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Title: [Analysis on operational safety of chronic radiation intestinal injury].
Author: He YJ, Ma TH, Zhu MM, Huang XY, Kuang YY, Wang HM, Qin QY, Huang BJ, Wang JP.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Nov 25; 22(11):1034-1040. PubMed ID: 31770834.
Abstract:
Objective: To investigate the safety and efficacy of surgical treatment for chronic radiation intestinal injury. Methods: A descriptive cohort study was performed. Clinical data of 73 patients with definite radiation history and diagnosed clinically as chronic radiation intestinal injury, undergoing operation at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 1, 2012 to February 28, 2019, were reviewed and analyzed retrospectively. Patients did not undergo operation or only received adhesiolysis were excluded. All the patients had preoperative examination and overall evaluation of the disease. According to severity of intestinal obstruction and patients' diet, corresponding nutritional support and conservative treatment were given. Surgical methods: The one-stage bowel resection and anastomosis was the first choice for surgical treatment of chronic radiation intestinal injury. Patients with poor nutritional condition were given enterostomy and postoperative enteral nutrition and second-stage stoma closure and intestinal anastomosis if nutritional condition improved. For those who were unable to perform stoma closure, a permanent stoma should be performed. Patients with severe abdominal adhesion which was difficult to separate, enterostomy or bypass surgery after adhesiolysis would be the surgical choice. For patients with tumor metastasis or recurrence, enterostomy or bypass surgery should be selected. Observation parameters: the overall and major (Clavien-Dindo grades III to V) postoperative complication within 30 days after surgery or during hospitalization; mortality within postoperative 30 days; postoperative hospital stay; time to postoperative recovery of enteral nutrition; time to removal of drainage tube. Results: Of the 73 patients who had been enrolled in this study, 10 were male and 63 were female with median age of 54 (range, 34-80) years. Preoperative evaluation showed that 61 patients had intestinal stenosis, 63 had intestinal obstruction, 11 had intestinal perforation, 20 had intestinal fistula, 3 had intestinal bleeding, and 6 had abdominal abscess, of whom 64(87.7%) patients had multiple complications. Tumor recurrence or metastasis was found in 15 patients. A total of 65(89.0%) patients received preoperative nutritional support, of whom 35 received total parenteral nutrition and 30 received partial parenteral nutrition. The median preoperative nutritional support duration was 8.5 (range, 6.0-16.2) days. The rate of one-stage intestine resection was 69.9% (51/73), and one-stage enterostomy was 23.3% (17/73). In the 51 patients undergoing bowel resection, the average length of resected bowel was (50.3±49.1) cm. Among the 45 patients with intestinal anastomosis, 4 underwent manual anastomosis and 41 underwent stapled anastomosis; 36 underwent side-to-side anastomosis, 5 underwent end-to-side anastomosis, and 4 underwent end-to-end anastomosis. Eighty postoperative complications occurred in 39 patients and the overall postoperative complication rate was 53.4% (39/73), including 39 moderate to severe complications (Clavien-Dindo grade III-V) in 20 patients (27.4%, 20/73) and postoperative anastomotic leakage in 2 patients (2.7%, 2/73). The mortality within postoperative 30 days was 2.7% (2/73); both patients died of abdominal infection, septic shock, and multiple organ failure caused by anastomotic leakage. The median postoperative hospital stay was 13 (11, 23) days, the postoperative enteral nutrition time was (7.2±6.9) days and the postoperative drainage tube removal time was (6.3±4.2) days. Conclusions: Surgical treatment, especially one-stage anastomosis, is safe and feasible for chronic radiation intestine injury. Defining the extent of bowel resection, rational selection of the anatomic position of the anastomosis and perioperative nutritional support treatment are the key to reduce postoperative complications. 目的： 探讨慢性放射性小肠损伤外科治疗的安全性。 方法： 采用描述性病例系列研究方法，回顾性总结分析中山大学附属第六医院胃肠外科2012年1月1日至2019年2月28日期间收治的有明确放射治疗史、临床确诊为慢性放射性小肠损伤、且经外科治疗的患者临床资料，排除非手术治疗或仅行肠粘连松解术者。术前完善常规检查并全面评估患者病情，根据患者肠梗阻程度及进食情况制定相应的营养支持策略和保守治疗方式。手术方法：一期行肠管切除及肠吻合，即争取完整切除病变肠管后根据肠管的解剖位置行肠吻合术。对于术前全身状况较差、难以耐受手术的患者，行分期手术，即肠造口，术后予肠内营养治疗；二期行肠造口还纳和肠管吻合，对于无法行造口还纳的患者，则行永久性造口；对于腹腔严重粘连、肠管难以分离的患者，行肠粘连松解后行肠造口术或行短路手术。对于原发肿瘤转移或复发的患者，选择肠造口术或短路手术。观察指标包括：术后30 d内或患者在住院期间发生的各种并发症的总和，按照国际通用的Clavien-Dindo外科并发症分级进行分类；术后30 d死亡率；术后恢复情况包括术后住院天数、术后恢复肠内营养时间、术后引流管拔除时间。 结果： 73例患者纳入本研究，男性10例，女性63例，年龄34~80（中位数为54）岁。术前评估结果显示：肠狭窄61例，肠梗阻63例，肠穿孔11例，肠瘘20例，肠出血3例，腹腔脓肿6例，其中64例患者（87.7%）并发多个并发症；原发肿瘤复发或转移的患者共15例。全组有65例（89.0%）接受术前营养支持治疗，其中35例接受完全肠外营养，30例接受部分肠外营养，其中有3例经空肠营养管提供营养；术前营养支持治疗时间为8.5（6.0，16.2）d。一期行肠管切除率为69.9%（51/73），一期造口率为23.3%（17/73）。行肠管切除的患者中，肠管切除长度为（50.3±49.1）cm。行肠管吻合的患者中，手工吻合4例，器械吻合41例；侧侧吻合36例，端侧吻合5例，端端吻合4例。39例（53.4%）共发生80例次术后并发症，有20例（27.4%）发生39例次中重度并发症（Clavien-Dindo分级Ⅲ~Ⅴ级），术后吻合口漏发生率为2.7%（2/73）。术后30 d病死率为2.7%（2/73），2例均为术后吻口漏引起腹腔感染、感染性休克，最终导致多器官功能衰竭而死亡。全部患者术后中位住院时间为13（11，23）d，术后恢复肠内营养时间为（7.2±6.9）d，术后引流管拔除时间为（6.3±4.2）d。 结论： 手术治疗、尤其是病变肠管切除一期吻合治疗慢性放射性小肠损伤安全可行。明确肠管切除范围、合理选择吻合口的解剖位置及围手术期营养支持治疗是降低术后并发症发生率的关键。.

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