腹腔镜Dixon术中高位结扎肠系膜下动脉后吻合口瘘的风险分析

发布时间：2018-04-17 11:31

  本文选题：直肠癌 + 直肠低位前切除术　； 参考：《山东大学》2017年硕士论文

【摘要】：研究背景目前,我国结直肠癌发病率和病死率持续上升,已成为我国最常见的消化道恶性肿瘤之一。相对高位直肠癌以及结肠癌来说,中低位直肠癌的预后较差,五年生存率约为40%左右。由此可见,中低位直肠癌在我国存在着发病率高,预后差的显著特点,对我国国民生命健康及生活质量有着显著影响。中低位直肠癌的主要治疗方式是以手术治疗为主的综合治疗措施,随着社会的发展和人民对生活质量的要求,腹腔镜外科技术的熟练,腹腔镜下直肠低位前切除术称为了临床治疗中最常见的手术方式。其恢复快,创伤小以及对肠系膜下动脉(inferior mesenteric artery,IMA)根部淋巴结清扫更彻底的优点,成为越来越多中国结直肠外科大夫的首选。腹腔镜Dixon手术中对于IMA的处理目前主要有HT(high tie,HT)和LT(lowtie,LT)两种。HT主要有操作简单,肠管松弛、吻合口张力小、可以减少对腹腔自主神经的损伤等优点,但同时可能影响吻合口血供,部分患者可能需要游离脾曲。LT对于吻合口血供的维持有更好效果,且部分学者认为可以减少术中出血量,但在行IMA根部三角区淋巴清扫时难度较大。综合文献报道,两种方法(D3清扫)对淋巴结清扫数目、吻合口漏发生率、复发率及生存率等影响孰优孰劣尚存争议。研究目的1.探讨分析直肠癌患者在腹腔镜下直肠低位前切除术(low anterior resection,LAR)中IMAHT后吻合口瘘发生率、游离脾曲的发生率、预防性造瘘的发生率的风险。2.探讨LAR术中HT和LT对于吻合口血供的影响。3.探讨不同吻合口血供对于游离脾曲发生率,预防性造瘘发生率以及吻合口瘘发生率的影响。研究方法按照如下入组标准,收集2012年1月—2016年12月于山东大学齐鲁医院结直肠外科接受直肠低位前切除术的101例,并收集患者完整住院病历。入组标准:(1)术前经肠镜活检和组织病理学检测证实肿块为直肠癌;(2)经术前影像学、直肠指诊及肠镜检查证实癌肿位于直肠中下段,即肿瘤距肛缘5cm 但12cm;(3)肿瘤无远处转移及局部其他器官的浸润;(4)手术方式为腹腔镜下直肠低位前切除术;排除标准:(1)术前已经行新辅助放化疗的患者;(2)下腹部手术史;(3)因并发急性肠梗阻、肠穿孔并急性腹膜炎、急性大出血等行急诊手术的患者;(4)手术过程中发现的腹腔广泛转移或邻近其他脏器的浸润转移。按照IMA的结扎方式,将入组病例分为HT组和LT组,其中HT组包括病号39例,LT组62例。回顾性分析总结所有入组患者的临床资料;运用卡方检验分析HT组和LT组吻合口瘘、游离脾曲、预防性造瘘发生率和吻合口血供分级的组间差异。按照入组病例吻合口血供分级重新分组:A组为切割闭合器切断后,断端可见明显搏动性出血,· B组为切割闭合器切断后,断端可见较明显渗血;C组为切割闭合器切断后,断端未见明显出血及渗血;运用卡方检验分析不同等级吻合口血供在吻合口瘘、游离脾曲和预防性造瘘发生率的组间差异。研究结果1.入组病例基本资料对比与HT组相比,LT组在年龄、性别、吸烟、饮酒、高血压、糖尿病、家族史、血白蛋白、血红蛋白(hemoglobin,HGB)、白细胞(white blood cell,WBC)、谷丙转氨酶(glutamic-pyruvic transaminase,ALT)、谷草转氨酶(glutamic-oxalacetic transaminase,AST)、肌酐(creatinine,Cr)、凝血酶原时间(prothrombin time,PT)等无统计学差异(p0.05);与HT组相比,LT组的癌胚抗原(carcinoembryonic antigen,CEA)和手术时间显著减少(p0.05)。见表1。2.HT组和LT组吻合口瘘、游离脾曲、预防性造瘘发生率和吻合口血供分级的组间比较2.1病例组吻合口瘘发生率的组间比较与HT组相比,LT组吻合口瘘发生率无统计学差异(p0.05)。2.2病例组游离脾曲发生率的组间比较与HT组相比,LT组游离脾曲发生率更小,有统计学差异(p0.05)。2.3病例组预防性造瘘发生率的组间比较与HT组相比,LT组行预防性造瘘的发生率无统计学差异(p0.05)。2.4病例组吻合口血供分级的组间比较与HT组相比,LT组吻合口血供更丰富,差别有统计学意义(p0.01)。3.不同吻合口血供分级间吻合口瘘、游离脾曲和预防性造瘘发生率的比较3.1不同吻合口血供分级间吻合口瘘发生率的比较与A组相比,B组吻合口瘘发生率增加(p0.01),C组吻合口瘘发生率无统计学差异(p0.05);与B组相比,C组吻合口瘘发生率无统计学差异(p0.05);3.2不同吻合口血供分级间游离脾曲发生率的比较与A组相比,B组和C组游离脾曲发生率无统计学差异(p0.05);与B组相比,C组游离脾曲发生率无统计学差异(p0.05);3.3不同吻合口血供分级间预防性造瘘发生率的比较与A组相比,B组和C组预防性造瘘发生率有统计学差异(p0.05);而与B组相比,C组预防性造瘘发生率有统计学差异(p0.01)。结论1.在直肠低位前切除术中IMA行高位结扎不是吻合口瘘发生的独立危险因素。2.IMA中高位结扎组相对低位结扎组游离脾曲发生率更小,吻合口血供更丰富。3.入组病例按吻合口血供分级重新分组,血供越丰富,吻合口瘘发生率越低,预防性造瘘发生率越小。
[Abstract]:Background: at present, China's colorectal cancer incidence and mortality rates continue to rise, China has become one of the most common malignant tumor of digestive tract. The relatively high rectal cancer and colon cancer, poor prognosis in rectal cancer, five year survival rate is about 40%. Thus, in low rectal cancer in our country there is a disease high rate, obvious characteristics of poor prognosis, has a significant impact on the health and quality of life of our national life. The main treatment of low rectal cancer is surgical treatment, with the requirements of the quality of life and social development and people, skilled laparoscopic surgery, laparoscopic low anterior resection of rectum the most common way to surgical operation in clinical treatment. The quick recovery, small trauma and the inferior mesenteric artery (inferior mesenteric, artery, IMA) root lymph node thoroughly The advantages, become more and more China colorectal surgeons preferred. Laparoscopic Dixon surgery for the treatment of IMA is the main HT (high tie HT) and LT (lowtie, LT) two.HT mainly has simple operation, small bowel relaxation, anastomotic tension, can reduce the injury of abdominal cavity of autonomic nerve etc. but at the same time, may affect the anastomotic blood supply, some patients may need to be free of splenic flexure of.LT has better effect for maintaining the anastomotic blood supply, and some scholars think that can reduce the amount of bleeding, but the lymph in IMA triangle root cleaning difficult. According to literature reported, two methods (D3.) the number of lymph node dissection, anastomotic leakage rate, recurrence rate and survival rate of the merits is controversial. Objective: 1. of rectal cancer patients in laparoscopic low anterior resection (low anterior resection, LAR IM) The incidence of anastomotic fistula after AHT, the incidence of splenic flexure free HT and LT LAR, to investigate the preventive effect of the postoperative anastomotic blood supply of.3. on different anastomotic blood supply for free of splenic flexure of the occurrence of the risk of.2. fistula, fistula incidence and prevention of anastomotic fistula. Effect of birth rate. Methods according to the following group, from January 2012 to December 2016 in Qilu Hospital of Shandong University accepted 101 cases of colorectal surgery rectal low anterior resection, and complete medical records were collected. Inclusion criteria: (1) preoperative colonoscopy biopsy and histopathology confirmed the tumor for rectal cancer (2;) by preoperative imaging, digital rectal examination and colonoscopy confirmed cancer in the lower rectum, tumor from the anal margin of 5cm 12cm; (3) the tumor metastasis and other local organs; (4) surgery for abdominal laparoscopic rectal low anterior 鍒囬櫎鏈，

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