MEDLINE/PubMed Journal Browser Search

Pubmed for Handhelds

PUBMED FOR HANDHELDS

Search MEDLINE/PubMed

Title: [Risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection for low rectal cancer].
Author: Zhang B, Zhuo GZ, Tian L, Zhao K, Zhao Y, Zhao YJ, Zhu J, Zhang T, Ding JH.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Aug 25; 22(8):755-761. PubMed ID: 31422614.
Abstract:
Objective: To evaluate the risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection (Lap-ISR) for patients with low rectal cancer. Methods: A retrospective case-control study was performed to collect clinicopathological data from a prospective database (registration number: ChiCTR-ONC-15007506) at the Department of Colorectal Surgery, the Characteristic Medical center of PLA Rocket Force. From June 2011 to August 2018, a total of 144 consecutive patients with low rectal cancer who underwent Lap-ISR were enrolled in the study. Inclusion criteria: (1) reconstruction of digestive tract by end-to-end hand-made coloanal anastomosis (HCAA); (2) distance from lower tumor margin to anorected sphincter ring < 1 cm and distance from lower tumor margin to intersphincteric groove ≥ 1 cm; (3) T1-3 stage tumor with expected negative circumferential resection margin evaluated by preoperative MRI or 3D endoanal ultrasound; (4) rectal cancer confirmed as well- or moderately-differentiated adenocarcinoma; (5) preoperative Wexner incontinence score >10 points. Exclusion criteria: (1) follow-up period less than 3 months; (2) multiple primary cancers; (3) undergoing colonic J-pouch, coloplasty or reconstruction of end-to-side coloanal anastomosis; (4) death within perioperative period (within 3 months after surgery). Coloanal anastomotic stricture was diagnosed if the index finger or 12 mm electronic colonoscope had obvious resistance through the anastomosis or new rectum, or could not pass, accompanied by clinical symptoms such as difficult defecation and anal incontinence. Degree of anastomotic stricture was divided into 3 grades: grade A required anal enlargement, laxative or enema to assist defecation without active surgical treatment; grade B required surgery or endoscopic intervention; grade C required definitive ostomy, including unreducible preventive ileostomy or permanent colostomy. Univariate and multivariate analysis were used to evaluate the effects of 28 variables, including baseline data (age, gender, body mass index, neoadjuvant therapy, etc.), tumor-related factors (distance between tumor low margin and anal edge, maximum diameter of tumor, TNM staging, etc.), surgery-related factors (operation time, intraoperative blood loss, ISR procedure, anastomotic height, etc.) and anastomotic leakage, on the postoperative coloanal anastomotic stricture. Univariate analysis used χ(2) test or Fisher's exact test, then factors with P<0.05 were further included in multivariate analysis using logistic regression. Results: A total of 144 patients were enrolled in the study, including 90 males and 54 females with a median age of 59 years and median BMI of 24.88 kg/m(2). R0 resection rate was 96.5% (139/144). Median tumor distal resection margin was 1.5 (0.5 to 3.0) cm. Median follow-up was 31.5 (4 to 86) months. Coloanal anastomotic stricture was observed in 19 patients (13.2%), including 3 cases (2.1%) of grade A, 9 cases (6.2%) of grade B, and 7 cases (4.9%) of grade C. The median interval from the initial surgery to diagnosis of anastomotic stricture was 7 (1 to 31) months. Univariate analysis showed that male (χ(2)=6.795, P=0.009), radiotherapy (χ(2)=13.330, P=0.001), operation type of ISR (χ(2)=7.996, P=0.013), and anastomotic leakage (χ(2)=10.198, P=0.004) were associated with the postoperative coloanal anastomotic stricture. Multivariate analysis further indicated that male (OR=5.975, 95% CI: 1.209-29.534, P=0.028), postoperative radiotherapy (OR=8.748, 95% CI: 2.397-31.929, P=0.001), and anastomotic leakage (OR=6.313, 95% CI: 1.834-21.734, P=0.003) were independent risk factor of postoperative coloanal anastomotic stricture. Conclusion: For male patients, or patients with postoperative radiotherapy or anastomotic leakage, close follow-up should be carried out to prevent postoperative coloanal anastomotic stricture following Lap-ISR. 目的： 探讨腹腔镜低位直肠癌经括约肌间切除（Lap-ISR）术后结肠-肛管吻合口狭窄的危险因素。 方法： 采用回顾性病例对照研究方法，收集2011年6月至2018年8月期间火箭军特色医学中心结直肠肛门外科低位直肠癌前瞻性数据库（注册号：ChiCTR-ONC-15007506）中收集的Lap-ISR治疗低位直肠癌患者的临床病理资料。病例纳入标准：（1）通过端-端直接行手工结肠-肛管吻合（HCAA）完成消化道重建；（2）肿瘤上限为肿瘤下缘距离肛门括约肌环<1 cm，下限为肿瘤下缘距离内外括约肌间沟≥1 cm；（3）术前MRI或三维肛肠腔内超声评估为预期环周切缘阴性的T(1~3)期肿瘤；（4）肿瘤为高、中分化腺癌；（5）术前Wexner失禁评分<10分。排除标准：（1）术后随访时间<3个月；（2）同时性多原发癌；（3）选择结肠J型储袋、结肠成形术、结肠-肛管端侧吻合的重建方式；（4）围手术期（定义为术后3个月内）死亡。结肠-肛管吻合口狭窄定义：食指或12 mm电子结肠镜镜身通过吻合口或新直肠存在明显阻力，或无法通过，伴有排粪费力、肛门失禁等临床症状。吻合口狭窄程度分为3级：A级（需扩肛、泻剂或灌肠辅助排粪，无需外科积极处理）；B级（需手术或内镜干预治疗）；C级（需行确定性造口，包括预防性回肠造口无法还纳或永久性结肠造口）。采用单因素和多因素分析评价患者一般资料（年龄、性别、体质指数、新辅助治疗等）、肿瘤相关因素（肿瘤下缘与肛缘距离、肿瘤最大直径、TNM分期等）、手术相关因素（手术时间、术中出血量、ISR手术方式、吻合口高度等）以及吻合口漏共28项变量对术后发生吻合口狭窄的影响。单因素分析采用χ(2)检验或Fisher精确检验，经单因素分析P<0.05的变量进一步采用有序分类自变量logistic回归进行多因素分析。 结果： 共计144例患者纳入本研究，男90例，女54例，中位年龄59岁，中位体质指数24.88 kg/m(2)。手术R(0)切除率96.5%（139/144），肿瘤远切缘中位距离1.5（0.5~3.0）cm。术后中位随访31.5（4~86）个月。19例（13.2%）患者发生吻合口狭窄，其中3例（2.1%）A级、9例（6.2%）B级、7例（4.9%）C级。术后诊断吻合口狭窄的中位时间为7（1~31）个月。单因素分析结果显示，男性（χ(2)=6.795，P=0.009）、放疗（χ(2)=13.330，P=0.001）、ISR手术方式（χ(2)=7.996，P=0.013）及吻合口漏（χ(2)=10.198，P=0.004）与Lap-ISR术后结肠-肛管吻合口狭窄均有关（均P<0.05）。多因素分析进一步表明，男性（OR=5.975，95%CI：1.209~29.534，P=0.028）、术后放疗（OR=8.748，95%CI：2.397~31.929，P=0.001）及吻合口漏（OR=6.313，95%CI：1.834~21.734，P=0.003）是Lap-ISR术后发生吻合口狭窄的独立危险因素（均P<0.05）。 结论： 对于男性以及Lap-ISR术后进行放疗或出现吻合口漏的患者，应密切随访，警惕出现结肠-肛管吻合口狭窄。.

[Abstract] [Full Text] [Related] [New Search]