Center for Colon and Rectal Surgery, Florida Hospital, Orlando, Florida.
Academic Surgical Unit, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom.
Dis Colon Rectum. 2018 Feb;61(2):172-178. doi: 10.1097/DCR.0000000000000962.
The management of the rectal wall defect after local excision of rectal neoplasms remains controversial, and the existing data are equivocal.
This study aimed to determine the effect of open versus closed defects on postoperative outcomes after local excision of rectal neoplasms.
Data from 3 institutions were analyzed. Propensity score matching was performed in one-to-one fashion to create a balanced cohort comparing open and closed defects.
This study was conducted at high-volume specialist referral hospitals.
Adult patients undergoing local excision via transanal endoscopic surgery from 2004 to 2016 were included. Patients were assigned to open- and closed-defect groups, and further stratified by full- or partial-thickness excision.
Closure of the rectal wall defect was performed at the surgeon's discretion.
The primary outcome measured was the incidence of 30-day complications.
A total of 991 patients were eligible (593 full-thickness excision with 114 open and 479 closed, and 398 partial-thickness excision with 263 open and 135 closed). After matching, balanced cohorts consisting of 220 patients with full-thickness excision and 210 patients with partial-thickness excision were created. Operative time was similar for open and closed defects for both full-and partial-thickness excision. The incidence of 30-day complications was similar for open and closed defects after full- (15% vs. 12%, p = 0.432) and partial-thickness excision (7% vs 5%, p = 0.552). The total number of complications was also similar after full- or partial-thickness excision. Patients undergoing full-thickness excision with open defects had a higher incidence of clinically significant bleeding complications (9% vs 3%, p = 0.045).
Data were obtained from 3 institutions with different equipment and perioperative management over a long time period.
There was no difference in overall complications between open and closed defects for patients undergoing local excision of rectal neoplasms, but there may be more bleeding complications in open defects after full-thickness excision. A selective approach to defect closure may be appropriate. See Video Abstract at http://links.lww.com/DCR/A470.
直肠肿瘤局部切除术后直肠壁缺损的处理仍存在争议，现有数据尚无定论。
本研究旨在确定直肠肿瘤局部切除术后开放与闭合缺损对术后结局的影响。
对 3 家机构的数据进行分析。采用 1∶1 倾向性评分匹配，创建了比较开放与闭合缺损的平衡队列。
本研究在高容量的专科转诊医院进行。
纳入 2004 年至 2016 年接受经肛门内镜微创手术的成年患者。患者被分为开放缺损组和闭合缺损组，并进一步分为全层或部分层切除。
直肠壁缺损的闭合由外科医生决定。
主要观察指标为 30 天并发症发生率。
共有 991 例患者符合条件（全层切除 593 例，其中 114 例为开放缺损，479 例为闭合缺损；部分层切除 398 例，其中 263 例为开放缺损，135 例为闭合缺损）。匹配后，创建了全层切除 220 例和部分层切除 210 例的平衡队列。开放缺损与闭合缺损的手术时间相似，无论全层或部分层切除。全层切除后，开放与闭合缺损的 30 天并发症发生率相似（15%比 12%，p=0.432），部分层切除后相似（7%比 5%，p=0.552）。全层或部分层切除后总并发症数也相似。全层切除伴开放缺损患者的临床显著出血并发症发生率较高（9%比 3%，p=0.045）。
数据来自 3 家机构，这些机构在很长一段时间内使用不同的设备和围手术期管理。
对于接受直肠肿瘤局部切除术的患者，开放与闭合缺损之间的总体并发症无差异，但全层切除后开放缺损可能有更多出血并发症。选择性闭合缺损可能是合适的。详见视频摘要，网址：http://links.lww.com/DCR/A470。
