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直肠癌前切除术后早期小肠梗阻的危险因素。

Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer.

机构信息

Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, 4-11-1 Izumihoncho, Komae-Shi, Tokyo, 201-8601, Japan.

Department of Surgery, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, 105-8471, Japan.

出版信息

World J Surg. 2018 Jan;42(1):233-238. doi: 10.1007/s00268-017-4152-y.

Abstract

PURPOSE

The aim of the study was to evaluate risk factors for small bowel obstruction (SBO) in early postoperative period after anterior resection for rectal cancer.

METHODS

Patients who underwent anterior resection (AR) [high AR (HAR) or low AR (LAR)] for rectal cancer between January 2009 and April 2016 were enrolled into the study after fulfilling selection criteria. In included patients, risk factors for early postoperative SBO (EPSBO) were analyzed by means of univariate and multivariate analysis. Cases with perioperative major complications other than intestinal obstruction and with simultaneous resection of other organs were excluded. The same analyses were also performed for cases of redo surgery due to EPSBO. EPSBO was defined as clinically and radiologically confirmed SBO that developed after resuming oral intake within 30 days following surgery. The logistic regression method was used for statistical analyses.

RESULTS

In enrolled 180 patients, EPSBO occurred in 23 (12.8%). In univariate analysis, male sex [odds ratio (OR) = 2.17, 95% CI = 0.82-6.84, p < 0.0001], previous abdominal surgery (OR = 0.20, 95% CI = 0.03-0.73, p = 0.0117), low tumor (OR = 3.26, 95% CI = 1.28-8.13, p = 0.0140), LAR (OR = 17.25, 95% CI = 3.49-312.55, p < 0.0001), D3 node dissection (OR = 13.61, 95% CI = 2.75-246.69, p = 0.0002), defunctioning ileostomy (DI) formation (OR = 9.88, 95% = 3.80-29.14, p < 0.0001), and prolonged operation time (OR = 1.01, 95% CI = 1.00-1.01, p = 0.0122) were significantly related to EPSBO. Multivariate analysis demonstrated that D3 node dissection (OR = 10.93, 95% CI = 1.94-208.23, p = 0.0038) and DI formation (OR = 5.82, 95% CI = 1.55-25.31, p = 0.0083) were independent risk factors for EPSBO. Four cases (17.4%) with EPSBO required re-operation because conservative therapies failed; all were laparoscopic DI formation cases. In three of those four cases, stenosis of stoma at the level of the posterior sheath of rectus abdominis muscle was the reason of SBO, and in one case it was kinking of the stomal limb.

CONCLUSIONS

D3 lymph node dissection and DI formation are independent risk factors for EPSBO in AR.

摘要

目的

本研究旨在评估直肠癌前切除术后早期发生小肠梗阻(SBO)的危险因素。

方法

本研究纳入了 2009 年 1 月至 2016 年 4 月期间接受直肠前切除术(AR)[高位 AR(HAR)或低位 AR(LAR)]的患者。在满足选择标准后,将这些患者纳入研究。在纳入的患者中,通过单因素和多因素分析来分析早期术后 SBO(EPSBO)的危险因素。排除了围手术期除肠梗阻以外的其他主要并发症以及同时切除其他器官的病例。对于因 EPSBO 而再次手术的病例,也进行了相同的分析。EPSBO 定义为术后恢复口服饮食后 30 天内经临床和影像学证实的 SBO。采用逻辑回归法进行统计分析。

结果

在纳入的 180 例患者中,有 23 例(12.8%)发生了 EPSBO。单因素分析显示,男性(OR=2.17,95%CI=0.82-6.84,p<0.0001)、既往腹部手术史(OR=0.20,95%CI=0.03-0.73,p=0.0117)、低位肿瘤(OR=3.26,95%CI=1.28-8.13,p=0.0140)、LAR(OR=17.25,95%CI=3.49-312.55,p<0.0001)、D3 淋巴结清扫术(OR=13.61,95%CI=2.75-246.69,p=0.0002)、预防性回肠造口术(DI)(OR=9.88,95%CI=3.80-29.14,p<0.0001)和手术时间延长(OR=1.01,95%CI=1.00-1.01,p=0.0122)与 EPSBO 显著相关。多因素分析显示,D3 淋巴结清扫术(OR=10.93,95%CI=1.94-208.23,p=0.0038)和 DI 形成(OR=5.82,95%CI=1.55-25.31,p=0.0083)是 EPSBO 的独立危险因素。4 例(17.4%)EPSBO 患者因保守治疗失败而需要再次手术;均为腹腔镜 DI 形成病例。在这 4 例患者中,有 3 例是由于腹直肌后鞘层面吻合口狭窄导致 SBO,1 例是由于吻合口肠襻扭转。

结论

D3 淋巴结清扫术和 DI 形成是 AR 术后发生 EPSBO 的独立危险因素。

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