1、直肠癌低位前切除术后吻合口瘘 Anastomotic Leakage After Low Anterior Resection Anastomotic Leakage After Low Anterior Resection For Rectal CancerFor Rectal Cancer山东大学齐鲁医院1Introduction Anastomotic leakage (AL) after anterior resection of the rectum is a serious cause of morbidity and mortality , with the risk of a
2、permanent stoma . It may also be associated with an increased risk of local recurrence . The incidence of clinically significant leakage after LAR varies between 3% and 21%, but is thought to average 10%. Subclinical anastomotic failure may occur in up to 51% of patients. Anastomotic leakage is a fe
3、ared complication, resulting in a postoperative mortality rate of 69 percent, depending on whether a diverting stoma is created2直肠癌前切除后吻合口瘘定义和分级直肠癌前切除后吻合口瘘定义和分级 直肠癌前切除后吻合口瘘定义和严重度分级建议直肠癌前切除后吻合口瘘定义和严重度分级建议Definition and grading of anastomotic leakage following anterior resection of the rectum: a propo
4、sal by the International Study Group of Rectal Cancer. Surgery. 2010 Mar;147(3):339-51. 定义结直肠或结肠肛管吻合区（包括直肠储袋的缝合和吻合线）肠壁完整性缺损，导致肠管内外区交通；靠近吻合口的盆腔脓肿也认定为吻合口漏。分级A不需要积极的治疗干预B需要积极的治疗干预，但不需要再次剖腹手术C需要再次剖腹手术3吻合口瘘定义 AL was defined as follows: peritonitis and a defect in the anastomosis, discharge of pus from th
5、e anus, and recto-vaginal fistula or faeces or gas from the abdominal drain. The time limit for AL was set at 30 days after surgery for patients discharged from the hospital within this time. There was no time limit for in-hospital patients. Leakage was confirmed by digital rectal examination, CT sc
6、an, endoscopy, contrast enema, reoperation. 4吻合口瘘发生率能降低吗？吻合口瘘发生率能降低吗？ 检索 Medline 和 PubMed databases Keywords: “leakage,” “low anterior resection,”“rectal cancer,” “risk factors.” 可以确定(evidence suggests):吻合口越低更容易漏. 其他(well-documented)是男性,吸烟,术前营养不良 常规游离脾曲和使用J-pouch 似乎能降低吻合口漏率 术前放化疗对吻合口的影响正在严格审查中 保护性造口
7、的指征还有争论 大网膜成形术,肠道准备,使用引流,肿瘤分期似乎不能影响吻合口漏率 手术类型(开放或腔镜) 和吻合方法(手缝或吻合器) 也不是关键5危险因素(The Patient) 病人-男性 可能是男性狭窄的骨盆，在切除时视野不佳导致手术操作更困难. 吸烟和酗酒在多因素分析中也被证实是危险因素，主要通过影响小血管，导致组织缺氧，影响组织愈合.6吻合口高度(Height of the Anastomosis) These data provide substantial evidence that lower anastomoses are prone to leakage.nleakage
8、rateKaranjia219漏24例（11%），吻合口均低于6cmLopez-Kostner F819吻合口高于15cm为0.14%,10-15cm为5.4%，低于10cm为8.4%Vignali1014高位前切除为1%，低于7cm为7.7%，多因素分析唯一危险因素是低于7cm7吻合器vs手缝(Stapled VS Handsewn)nMeta(RCT)结论MacRae HM(1998)13no difference in the leakage rate between the two groups.Neutzling CB(2012)12339no difference in the l
9、eakage rate.Docherty JG(1995)732prospective, multicenter, randomized studystapled anastomoses are as safe as manually constructed anastomoses8术前放疗(Preoperative Radiation Therapy) These conclusions must be interpreted with caution since the absence of concomitant chemotherapy and the liberal use of a
10、 protective stoma in that study may have obscured the data9Laparoscopic LAR The incidence of anastomotic leak after laparoscopic rectal surgery ranges between 0% and 17%. A recent Cochrane review concluded that the leakage rate is comparable with that of open anterior resection, in accordance with o
11、ther studies on laparoscopic low anterior resection.10The Surgeon and the Technique The main goal when operating on a patient with rectal cancer is to create an anastomosis that is well perfused without tension.11To be well perfused Sheridan et al. reported that oxygen tension(氧分压) on the anastomosi
12、s is a predictive factor for leakage. In a recent prospective study, Hirano et al. found by using near-infrared spectroscopy (近红外光谱学)that patients with leakage had lower tissue oxygen saturation(氧饱和度) at the anastomosis site than patients without anastomotic leakage.12Without tension To create a wel
13、l-perfused anastomosis without tension, routine mobilization of the splenic flexure has been proposed. Karanjia et al. reported that if the sigmoid colon was used for the anastomosis without full mobilization of the splenic flexure the leakage rate was 22%, compared with 9% if full mobilization was
14、done. Another important reason for mobilizing the splenic flexure is that the adequately mobilized descending colon can occupy the pelvis, reducing the dead space and diminishing the risk of abscess or pelvic collection formation. 13High ligation may severely compromise the blood supply of the sigmo
15、id colon As the marginal artery of the descending colon is a more reliable vessel for the blood supply, the descending colon is preferred for the anastomosis. A surgical advantage of high tie is that it renders the left colon more mobile, which might facilitate construction of the coloanal anastomos
16、is. It should be noted, however, that many surgeons adopt a more selective approach towards mobilization of the splenic flexure.14Omentoplasty AND extraperitoneal anastomosis There is no prospective evidence that omentoplasty reduces the leakage rate and that it should not be routinely used. The per
17、itonealization of the pelvis and the extraperitoneal positioning of the anastomosis have been evaluated with conflicting results. Some believe that this technique reduces the occurrence of peritonitis after anastomotic leakage, but others disagree. While it seems possible that the above maneuvers ma
18、y mitigate(减轻) the consequences of anastomotic leakage, we do not think that there is a proven mechanism to reduce the rate of this complication.15大网膜成形术(Omentoplasty)16大网膜成形术(Omentoplasty)17Nutrition The nutritional status of the patient affects the leakage rate. Low albumin levels and preoperative
19、 starvation delay the healing process of the anastomosis and ultimately affect its strength. Golub et al. reported that a preoperative albumin value lower than 30 g/dl and recent weight loss of more than 5 kg are risk factors for leakage. A multivariate analysis by Makela et al. reached the same con
20、clusions.18Bowel Preparation Traditionally, bowel preparation preceded any elective bowel surgery; however, single- institution studies have shown that bowel preparation is not necessary even after TME for rectal cancer. Furthermore, large series have shown that bowel preparation does not affect the
21、 anastomotic leakage rate. A Cochrane Database review of nine randomized prospective trials found no convincing evidence that bowel preparation is associated with reduced rates of leakage and that its use should be reconsidered.19Blood Transfusion It is debatable whether blood transfusions increase
22、the leakage rate. Univariate and multivariate analyses have shown that perioperative blood transfusions induce immunosuppression predisposing to various postoperative infections, therefore increasing the risk of anastomotic leakage. However, the need for blood transfusion is also associated with mor
23、e technically demanding operations and the surgeons expertise. Based on the existing facts, we think that blood transfusions may be perceived as surrogate markers of technical difficulties or surgical inexperience.20Preventive Measures The Pelvic Drain The rationale failed to show any such benefit.
24、accused of increasing the leakage rate pelvic drain serves as “an eye” We believe that the pelvic drain does not prevent leakage, but it may assist in its management21The J-PouchJ-pouch groupend-to-end anastomosisHallbook et al.2%15%The Dutch study8.4% 12.4%Explanations for this differencefull mobil
25、ization of the descending colon“filling” of the pelvis22The Defunctioning Stoma Surgeons express different attitudes towards its use. the leakage rate was reduced by the presence of a protective stoma On the contrary, there are studies that claim that the protective stoma does not reduce the leakage
26、 rate after LAR and that it is not necessary for every patient subjected to TME creation of a stoma only when the intraoperative check of the anastomosis is positive for leakage The surgical community is divided into advocates and deniers of a protective stoma after LAR. A more selective approach to
27、ward its use might be the golden medium.23Conclusions Male sex, smoking, alcohol abuse, and preoperative malnutrition are all risk factors for anastomotic leakage. The current evidence confirms the importance of the height of the anastomosis and its impact on anastomotic failure. Routine splenic fle
28、xure mobilization is advisable and the descending colon is preferred to the sigmoid for the construction of the anastomosis. The use of a J-pouch seems to decrease the leakage rate after LAR.24Conclusions The size and stage of the primary tumor do not affect the leakage rate. The type of the anastom
29、osis, stapled or hand-sewn, does not impact on the leakage rate. Laparoscopic LAR is as safe as conventional surgery. The short scheme of RT is no longer considered a risk factor. Omentoplasty, extraperitoneal positioning of the anastomosis, bowel preparation and the use of a pelvic drain do not red
30、uce the leakage rate.25Conclusions The value of creating a protective stoma is debatable. Many surgeons think that it is indicated after any anastomosis lower than 6 cm from the anal verge, whereas others propose its elective use in a subgroup of these patients. The appropriate course of action conc
31、erning the creation of a protective stoma needs careful intraoperative decision-making by the attending surgeon taking into consideration the patient, the course of the operation, and the cost of an unnecessary protective stoma.26吻合口漏标准化的诊断治疗路径27 Drainage and/or Antibiotics Alone Repair/Revision of
32、the Anastomosis Without Diversion Proximal Loop Diversion Anastomotic Resection and End Stoma28吻合口瘘的CT表现 吻合口旁气体是漏的可靠标志. 造影剂灌肠渗漏高度准确. 吻合线的形态不能准确评估吻合口的完整性.2930Laparoscopic reoperation of anastomotic leakage after a laparoscopic low anterior resection of the rectum A poor view due to distended bowels h
33、as been reported as the most frequent causes of conversion to open surgery during laparoscopic surgery for peritonitis. However, during this operation, the bowels had not distended and the view was good. We think the promptness is the key to successful laparoscopic reoperation.31Chronic sinus tract
34、Failure of healing results in persistence of the dehiscence, with formation of a chronic sinus tract. Some may appear to have healed on subsequent contrast studies, but others persist. The patient therefore continues to suffer the significant morbidity of an ileostomy as reversal may bring about the
35、 undesired consequence of pelvic sepsis, requiring surgery. Management of the chronic sinus is difficult. Many methods have been described for its treatment, including deroofing mucosal advancement, resection and anastomosis, resection and permanent stoma, and sealing of the track with tissue glue32
36、3334Chronic anastomotic sinus after low anterior resection: when can the defunctioning stoma be reversed? Management of asymptomatic isolated anastomotic leak In patients with asymptomatic AL, closure of the protective ileostomy at 11 and at 15 months, respectively, did not result in septic complica
37、tions. Lim et al. reported a 100% rate of ileostomy closure for asymptomatic AL but the success rate was only 30% for symptomatic AL35Management of anastomotic leaks with chronic sepsis and/or stricture36Re-do anastomosisDelayed coloanal anastomosis by the technique of Baulieux Coloanal anastomosis
38、through the rectal stump37Management of isolated anastomotic stricture Short anastomotic strictures Simple local treatment; finger dilatation Excision of a short stricture can also be performed using a circular stapler. Enteroplasty to enlarge the stenosis Endoscopic hydrostatic balloon dilatation P
39、lacement of a colonic stent for Placement of a colonic stent results in a rectal syndrome, making this approach inadvisable. Long anastomotic stricture38 Long anastomotic stricture there is no role for local treatment and abdominal surgical revision is needed coloanal anastomosis through the rectal stump or preferably a delayed coloanal anastomosis by the technique of Baulieux39
