Hirsch C J, Gingold B S, Wallack M K
Department of Surgery, St. Vincents Hospital & Medical Center of New York, New York 10011, USA.
Dis Colon Rectum. 1997 Jan;40(1):42-6. doi: 10.1007/BF02055680.
This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma.
From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum.
Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent.
The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.
本回顾性研究旨在评估吸引-冲洗引流系统在减少吻合口并发症方面的疗效。目前对于直肠中上段病变的治疗趋势强调，只要不影响切除范围，就应尽量保持肛门括约肌机制的完整。在腹膜反折以下进行吻合的直肠乙状结肠切除术可实现这一目标，但会带来相当高的发病率和死亡率，这在很大程度上与随后的吻合口破裂以及由此导致的盆腔脓肿和粪瘘形成有关。血液、血清和细胞碎片的积聚通过充当细菌可能滋生的培养基，对吻合口破裂有显著影响，导致脓肿形成，进而对相邻低位吻合口的完整性产生有害影响。许多外科医生接受了这种风险，并常规进行转流性结肠造口术，以尽量减少腹膜反折以下吻合口破裂的后果。作者认为，如果能充分降低这种风险，就无需进行保护性造口。
1980年至1988年，连续60例患者接受了前切除术或低位前切除术，术中使用封闭式雪莉水槽冲洗系统促进术后盆腔引流，从而避免血肿形成。自最初的60例患者研究组以来，又有100例连续患者纳入本研究。该队列组同样由直肠上、中、下段病变且接受直肠前切除术或低位前切除术的患者组成。
最初的60例患者中有53例未进行保护性造口。该系列的临床漏出率为1.67%。这一更新的100例患者系列的临床漏出率为1%，160例连续患者的总体临床漏出率为1.25%。该系列无死亡病例，总体发病率为7.5%。
作者认为，在直肠全部或部分切除术后清除盆腔内的血液、血清和细胞碎片可将吻合口破裂的风险降至最低。采用这种常规方法，大多数接受全部或部分直肠系膜前切除术或低位前切除术的患者不再需要覆盖性结肠造口术。
