME)术后低位吻合器吻合口在预防吻合口漏中的作用和可行性。方法采用描述性病例系列研究方法。回顾性收集2019年1月至2020年12月期间中山大学附属第六医院结直肠肛门外科行taTME并行经肛手工加固吻合口的患者资料。纳入标准:(1)年龄>18岁;(2)术前病理学诊断直肠癌;(3)肿瘤距离肛缘≤8 cm(根据盆腔MR);(4)术前评估为初治可切除病变;(5)无论是否接受新辅助化疗或放疗;(6)行taTME手术,行吻合器端端吻合,并行可吸收线间断加固吻合口,吻合口距离肛门≤5 cm。排除标准:(1)既往具有恶性结直肠肿瘤病史;(2)合并肠梗阻、肠穿孔、肠出血等需急诊手术患者;(3)局部复发及远处转移患者;(4)术后随访时间<3个月。经肛手工加固吻合口主要步骤:在确认吻合口无出血后,使用3-0单股可吸收线采用"8"字缝合法间断加固吻合口,缝合肠壁的浆肌层,一圈缝合6~8针。上一针的出针点对应下一针进针点。术中可根据吻合器吻合的结果,对吻合口薄弱部位进行加固。主要观察指标为吻合口漏发生情况和是否二次手术及其方式;吻合口漏感染率和吻合口狭窄率;术中和术后的一般情况。结果51例患者纳入研究,均顺利完成taTME和经肛吻合口加固手术,手术中位用时169(109~337)min,术中出血量中位数50(10~600)ml。术后住院天数中位数8(5~16)d。所有患者均获得完整直肠系膜,无远切缘阳性病例,1例(2.0%)患者出现环周切缘阳性。12例(23.5%)患者行预防性回肠造口,1例(2.0%)患者发生吻合口狭窄,予以人工扩肛处理后痊愈。有3例(5.9%)患者发生需要手术干预的C级吻合口漏、均为男性,其中2例术中未行预防性造口,行二次手术予以回肠造口及吻合口修补后痊愈;有1例经肛门探查修补吻合口,予以抗感染对症处理后痊愈。1例(2.0%)出现肛周感染,给予抗感染及�Objective To explore the efficacy and feasibility of transanal hand-sewn reinforcement of low stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision(taTME).Methods A descriptive cohort study was conducted.Clinical data of 51 patients with rectal cancer who underwent taTME with transanal hand-sewn reinforcement of low stapled anastomosis at Department of Colorectal Surgery,the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2020 were retrospectively collected.Inclusion criteria:(1)age>18 years old;(2)rectal cancer confirmed by preoperative pathology;(3)distance from tumor to anal verge≤8 cm according to pelvic MR;(4)the lesion was evaluated to be resectable before operation;(5)with or without neoadjuvant chemotherapy and radiotherapy;(6)taTME,end-to-end stapled anastomosis,and reinforcement in the anastomosis with absorbable thread intermittently were performed,and the distance between anastomosis and anal verge was≤5 cm.Exclusion criteria:(1)previous history of colorectal cancer surgery;(2)emergency surgery due to intestinal obstruction,bleeding or perforation;(3)patients with local recurrence or distant metastasis;(4)the period of postoperative follow-up less than 3 months.The procedure of transanal hand-sewn reinforcement was as follows:firstly,no sign of bleeding was confirmed after checking the anastomosis.Then,the anastomosis was reinforced by suturing the muscle layer of rectum intermittently in a figure-of-eight manner using 3-0 single Vicryl.The entry site of the next suture was close next to the exit site of the last one.Any weak point of the anastomosis could also be reinforced according to the specimen from the circular stapler.The primary outcome were the incidence of anastomotic leak,methods of the secondary operation,anastomotic infection,anastomotic stricture,and conditions of Intraoperative and postoperative.Results All the 51 enrolled patients completed surgery successfully without any conversion to open surgery.The media

关 键 词：直肠肿瘤 经肛全直肠系膜切除术 吻合口漏 吻合口加固 经肛 

分 类 号：R735.37[医药卫生—肿瘤]