Kitahara Tomoaki, Sato Yu, Oshiro Takashi, Matsunaga Rie, Nagashima Makoto, Okazumi Shinichi
Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan.
World J Gastrointest Surg. 2020 Dec 27;12(12):507-519. doi: 10.4240/wjgs.v12.i12.507.
Current medical treatments can achieve remission of ulcerative colitis (UC). Surgery is required when potent drug treatment is ineffective or when colon cancer or high-grade dysplasia develops. The standard procedure is restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performed as two- or three-stage RPC with diverting ileostomy. Postoperative stoma outlet obstruction (SOO) is frequent, but the causes are not well known.
To identify the risk factors for SOO after stoma surgery in patients with UC.
We retrospectively reviewed the files of 148 consecutive UC patients who underwent surgery with stoma construction. SOO was defined as small bowel obstruction symptoms and intestinal dilatation just below the penetrating part of the stoma on computed tomography. Patients were divided into two groups: Those who developed SOO within 30 d after surgery and those who did not. Patient characteristics, intraoperative parameters, the stoma site, and rectus abdominis muscle thickness were collected. Moreover, we identified the patients who repeatedly developed SOO. Univariate and multivariate analyses were performed to identify risk factors for SOO and recurring SOO.
Eighty-nine patients who underwent two-stage RPC were included between January 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%) patients after a median time of 9 d (range 2-26). Compared to patients without SOO, patients with SOO had a significantly higher rate of malignant tumors or dysplasia (36.0% 17.1%, = 0.032), lower total glucocorticoid dose one month before surgery (0 mg 0 mg, = 0.026), higher preoperative total protein level (6.8 g/dL 6.3 g/dL, = 0.048), higher rate of loop ileostomy (88.0% 55.3%, = 0.002), and higher maximum stoma drainage volume (2300 mL 1690 mL, = 0.004). Loop ileostomy (OR = 6.361; 95%CI 1.322-30.611; = 0.021) and maximum stoma drainage volume (OR = 1.000; 95%CI 1.000-1.001; = 0.015) were confirmed as independent risk factors for SOO. Eighteen patients with SOO were treated conservatively without recurrence (sSOO group). Seven (28.0%) patients repeatedly developed SOO (rSOO group) during the observation period. A significant difference was observed in the rectus abdominis muscle thickness between the two groups (sSOO 9.3 mm, rSOO 12.7 mm, = 0.006). Muscle thickness was confirmed as an independent risk factor for recurring SOO (OR = 2.676; 95%CI 1.176-4.300; = 0.008).
In this study, high maximum stoma drainage volume and loop ileostomy are independent risk factors for SOO. Additionally, among patients with a thick rectus abdominis muscle, the risk of SOO recurrence is high.
目前的医学治疗可使溃疡性结肠炎（UC）缓解。当强效药物治疗无效或发生结肠癌或高级别发育异常时，则需要进行手术。标准手术是保留直肠结肠切除术（RPC）并进行回肠储袋肛管吻合术，通常作为带有转流性回肠造口术的两阶段或三阶段RPC进行。术后造口出口梗阻（SOO）很常见，但病因尚不清楚。
确定UC患者造口手术后发生SOO的危险因素。
我们回顾性分析了148例连续接受造口手术的UC患者的病历。SOO定义为计算机断层扫描显示小肠梗阻症状及造口穿透部位下方的肠管扩张。患者分为两组：术后30天内发生SOO的患者和未发生SOO的患者。收集患者特征、术中参数、造口部位及腹直肌厚度。此外，我们还确定了反复发生SOO的患者。进行单因素和多因素分析以确定SOO及复发性SOO的危险因素。
2008年1月至2020年3月期间，89例行两阶段RPC的患者纳入研究。术后，25例（16.9%）患者发生SOO，中位时间为9天（范围2 - 26天）。与未发生SOO的患者相比，发生SOO的患者恶性肿瘤或发育异常的发生率显著更高（36.0%对17.1%，P = 0.032），术前1个月总糖皮质激素剂量更低（0毫克对0毫克，P = 0.026），术前总蛋白水平更高（6.8克/分升对6.3克/分升，P = 0.048），袢式回肠造口术的发生率更高（88.0%对55.3%，P = 0.002），最大造口引流量更高（2300毫升对1690毫升，P = 0.004）。袢式回肠造口术（OR = 6.361；95%CI 1.322 - 30.611；P = 0.021）和最大造口引流量（OR = 1.000；95%CI 1.000 - 1.001；P = 0.015）被确认为SOO的独立危险因素。18例发生SOO的患者经保守治疗未复发（sSOO组）。7例（28.0%）患者在观察期内反复发生SOO（rSOO组）。两组腹直肌厚度存在显著差异（sSOO组9.3毫米，rSOO组12.7毫米，P = 0.006）。肌肉厚度被确认为复发性SOO的独立危险因素（OR = 2.676；95%CI 1.176 - 4.300；P = 0.008）。
在本研究中，最大造口引流量高和袢式回肠造口术是SOO的独立危险因素。此外，在腹直肌较厚的患者中，SOO复发风险较高。
