Hu Gang, Ma Ji, Qiu Wen-Long, Mei Shi-Wen, Zhuang Meng, Xue Jun, Liu Jun-Guang, Tang Jian-Qiang
Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
Department of General Surgery, Datong Third People's Hospital, Datong 037008, Shanxi Province, China.
World J Gastrointest Surg. 2025 Mar 27;17(3):95983. doi: 10.4240/wjgs.v17.i3.95983.
Diverting stoma (DS) is routinely proposed in intersphincteric resection for ultralow rectal cancer, but it is associated with increased stoma-related complications and economic burden. Appropriate patient selection and operative strategies to avoid stoma formation need further elucidation.
To select patients who may not require DS.
This study enrolled 505 consecutive patients, including 84 who underwent stoma-free (SF) intersphincteric resection. After matching, patients were divided into SF ( = 78) and DS ( = 78) groups. The primary endpoint was the anastomotic leakage (AL) rate within 6 months and its protective factors for both the total and SF cohorts. The secondary endpoints included overall survival and disease-free survival.
The AL rate was greater in the SF group than in the DS group (12.8% 2.6%, = 0.035). Male sex [(odds ratio (OR) = 2.644, = 0.021], neoadjuvant chemoradiotherapy (nCRT) (OR = 6.024, < 0.001), and tumor height from the anal verge ≤ 4 cm (OR = 4.160, = 0.007) were identified as independent risk factors. Preservation of the left colic artery (LCA) was protective in both the total cohort (OR = 0.417, = 0.013) and the SF cohort (OR = 0.312, = 0.027). The female patients who did not undergo nCRT and had preservation of the LCA experienced a significantly lower incidence of AL (2/97, 2.1%). The 3-year overall survival or disease-free survival did not significantly differ between the groups.
Female patients who do not receive nCRT may avoid the need for DS by preserving the LCA without increasing the risk of AL or compromising oncological outcomes.
在超低位直肠癌的括约肌间切除术中，常规会采用转流造口术（DS），但它会增加与造口相关的并发症及经济负担。需要进一步明确合适的患者选择及避免造口形成的手术策略。
筛选可能不需要DS的患者。
本研究纳入了505例连续患者，其中84例行无造口（SF）括约肌间切除术。匹配后，患者被分为SF组（n = 78）和DS组（n = 78）。主要终点是6个月内的吻合口漏（AL）率及其在总队列和SF队列中的保护因素。次要终点包括总生存期和无病生存期。
SF组的AL率高于DS组（12.8%比2.6%，P = 0.035）。男性[比值比（OR）= 2.644，P = 0.021]、新辅助放化疗（nCRT）（OR = 6.024，P < 0.001）以及肿瘤距肛缘高度≤4 cm（OR = 4.160，P = 0.007）被确定为独立危险因素。保留左结肠动脉（LCA）在总队列（OR = 0.417，P = 0.013）和SF队列（OR = 0.312，P = 0.027）中均具有保护作用。未接受nCRT且保留LCA的女性患者AL发生率显著更低（2/97，2.1%）。两组间3年总生存期或无病生存期无显著差异。
未接受nCRT的女性患者可通过保留LCA避免行DS，而不增加AL风险或影响肿瘤学结局。
