Veyrie Nicolas, Ata Toufik, Muscari Fabrice, Couchard Anne-Cécile, Msika Simon, Hay Jean-Marie, Fingerhut Abe, Dziri Chadli
Department of Digestive Surgery, Hôpital Hôtel-Dieu, APHP, University of Paris V, Paris, France.
J Am Coll Surg. 2007 Dec;205(6):785-93. doi: 10.1016/j.jamcollsurg.2007.06.284. Epub 2007 Sep 17.
Anastomotic leakage in colorectal surgery remains a major challenge because of its early and late consequences.
To determine whether prevalence and risk factors for anastomotic leakage (AL) differed between right and left elective colectomy for cancer, we conducted univariate and multivariate analyses and compared 33 variables (15 preoperative, 18 intraoperative) culled prospectively for 520 right and 1,230 left colectomies, followed by immediate anastomosis in 1,750 adult patients with or without AL.
The overall AL rate was 4% (71 of 1,750) and was significantly lower (p < 0.0001) for right (7 of 520=1.35%) than for left colectomy (64 of 1,230=5.20%). Overall mortality was 4.1% (68 of 1,750), and was not statistically different (p=0.50) between right (4.6%, 24 of 520) and left (3.6%, 44 of 1,230)) colectomy. In right colectomy, differences in associated mortality rates with (14.3%, 1 of 7) and without (4.5%, 23 of 513) AL were not statistically significant (p=0.28), but in left colectomy, associated mortality was statistically significantly higher (p < 0.006) with AL (10.9%, 7 of 64) than without it (3.2%, 37 of 1,166). Independent risk factors for AL were preoperative in right colectomy: loss of weight (> 10%), odds ratio (OR)=5.62, with 95% CI 1.06 to 29.8; and intraoperative in left colectomy: palliative resection (OR=2.12; 95% CI 1.06 to 4.23), "poor" colonic cleanliness (OR=2.4; 95% CI 1.34 to 4.28), proximal colorectal anastomosis (OR=1.34; 95% CI 1 to 1.8), and distal colorectal anastomosis (OR=3.91; 95% CI 1.64 to 9.81).
In right colectomy for cancer, preoperative nutritive support leading to regain of lost weight could reduce postoperative morbidity. Concerning left colectomy, if colonic cleanliness is poor, intraoperative colonic lavage should be done. When poor colonic cleanliness is associated with palliative resection and low distal rectal anastomosis, a protective stoma should be considered.
由于结直肠手术吻合口漏的早期和晚期后果，它仍然是一个重大挑战。
为了确定右半结肠癌和左半结肠癌择期结肠切除术吻合口漏（AL）的发生率和危险因素是否存在差异，我们进行了单因素和多因素分析，并比较了前瞻性收集的520例右半结肠切除术和1230例左半结肠切除术的33个变量（15个术前变量、18个术中变量），这些手术均在1750例有或无AL的成年患者中进行了即时吻合。
总体AL发生率为4%（1750例中的71例），右半结肠切除术（520例中的7例 = 1.35%）的发生率显著低于左半结肠切除术（1230例中的64例 = 5.20%）（p < 0.0001）。总体死亡率为4.1%（1750例中的68例），右半结肠切除术（4.6%，520例中的24例）和左半结肠切除术（3.6%，1230例中的44例）之间无统计学差异（p = 0.50）。在右半结肠切除术中，发生AL的相关死亡率（14.3%，7例中的1例）与未发生AL的相关死亡率（4.5%，513例中的23例）无统计学差异（p = 0.28），但在左半结肠切除术中，发生AL的相关死亡率（10.9%，64例中的7例）显著高于未发生AL的相关死亡率（3.2%，1166例中的37例）（p < 0.006）。右半结肠切除术AL的独立危险因素为术前：体重减轻（> 10%），比值比（OR） = 5.62，95%置信区间为1.06至29.8；左半结肠切除术AL的独立危险因素为术中：姑息性切除（OR = 2.12；95%置信区间为1.06至4.23）、结肠清洁度“差”（OR = 2.4；95%置信区间为1.34至4.28）、近端结直肠吻合（OR = 1.34；95%置信区间为1至1.8）以及远端结直肠吻合（OR = 3.91；95%置信区间为1.64至9.81）。
在右半结肠癌结肠切除术中，术前营养支持使体重恢复可降低术后发病率。对于左半结肠切除术，如果结肠清洁度差，应在术中进行结肠灌洗。当结肠清洁度差与姑息性切除及低位直肠远端吻合相关时，应考虑行保护性造口术。
