Mak Joanna Chung Kiu, Foo Dominic Chi Chung, Wei Rockson, Law Wai Lun
Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
World J Surg. 2017 Nov;41(11):2912-2922. doi: 10.1007/s00268-017-4090-8.
Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer.
The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors.
From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model.
This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively.
Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.
手术技术的进步和直肠癌治疗模式的改变导致腹会阴联合切除术率大幅下降，低位直肠癌可行保留括约肌手术。
本研究旨在评估低位直肠癌保留括约肌手术后永久性造口的长期发生率及其相关危险因素。
纳入2000年至2014年因低位直肠癌（距肛缘5 cm以内）接受保留括约肌的低位前切除术的患者。采用Cox比例风险回归模型研究永久性造口随时间的发生情况及其危险因素。
本研究纳入了194例行低位直肠癌超低位前切除术的患者，存活患者的中位随访期为77个月。最终有46例（23.7%）患者需要永久性造口。吻合口相关并发症和疾病进展是永久性造口的主要原因。临床吻合口漏（风险比5.72；95%置信区间2.31-14.12；p<0.001）和新辅助放化疗（风险比2.34；95%置信区间1.12-4.90；p=0.024）是永久性原发性造口的预测因素。局部复发（风险比16.09；95%置信区间5.88-44.03；p<0.001）和T4期疾病（风险比11.28；95%置信区间2.99-42.49；p<0.001）是永久性继发性造口的预测因素。永久性造口的5年和10年累积发生率分别为24.1%和28.0%。
疾病进展、既往放化疗、吻合口漏和局部复发使患者易发生永久性造口，在考虑保留括约肌手术时应予以考虑。
