Hanna Mark H, Vinci Alessio, Pigazzi Alessio
Department of Surgery, Irvine School of Medicine, University of California, Irvine, 333 City Blvd. West Suite 850, Orange, CA, 92868, USA.
Langenbecks Arch Surg. 2015 Feb;400(2):145-52. doi: 10.1007/s00423-015-1275-1. Epub 2015 Jan 30.
The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice.
Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion.
Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion.
Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.
在接受直肠切除和吻合术的患者中，使用袢式回肠造口术进行粪便转流的作用存在争议。关于功能丧失性造口的预期益处与发病率，存在相互矛盾的证据。这是一篇对相关外科文献的综述，评估了在当前结直肠外科实践中构建转流性回肠造口术的风险、益处和成本。
回顾了过去50年的回顾性和前瞻性文章，以确定吻合口漏（AL）的定义，评估AL的风险因素，并评估吻合口的评估方法。然后，我们汇总了支持和反对粪便转流的证据、造口并发症的发生率和后果，以及比较袢式回肠造口术与袢式结肠造口术作为粪便转流最佳方法的证据。
证据表明，尽管粪便转流不会降低术后死亡率，但它确实能显著降低吻合口漏的风险，以及在发生漏时进行紧急再次手术的必要性。从技术角度来看，转流性造口是一种低风险的外科手术，但会带来大量术后发病率，这可能会极大地妨碍患者的生活质量和康复。高危患者，如低位结直肠吻合术（距肛缘<10 cm）、结肠肛管吻合术、技术难度大的切除术、营养不良的患者以及男性患者，似乎从粪便转流中获益最大。
建议将粪便转流作为一种选择性工具，以保护或改善结直肠吻合术后的吻合口漏。在选择性用于盆腔低位吻合且发生AL风险增加的高危患者时，它最为有益。需要新的工具来识别前切除术术后吻合失败的高危患者。
