Schmidt O, Merkel S, Hohenberger W
Department of Surgery, University of Erlangen, Krankenhausstr. 12, D-91054 Erlangen, Germany.
Eur J Surg Oncol. 2003 Apr;29(3):239-43. doi: 10.1053/ejso.2002.1416.
One of the most significant surgical complications following rectal resection with primary anastomosis is anastomotic leakage. The aim of this study was to evaluate the benefit of intraoperative anastomotic testing of stapled anastomoses and the impact on leakage rate.
Between 1987 and 2000, 1360 consecutive rectal resections for carcinoma were performed. In 933 operations rectal resection was completed with either stapled (n=788), handsewn (n=80) or coloanal (n=65) anastomosis. Since 1995 we introduced intraoperative anastomotic testing, routinely. Between 1995 and 2000, 296 patients were treated with stapled anastomosis following rectal resection. Different variables influencing anastomotic leakage were evaluated.
Between 1987 and 2000, 68 of 933 patients treated by resection and anastomosis developed a clinically significant anastomotic leak (7.3%) where as between 1995 and 2000 the leakage rate was 9.8% of all patients with stapled anastomosis. There was an increase in resection rate from 62 to 72%. Since 1995 we demonstrated either intraluminal bleeding or leakage in 18.1% of all stapled anastomoses by intraoperative anastomotic testing. The postoperative anastomotic leakage rate was equal in those patients with normal and abnormal findings of anastomotic testing even though 74% of all patients with irregular findings were treated by performing a protective stoma simultaneously. We found no significant risk factor for the development of anastomotic leakage.
We recommend a protective stoma with any anastomosis within the lower third of the rectum. Anastomoses within the middle and upper third of the rectum demonstrate a lower risk of anastomotic insufficiency and do not need a protective stoma, routinely.
直肠切除并一期吻合术后最严重的手术并发症之一是吻合口漏。本研究旨在评估术中对吻合器吻合进行检测的益处及其对漏出率的影响。
1987年至2000年期间，连续对1360例直肠癌患者进行了直肠切除术。在933例手术中，直肠切除术后采用吻合器吻合（n = 788）、手工缝合（n = 80）或结肠肛管吻合（n = 65）完成手术。自1995年起，我们常规引入术中吻合检测。1995年至2000年期间，296例患者在直肠切除术后采用吻合器吻合。对影响吻合口漏的不同变量进行了评估。
1987年至2000年期间，933例接受切除并吻合治疗的患者中有68例发生了具有临床意义的吻合口漏（7.3%），而1995年至2000年期间，所有采用吻合器吻合的患者漏出率为9.8%。切除率从62%上升至72%。自1995年起，通过术中吻合检测，我们在所有吻合器吻合中发现18.1%存在腔内出血或漏出。尽管所有检测结果异常的患者中有74%同时进行了保护性造口术，但吻合检测结果正常和异常的患者术后吻合口漏出率相同。我们未发现吻合口漏发生的显著危险因素。
我们建议对直肠下三分之一内的任何吻合均采用保护性造口。直肠中三分之一和上三分之一内的吻合显示吻合口功能不全的风险较低，通常不需要保护性造口。
