【作者】 李玉龙；

【导师】 孙培春；

【作者基本信息】 郑州大学 ， 外科学（专业学位）， 2024， 硕士

【摘要】 背景结直肠癌(Colorectal Cancer,CRC)是最常见的消化道恶性肿瘤之一,严重威胁着国人的身体健康。手术切除是直肠癌治疗的关键手段,直肠癌保肛手术的不断发展,提高了患者术后的生活质量。然而,吻合口漏(Anastomotic Leakage,AL)仍是直肠癌保肛术后最严重的并发症之一,往往伴随急性局限性或弥漫性腹膜炎及脓毒血症,延长患者的住院时间,增加了患者治疗费用,严重影响患者术后的生活质量,增加了患者因并发症死亡的风险,激化医患矛盾,也影响了患者肿瘤的预后。为降低吻合口漏的风险,减轻吻合口漏相关并发症的严重程度,对于发生吻合口漏风险高的患者,外科医师常同期行预防性造口术。然而并非所有的预防性造口都能如期还纳,预防性造口长期存在及造口相关并发症严重影响了患者生活质量。本研究回顾性收集于郑州大学人民医院胃肠外科行直肠癌前切除术且术中同期行预防性造口术的直肠癌患者病例资料,分析预防性造口无法如期还纳的危险因素。目的分析直肠癌前切除术同期行预防性造口术的患者病例资料,探究预防性造口无法如期还纳的危险因素,以期早期识别这部分患者,为临床医生提供决策支持。材料与方法本研究回顾性收集2017年01月至2022年01月于郑州大学人民医院胃肠外科行直肠癌前切除术且术中行预防性造口的患者为研究对象,根据纳入及排除标准筛选患者,预防性造口无法如期还纳定义为初次手术12个月后预防性造口仍未还纳或还纳后重新造口,根据预防性造口完成还纳的时间,将其分为如期还纳组与无法如期还纳组,收集的病例资料包括年龄、性别、体质量指数(Body Mass Index,BMI)、既往腹部手术史、吸烟史、糖尿病、放疗、美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级、术前肠梗阻情况、白蛋白水平、血红蛋白水平、手术方式、手术时间、术中出血量、造口位置、术后吻合口漏、吻合口距肛缘距离、肿瘤pTNM分期、肿瘤最大径、局部复发或远处转移情况。采用统计学软件SPSS 25.0对收集的病例数据进行分析,先行单因素分析,将单因素分析有统计学意义(P<0.05)的因素纳入多因素Logistic回归分析探索预防性造口无法如期还纳的危险因素。结果1、本研究共纳入行直肠癌前切除术且同期行预防性造口术的患者资料258例,根据完成还纳的时间分为两组,其中如期还纳组219例,无法如期还纳组39例,预防性造口完成还纳的中位时间5(1-12)个月。2、对两组临床资料进行统计学分析,在单因素分析中两组在性别、BMI、既往腹部手术史、吸烟史、糖尿病、高血压、术前肠梗阻、血红蛋白水平、白蛋白水平、手术时间、术中出血量、放疗、肿瘤最大径、辅助化疗等并无显著统计学差异(P>0.05)。两组在年龄、ASA分级、手术方式、造口位置、术后吻合口漏、吻合口距肛缘距离、pTNM分期、局部复发或者转移方面有统计学差异(P<0.05)。3、将上述单因素有统计学意义的因素纳入多因素logistic回归分析,结果显示,年龄≥65 岁(OR=4.302,95%CI:1.655-11.183,P=0.003)、吻合口距肛缘距离>10cm(OR=4.291,95%CI:1.377-13.373,P=0.012)、pTNM分期为Ⅲc-Ⅳ期(OR=4.007,95%CI:1.328-12.083,P=0.014)、吻合口漏(OR=6.934,95%CI:1.844-26.075,P=0.004)、局部复发或远处转移(OR=90.655,95%CI:14.729-557.953,P<0.001)是预防性造口无法如期还纳的独立危险因素。结论1、ASA分级≥3级、开腹手术、横结肠造口是预防性造口无法如期还纳的重要影响因素。2、年龄≥65岁、吻合口距肛缘距离>10cm、吻合口漏、pTNM分期为Ⅲc-Ⅳ期、局部复发或者远处转移是预防性造口无法如期还纳的独立危险因素。更多还原

【Abstract】 BackgroundColorectal cancer is one of the most common malignant tumors of the digestive tract,which seriously threatens the health of Chinese people.Surgery is the key method for the treatment of rectal cancer.The continuous development of sphincter-preserving surgery for rectal cancer has improved the quality of life of patients and the prognosis of tumors.However,anastomotic leakage is still one of the most serious complications after sphincter-preserving surgery for rectal cancer,which is often accompanied by acute localized or diffuse peritonitis and sepsis,which prolongs the length of hospital stay,increases the cost of treatment,seriously affects the quality of life of patients after surgery,increases the risk of death due to complications,intensives the contradiction between doctors and patients,and also affects the prognosis of patients.In order to reduce the risk of anastomotic leakage and reduce the severity of complications related to anastomotic leakage,surgeons often perform prophylactic stoma at the same time for patients with high risk of anastomotic leakage.However,not all defunctioning stoma can be closed as scheduled.The long-term existence of defunctioning stoma and stoma-related complications seriously affect the quality of life of patients.This study retrospectively collected the clinical data of patients with rectal cancer who underwent anterior resection of rectal cancer and prophylactic stoma at the same time in the Department of Gastrointestinal Surgery,Zhengzhou University People’s Hospital,and analyzed the risk factors of delayed closure of preventive stoma.ObjectiveTo analyze the clinical data of patients with anterior resection of rectal cancer who underwent simultaneous preventive stoma,and to explore the risk factors of delayed closure of preventive stoma,in order to identify these patients early and provide decision-making support for clinicians.Materials and MethodsPatients with rectal cancer who underwent anterior resection and intraoperative preventive stoma at the Department of Gastrointestinal Surgery,People’s Hospital of Zhengzhou Universit from January 2017 to January 2022 were retrospectively selected as the research objects.Patients were screened according to the inclusion and exclusion criteria.The failure to have the preventive stoma closed as scheduled was defined as the stoma still not closed after 12 months of the first operation or the stoma was reopened after the first operation.According to the time of completion of preventive stoma closure,they were divided into the scheduled stoma closure group and the non-scheduled stoma closure group.The clinical data included age,gender,Body Mass Index(BMI),previous abdominal surgery history,smoking history,diabetes mellitus,radiotherapy,American Society of Anesthesiologists(ASA)score,preoperative intestinal obstruction,albumin level,hemoglobin level,operation method,operation time,intraoperative blood loss,stoma position,postoperative anastomotic leakage,distance from anastomosis to anal verge,tumor TNM stage,tumor maximum diameter,local or recurrent metastasis.Statistical software SPSS 25.0 was used to analyze the collected case data.Univariate analysis was performed first,and the factors with statistically significant differences(P<0.05)were included in multivariate Logistic regression analysis to explore the risk factors of failure to return preventive stoma on schedule.Results1.A total of 258 patients with rectal cancer who underwent preventive stoma at the same time were included in this study.The median time of defunctioning stoma closure was 5(1-12)months.2.The clinical data of the two groups were statistically analyzed.In the univariate analysis,there was no significant difference between the two groups in gender,BMI,previous abdominal surgery history,smoking history,diabetes,hypertension,preoperative intestinal obstruction,hemoglobin level,albumin level,operation time,intraoperative blood loss,radiotherapy,tumor maximum diameter,adjuvant chemotherapy(P>0.05).There were significant differences between the two groups in age,ASA grade,surgical method,stoma location,postoperative anastomotic leakage,distance from anastomosis to anal verge,pTNM stage,local recurrence or metastasis(P<0.05).3.Multivariate logistic regression analysis showed that age≥65 years old(OR=4.302,95%CI:1.655-11.183,P=0.003)and distance from anastomosis to anal verge>10cm(OR=4.291,95%CI:1.377-13.373,P=0.012)were associated with statistically significant factors.pTNM stage IIIc-IV(OR=4.007,95%CI:1.328-12.083,P=0.014),anastomotic leakage(OR=6.934,95%CI:1.844-26.075,P=0.004),local recurrence OR distant metastasis(OR=90.655,95%CI:14.729-557.953,P<0.001)were independent risk factors for delayed stoma closure.Conclusion1.ASA grade≥3,open surgery and transverse colostomy were the important influencing factors of delayed closure of preventive colostomy.2.Age>65 years,anastomotic level>10cm,anastomotic leakage,pTNM stageⅢc-Ⅳ,local recurrence or distant metastasis are independent risk factors for delayed closure of destomas.更多还原