Dolinsky David, Levine Marc S, Rubesin Stephen E, Laufer Igor, Rombeau John L
Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA.
AJR Am J Roentgenol. 2007 Jul;189(1):25-9. doi: 10.2214/AJR.06.1382.
The purpose of our study was to determine the utility of contrast enemas for detecting clinically relevant anastomotic strictures after total proctocolectomy and ileal pouch-anal anastomosis and to facilitate management by defining a critical anastomotic caliber at or below which obstruction is likely to develop after ileostomy closure.
Our radiology database revealed 42 patients with contrast enemas after total proctocolectomy and ileal pouch-anal anastomosis who fulfilled our exclusion criteria. The initial postoperative contrast enemas were reviewed blindly to determine the diameter of the ileoanal anastomosis. The diagnosis of a stricture was made only if the patient had signs of intestinal obstruction after ileostomy closure with confirmation on follow-up contrast enema or sigmoidoscopy and clinical improvement after anastomotic dilatation. The data were then correlated to determine if there was a critical anastomotic caliber at or below which such strictures were likely to develop. Using this threshold value, the sensitivity and specificity of routine contrast enemas for detecting clinically relevant anastomotic strictures were then determined.
Six (14%) of the 42 patients who underwent total proctocolectomy and ileal pouch-anal anastomosis had strictures at the ileoanal anastomosis on contrast enemas. The mean diameter of the anastomosis was 5.8 mm in the six patients with anastomotic strictures versus 15 mm in the 36 patients without strictures (p = 0.0002). If an anastomotic diameter of 8 mm is defined as the critical caliber at or below which clinically relevant strictures are present, the sensitivity of contrast enemas for detecting strictures at the ileoanal anastomosis was 100% (six of six patients) and the specificity was 92% (33 of 36 patients).
Routine contrast enema after total proctocolectomy and ileal pouch-anal anastomosis is a sensitive test for detecting clinically relevant strictures at the ileoanal anastomosis when an anastomotic diameter of 8 mm or less is used as the threshold value for diagnosing these strictures. Such patients may need dilatation procedures to decrease the risk of anastomotic obstruction after ileostomy closure.
我们研究的目的是确定在全直肠结肠切除术后回肠储袋肛管吻合术（IPAA）中，对比灌肠对于检测临床相关吻合口狭窄的效用，并通过确定一个关键的吻合口管径来辅助管理，即当吻合口管径小于或等于此值时，回肠造口关闭后可能会发生梗阻。
我们的放射学数据库显示，有42例接受全直肠结肠切除术后回肠储袋肛管吻合术且符合我们排除标准的患者进行了对比灌肠。对术后初次对比灌肠进行盲法评估，以确定回肠肛管吻合口的直径。仅当患者在回肠造口关闭后出现肠梗阻体征，且后续对比灌肠或乙状结肠镜检查证实，并在吻合口扩张后临床症状改善时，才诊断为狭窄。然后对数据进行关联分析，以确定是否存在一个关键的吻合口管径，小于或等于此值时可能会发生此类狭窄。使用该阈值，进而确定常规对比灌肠检测临床相关吻合口狭窄的敏感性和特异性。
42例接受全直肠结肠切除术后回肠储袋肛管吻合术的患者中，6例（14%）在对比灌肠时发现回肠肛管吻合口狭窄。6例吻合口狭窄患者的吻合口平均直径为5.8 mm，而36例无狭窄患者的吻合口平均直径为15 mm（p = 0.0002）。如果将吻合口直径8 mm定义为存在临床相关狭窄的关键管径，对比灌肠检测回肠肛管吻合口狭窄的敏感性为100%（6例患者中的6例），特异性为92%（36例患者中的33例）。
当以8 mm或更小吻合口直径作为诊断全直肠结肠切除术后回肠储袋肛管吻合术临床相关狭窄的阈值时，常规对比灌肠是检测回肠肛管吻合口临床相关狭窄的敏感方法。此类患者可能需要进行扩张手术，以降低回肠造口关闭后吻合口梗阻的风险。
