Maya Antonio M, Boutros Marylise, DaSilva Giovanna, Wexner Steven D
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida.
Dis Colon Rectum. 2015 May;58(5):488-93. doi: 10.1097/DCR.0000000000000330.
Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity.
The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision.
This was a retrospective medical chart review.
The study was conducted in a single clinical institution.
Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken.
Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured.
A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn's disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4-30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363-2182 days), requiring a median of 1.5 procedures.
This was a single-center retrospective review with a small sample size.
Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.
回肠肛管储袋切除术后会阴伤口并发症仍然是发病的一个重要原因。
本研究旨在描述储袋切除术后会阴伤口并发症的发生率、结局及预测因素。
这是一项回顾性病历审查。
该研究在单一临床机构进行。
确定了1992年7月至2012年7月在我们机构接受储袋切除术的患者。回顾患者及围手术期变量。进行多变量和单变量分析。
测量会阴伤口（包括会阴伤口感染和持续性会阴窦[6个月未愈合]）及会阴疝。
共有47例患者（平均年龄46岁；42.6%为男性）因家族性腺瘤性息肉病（10.6%）、黏膜溃疡性结肠炎（61.7%）或克罗恩病（27.7%）接受储袋切除术，其中36.2%因与回肠肛管吻合术相关的脓毒症（骶前脓肿；会阴、骶骨或储袋阴道瘘；以及吻合口缺损），44.7%因储袋功能障碍，10.6%因难治性储袋炎，8.5%因肿瘤。14例（29.8%）发生会阴伤口并发症，包括100%会阴伤口感染、28.6%持续性会阴窦和7.1%会阴疝。会阴伤口感染与愈合延迟（>6周；71.4%对24.2%；p = 0.002）及与回肠肛管吻合术相关的脓毒症（28.6%对0%；p = 0.001）相关。有和没有会阴伤口并发症的患者在年龄、诊断、粪便转流、免疫抑制、合并症、营养及手术变量方面相似。大多数患者接受了括约肌间分离术（87.2%）及一期会阴缝合（97.0%）。会阴伤口并发症与作为储袋切除指征的与回肠肛管吻合术相关的脓毒症（57.1%对27.2%；p = 0.05）、术中储袋穿孔（35.7%对9.1%，p = 0.03）及吸烟（21.4%对3.0%；p = 0.04）显著相关。在多变量逻辑回归中，与回肠肛管吻合术相关的脓毒症及当前吸烟状态（OR，19.3[95%CI，1.8 - 488.1]）是会阴伤口并发症的显著独立预测因素（OR，6.4[95%CI，1.4 - 30.2]）。所有持续性会阴窦患者在中位734天（范围363 - 2182天）时均成功愈合，中位需要1.5次手术。
这是一项单中心回顾性研究，样本量小。
术前与回肠肛管吻合术相关的脓毒症及当前吸烟是储袋切除术后会阴伤口并发症的重要危险因素。
