Jestin P, Påhlman L, Gunnarsson U
Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
Colorectal Dis. 2008 Sep;10(7):715-21. doi: 10.1111/j.1463-1318.2007.01466.x. Epub 2008 Mar 3.
With introduction of the total mesorectal excision technique and preoperative radiotherapy in rectal cancer surgery, the local recurrence rate has decreased and the overall survival has improved. One drawback, however, is the high anastomotic leakage rate of approximately 10-18%. Male gender and low anastomoses are known risk factors for such leakage. The aim of this study was to identify potentially modifiable risk factors.
In a case-control study, data from the Swedish Rectal Cancer Registry (1995-2000) were analysed. Cases were all patients with anastomotic leakage after an anterior resection (n = 134). Two controls were randomly selected for each case. The medical records (n = 402) were checked against a study protocol. Due to incorrect recording two cases and 28 controls were excluded from further analyses.
In the multivariate analysis significant risk factors were American Society of Anesthesiologists score > 2 [OR = 1.40 (95% CI 1.05-1.83)], preoperative radiotherapy [OR = 1.34 (95% CI 1.06-1.69)], intraoperative adverse events [OR = 1.85 (95% CI 1.32-2.58)], level of anastomosis <or= 6 cm [OR = 1.39 (95% CI 1.01-1.90)] and severe bleeding [OR = 1.45 (95% CI 1.14-1.84)]. Diverting stoma protected from leakage [OR = 0.68 (95% CI 0.52-0.88)]. Male gender was a risk factor in the univariate but not in the multivariate analysis [OR = 1.30 (95% CI 1.04-1.63) and OR = 1.26 (95% CI 1.00-1.58), respectively]. Except for a protective stoma, none of the variables considered as possible targets for improvement, such as postoperative epidural anaesthesia, observation at intensive care unit for more than 24 h, and intraabdominal drainage, proved to be protective factors either in the univariate or in the multivariate analyses.
The most important risk factors for leakage were adverse intraoperative events, low anastomoses and preoperative radiotherapy. A diverting stoma is protective and can reduce the consequences when leakage occurs. Further analyses with focus on the surgical technique and individual surgeon may be valuable in identifying targets for improvement.
随着直肠癌手术中全直肠系膜切除技术和术前放疗的引入，局部复发率有所下降，总体生存率得到提高。然而，一个缺点是吻合口漏发生率较高，约为10%-18%。已知男性和低位吻合是发生这种渗漏的危险因素。本研究的目的是确定潜在的可改变危险因素。
在一项病例对照研究中，分析了瑞典直肠癌登记处（1995-2000年）的数据。病例为所有前切除术术后发生吻合口漏的患者（n = 134）。为每个病例随机选择两名对照。对照研究方案检查病历（n = 402）。由于记录错误，两名病例和28名对照被排除在进一步分析之外。
多因素分析中，显著的危险因素包括美国麻醉医师协会评分>2 [比值比（OR）= 1.40（95%可信区间1.05-1.83）]、术前放疗[OR = 1.34（95%可信区间1.06-1.69）]、术中不良事件[OR = 1.85（95%可信区间为1.32-2.58）]、吻合口水平≤6 cm [OR = 1.39（95%可信区间1.01-1.90）]和严重出血[OR = 1.45（95%可信区间1.14-1.84）]。转流造口可预防渗漏[OR = 0.68（95%可信区间0.52-0.88）]。男性在单因素分析中是危险因素，但在多因素分析中不是[分别为OR = 1.30（95%可信区间1.04-1.63）和OR = 1.26（95%可信区间1.00-1.58）]。除了保护性造口外，在单因素或多因素分析中，没有一个被视为可能改善目标的变量，如术后硬膜外麻醉、在重症监护病房观察超过24小时和腹腔引流，被证明是保护因素。
渗漏的最重要危险因素是术中不良事件、低位吻合和术前放疗。转流造口具有保护作用，可减少渗漏发生时的后果。进一步关注手术技术和个体外科医生的分析可能有助于确定改进目标。
