Division of Surgical Oncology and Digestive Surgery, Department of Oncology, San Luigi University Hospital, University of Turin, Turin, Italy.
Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy.
Colorectal Dis. 2022 Mar;24(3):264-276. doi: 10.1111/codi.15997. Epub 2021 Dec 6.
Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.
The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured.
A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection.
While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.
直肠癌保肛手术后吻合口漏具有较高的发病率和相关死亡率。识别这些危险因素可以改变手术计划，包括造口的适应证。本回顾性多中心研究旨在评估吻合口漏的发生率，确定独立的危险因素，并建立一个临床预测模型来计算漏的概率。
本研究使用了意大利外科肿瘤学会结直肠癌网络的 24 个意大利转诊中心的数据。患者被分为两组，AL（吻合口漏）或 NoAL（无吻合口漏）。通过单变量和多变量分析，测量了患者、疾病、治疗和术后结果相关因素对吻合口漏的影响。
共纳入 5398 例患者，AL 组 552 例，NoAL 组 4846 例。总的漏诊率为 10.2%，平均时间间隔为 6.8 天。30 天漏诊相关死亡率为 2.6%。性别、体重指数、肿瘤位置、入路类型、使用的吻合器数量、体重减轻、临床 T 分期和联合多器官切除被确定为独立的危险因素。造口并没有降低漏诊率，但显著降低了漏诊的严重程度和再次手术率。建立了一个列线图风险评分（RALAR 评分），以预测手术结束时吻合口漏的风险。
虽然预防性造口术并不能降低漏诊风险，但可以显著降低其严重程度。外科医生应该认识到直肠切除术后吻合口漏的独立危险因素，并可以计算出风险评分来选择高危患者进行保护性造口术。
