Penna Ch
Service de Chirurgie Générale, Digestive et Oncologique, Hôpital Ambroise Paré-Boulogne.
J Chir (Paris). 2003 Jun;140(3):149-55.
The risk of anastomotic leak after resection of cancers of the mid or low rectum with mesorectal excision is about 10%--the lower the colo-rectal or colo-anal anastomosis, the higher the risk of leak. If the fistula is asymtomatic and the leak is walled off, it is best to defer the closure of the diverting ileostomy for 2-3 months and to proceed only when a radiologic contrast study shows the fistula to have disappeared. More commonly, the anastomotic fistula presents as a pelvic abscess. It is simple and logical to drain the abscess into the digestive tube by enlarging the orifice of the fistula; this can usually be done with a brief general anesthetic. Less commonly, the abscess may present at some distance from the anastomotic leak; this calls for percutaneous drainage. If abscess drainage fails, if pelvic sepsis persists, or if the leak presents from the start as generalized peritonitis, laparotomy is called for in order to lavage the abscess cavity, place effective drains, and perform, if necessary, a diverting stoma upstream. Two strategies are possible: 1) drain placement at the leak site with upstream loop diverting stoma, or 2) takedown of the anastomosis, closure of the distal stump as a Hartmann pouch, and proximal end colostomy in the left lower quadrant. In the first instance, one must be sure the fistula has healed before stoma closure. In the second, the problem is to obtain (at a second stage) sufficient length of well-vascularized proximal colon to make an anastomosis to a short Hartmann pouch or to the anus in a pelvis scarred and inflamed by infection and radiation. A Soave procedure may allow an anastomosis with less risk to peri-rectal innervation and with less blood loss. Two maneuvers which may help to gain length are the Toupet technique for freeing the transverse mesocolon or the Deloyer technique of mobilizing the hepatic flexure. In the face of post-operative pelvic sepsis, an early intervention adapted to the circumstances will increase the chances of healing and reestablishment of intestinal continuity, and may avoid multiple complex interventions with poor functional results including incontinence, urgency, and difficult evacuation.
中低位直肠癌经直肠系膜切除术后吻合口漏的风险约为10%——结直肠或结肠肛管吻合位置越低，漏的风险越高。如果瘘无症状且漏已被包裹，最好将转流性回肠造口关闭推迟2至3个月，仅在放射学造影检查显示瘘已消失时再进行。更常见的情况是，吻合口瘘表现为盆腔脓肿。通过扩大瘘口将脓肿引流至消化道既简单又合理；这通常在短暂全身麻醉下即可完成。较少见的情况是，脓肿可能出现在距吻合口漏有一段距离的地方；此时需要经皮引流。如果脓肿引流失败、盆腔脓毒症持续存在，或者漏一开始就表现为弥漫性腹膜炎，则需要进行剖腹手术，以便冲洗脓肿腔、放置有效的引流管，并在必要时在上游进行转流造口。有两种策略可行：1）在漏口处放置引流管并在上游行袢式转流造口，或2）拆除吻合口，将远端残端闭合为Hartmann袋，并在左下腹行近端结肠造口。在第一种情况下，必须确保瘘愈合后再关闭造口。在第二种情况下，问题在于（在第二阶段）获得足够长度的血供良好的近端结肠，以便与短的Hartmann袋或与因感染和放疗而瘢痕化且发炎的盆腔中的肛门进行吻合。Soave手术可能使吻合术对直肠周围神经支配的风险更小、失血更少。两种可能有助于增加长度的操作是游离横结肠系膜的Toupet技术或游离肝曲的Deloyer技术。面对术后盆腔脓毒症，根据具体情况进行早期干预将增加愈合和恢复肠道连续性的机会，并可能避免多次功能结果不佳的复杂干预，包括失禁、尿急和排便困难。
