Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Colorectal Dis. 2024 May;26(5):1004-1013. doi: 10.1111/codi.16958. Epub 2024 Mar 25.
Ileorectal anastomosis (IRA) following total abdominal colectomy (TAC) allows for resortation of bowel continuity but prior studies have reported rates of anastomotic leak (AL) to be as high as 23%. We aimed to report rates of AL and complications in a large cohort of patients undergoing IRA. We hypothesized that AL rates were lower than previously reported and that selective use of diverting loop ileostomy (DLI) is associated with decreased AL rates.
Patients undergoing TAC or end-ileostomy reversal with IRA, with or without DLI, between 1980 and 2021 were identified from a prospectively maintained institutional database and retrospectively analysed. Redo IRA cases were excluded. Short-term (30-day) surgical outcomes were collected using our database. AL was defined using a combination of imaging and, in the case of return to the operating room, intraoperative findings.
Of 823 patients in the study cohort, DLI was performed in 27% and performed more frequently for constipation and inflammatory bowel disease. The overall AL rate was 3% (1% and 4% in those with and without DLI, respectively) and diversion was found to be protective against leak (OR 0.28, 95% CI 0.08-0.94, p = 0.04). However, patients undergoing diversion had a higher overall rate of postoperative complications (51% vs. 36%, p < 0.001) including superficial wound infection, urinary tract infection, dehydration, blood transfusion and portomesenteric venous thrombosis (all p < 0.04).
Our study represents the largest series of patients undergoing IRA reported to date and demonstrates an AL rate of 3%. While IRA appears to be a viable surgical option for diverse indications, our study underscores the importance of careful patient selection and thoughtful consideration of staging the anastomosis and temporary faecal diversion when necessary.
全腹结肠切除（TAC）后行回直肠吻合术（IRA）可恢复肠道连续性，但先前的研究报告吻合口漏（AL）的发生率高达 23%。我们旨在报告大量接受 IRA 治疗的患者的 AL 发生率和并发症。我们假设 AL 发生率低于先前报道，并且选择性使用预防性回肠造口术（DLI）与降低 AL 发生率相关。
从一个前瞻性维护的机构数据库中确定了 1980 年至 2021 年间接受 TAC 或末端回肠造口术 IRA 翻修术的患者，包括 DLI 或不包括 DLI 的 IRA，并进行了回顾性分析。排除再次 IRA 病例。使用我们的数据库收集短期（30 天）手术结果。AL 的定义是结合影像学检查，如果需要返回手术室，还包括术中发现。
在研究队列的 823 名患者中，27%的患者行 DLI，DLI 更多用于治疗便秘和炎症性肠病。总的 AL 发生率为 3%（有和无 DLI 的患者分别为 1%和 4%），且引流术可预防漏（OR 0.28，95%CI 0.08-0.94，p=0.04）。然而，接受引流术的患者术后总体并发症发生率较高（51%比 36%，p<0.001），包括浅表伤口感染、尿路感染、脱水、输血和门腔静脉血栓形成（均 p<0.04）。
我们的研究代表了迄今为止报告的最大系列接受 IRA 治疗的患者，显示 AL 发生率为 3%。尽管 IRA 似乎是一种可行的手术选择，但用于多种适应证，但我们的研究强调了仔细选择患者和考虑分期吻合术以及在必要时进行临时性粪便转流的重要性。
