医学ppt课件直肠癌术后吻合口瘘

IntroductionAnastomoticleakage(AL)afteranteriorresectionoftherectumisaseriouscauseofmorbidityandmortality,withtheriskofapermanentstoma.Itmayalsobeassociatedwithanincreasedriskoflocalrecurrence.TheincidenceofclinicallysignificantleakageafterLARvariesbetween3%and21%,butisthoughttoaverage10%.Subclinicalanastomoticfailuremayoccurinupto51%ofpatients.Anastomoticleakageisafearedcomplication,resultinginapostoperativemortalityrateof69percent,dependingonwhetheradivertingstomaiscreatedIntroductionAnastomoticleakag1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Definitionandgradingofanastomoticleakagefollowinganteriorresectionoftherectum:aproposalbytheInternationalStudyGroupofRectalCancer.Surgery.2010Mar;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2吻合口瘘定义ALwasdefinedasfollows:peritonitisandadefectintheanastomosis,dischargeofpusfromtheanus,andrecto-vaginalfistulaorfaecesorgasfromtheabdominaldrain.ThetimelimitforALwassetat30daysaftersurgeryforpatientsdischargedfromthehospitalwithinthistime.Therewasnotimelimitforin-hospitalpatients.Leakagewasconfirmedbydigitalrectalexamination,CTscan,endoscopy,contrastenema,reoperation.吻合口瘘定义ALwasdefinedasfollow3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PubMeddatabasesKeywords:“leakage,”“lowanteriorresection,”“rectalcancer,”“riskfactors.”可以确定(evidencesuggests):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)也不是关键吻合口瘘发生率能降低吗？检索Medline和PubMe4危险因素(ThePatient)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.危险因素(ThePatient)病人-男性5吻合口高度(HeightoftheAnastomosis)Thesedataprovidesubstantialevidencethatloweranastomosesarepronetoleakage.nleakagerateKaranjia219漏24例（11%），吻合口均低于6cmLopez-KostnerF819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7cm吻合口高度(HeightoftheAnastomosi6吻合器vs手缝(Stapled VS Handsewn)nMeta(RCT)结论MacRaeHM(1998)13nodifferenceintheleakageratebetweenthetwogroups.NeutzlingCB(2012)12339nodifferenceintheleakagerate.DochertyJG(1995)732prospective,multicenter,randomizedstudystapledanastomosesareassafeasmanuallyconstructedanastomoses吻合器vs手缝(StapledVSHandsewn)nM7术前放疗(PreoperativeRadiationTherapy)Theseconclusionsmustbeinterpretedwithcautionsincetheabsenceofconcomitantchemotherapyandtheliberaluseofaprotectivestomainthatstudymayhaveobscuredthedata术前放疗(PreoperativeRadiationTh8Laparoscopic LARTheincidenceofanastomoticleakafterlaparoscopicrectalsurgeryrangesbetween0%and17%.ArecentCochranereviewconcludedthattheleakagerateiscomparablewiththatofopenanteriorresection,inaccordancewithotherstudiesonlaparoscopiclowanteriorresection.LaparoscopicLARTheincidence9The Surgeon and the TechniqueThemaingoalwhenoperatingonapatientwithrectalcanceristocreateananastomosisthatiswellperfusedwithouttension.TheSurgeonandtheTechniqueT10TobewellperfusedSheridanetal.reportedthatoxygentension(氧分压)ontheanastomosisisapredictivefactorforleakage.Inarecentprospectivestudy,Hiranoetal.foundbyusingnear-infraredspectroscopy(近红外光谱学)thatpatientswithleakagehadlowertissueoxygensaturation(氧饱和度)attheanastomosissitethanpatientswithoutanastomoticleakage.TobewellperfusedSheridanet11WithouttensionTocreateawell-perfusedanastomosiswithouttension,routinemobilizationofthesplenicflexurehasbeenproposed.Karanjiaetal.reportedthatifthesigmoidcolonwasusedfortheanastomosiswithoutfullmobilizationofthesplenicflexuretheleakageratewas22%,comparedwith9%iffullmobilizationwasdone.Anotherimportantreasonformobilizingthesplenicflexureisthattheadequatelymobilizeddescendingcoloncanoccupythepelvis,reducingthedeadspaceanddiminishingtheriskofabscessorpelviccollectionformation.WithouttensionTocreateawel12HighligationmayseverelycompromisethebloodsupplyofthesigmoidcolonAsthemarginalarteryofthedescendingcolonisamorereliablevesselforthebloodsupply,thedescendingcolonispreferredfortheanastomosis.Asurgicaladvantageofhightieisthatitrenderstheleftcolonmoremobile,whichmightfacilitateconstructionofthecoloanalanastomosis.Itshouldbenoted,however,thatmanysurgeonsadoptamoreselectiveapproachtowardsmobilizationofthesplenicflexure.Highligationmayseverelycomp13OmentoplastyANDextraperitonealanastomosisThereisnoprospectiveevidencethatomentoplastyreducestheleakagerateandthatitshouldnotberoutinelyused.Theperitonealizationofthepelvisandtheextraperitonealpositioningoftheanastomosishavebeenevaluatedwithconflictingresults.Somebelievethatthistechniquereducestheoccurrenceofperitonitisafteranastomoticleakage,butothersdisagree.Whileitseemspossiblethattheabovemaneuversmaymitigate(减轻)theconsequencesofanastomoticleakage,wedonotthinkthatthereisaprovenmechanismtoreducetherateofthiscomplication.OmentoplastyANDextraperitone14大网膜成形术(Omentoplasty)大网膜成形术(Omentoplasty)15大网膜成形术(Omentoplasty)大网膜成形术(Omentoplasty)16NutritionThenutritionalstatusofthepatientaffectstheleakagerate.Lowalbuminlevelsandpreoperativestarvationdelaythehealingprocessoftheanastomosisandultimatelyaffectitsstrength.Golubetal.reportedthatapreoperativealbuminvaluelowerthan30g/dlandrecentweightlossofmorethan5kgareriskfactorsforleakage.AmultivariateanalysisbyMakelaetal.reachedthesameconclusions.NutritionThenutritionalstatu17BowelPreparationTraditionally,bowelpreparationprecededanyelectivebowelsurgery;however,single-institutionstudieshaveshownthatbowelpreparationisnotnecessaryevenafterTMEforrectalcancer.Furthermore,largeserieshaveshownthatbowelpreparationdoesnotaffecttheanastomoticleakagerate.ACochraneDatabasereviewofninerandomizedprospectivetrialsfoundnoconvincingevidencethatbowelpreparationisassociatedwithreducedratesofleakageandthatitsuseshouldbereconsidered.BowelPreparationTraditionally18BloodTransfusionItisdebatablewhetherbloodtransfusionsincreasetheleakagerate.Univariateandmultivariateanalyseshaveshownthatperioperativebloodtransfusionsinduceimmunosuppressionpredisposingtovariouspostoperativeinfections,thereforeincreasingtheriskofanastomoticleakage.However,theneedforbloodtransfusionisalsoassociatedwithmoretechnicallydemandingoperationsandthesurgeonsexpertise.Basedontheexistingfacts,wethinkthatbloodtransfusionsmaybeperceivedassurrogatemarkersoftechnicaldifficultiesorsurgicalinexperience.BloodTransfusionItisdebatab19PreventiveMeasuresThe Pelvic DrainTherationalefailedtoshowanysuchbenefit.accusedofincreasingtheleakageratepelvicdrainservesas“aneye”Webelievethatthepelvicdraindoesnotpreventleakage,butitmayassistinitsmanagementPreventiveMeasuresThePelvic20TheJ-PouchJ-pouchgroupend-to-endanastomosisHallbooketal.2%15%TheDutchstudy8.4%12.4%Explanationsforthisdifferencefullmobilizationofthedescendingcolon“filling”ofthepelvisTheJ-PouchJ-pouchgroupend-to21TheDefunctioningStomaSurgeonsexpressdifferentattitudestowardsitsuse.theleakageratewasreducedbythepresenceofaprotectivestomaOnthecontrary,therearestudiesthatclaimthattheprotectivestomadoesnotreducetheleakagerateafterLARandthatitisnotnecessaryforeverypatientsubjectedtoTMEcreationofastomaonlywhentheintraoperativecheckoftheanastomosisispositiveforleakageThesurgicalcommunityisdividedintoadvocatesanddeniersofaprotectivestomaafterLAR.Amoreselectiveapproachtowarditsusemightbethegoldenmedium.TheDefunctioningStomaSurgeon22ConclusionsMalesex,smoking,alcoholabuse,andpreoperativemalnutritionareallriskfactorsforanastomoticleakage.Thecurrentevidenceconfirmstheimportanceoftheheightoftheanastomosisanditsimpactonanastomoticfailure.Routinesplenicflexuremobilizationisadvisableandthedescendingcolonispreferredtothesigmoidfortheconstructionoftheanastomosis.TheuseofaJ-pouchseemstodecreasetheleakagerateafterLAR.ConclusionsMalesex,smoking,23ConclusionsThesizeandstageoftheprimarytumordonotaffecttheleakagerate.Thetypeoftheanastomosis,stapledorhand-sewn,doesnotimpactontheleakagerate.LaparoscopicLARisassafeasconventionalsurgery.TheshortschemeofRTisnolongerconsideredariskfactor.Omentoplasty,extraperitonealpositioningoftheanastomosis,bowelpreparationandtheuseofapelvicdraindonotreducetheleakagerate.ConclusionsThesizeandstage24ConclusionsThevalueofcreatingaprotectivestomaisdebatable.Manysurgeonsthinkthatitisindicatedafteranyanastomosislowerthan6cmfromtheanalverge,whereasothersproposeitselectiveuseinasubgroupofthesepatients.Theappropriatecourseofactionconcerningthecreationofaprotectivestomaneedscarefulintraoperativedecision-makingbytheattendingsurgeontakingintoconsiderationthepatient,thecourseoftheoperation,andthecostofanunnecessaryprotectivestoma.ConclusionsThevalueofcreati25吻合口漏标准化的诊断治疗路径吻合口漏标准化的诊断治疗路径26Drainageand/orAntibioticsAloneRepair/RevisionoftheAnastomosisWithoutDiversionProximalLoopDiversionAnastomoticResectionandEndStomaDrainageand/orAntibioticsAl27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.吻合口瘘的CT表现吻合口旁气体是漏的可靠标志.28医学ppt课件直肠癌术后吻合口瘘29LaparoscopicreoperationofanastomoticleakageafteralaparoscopiclowanteriorresectionoftherectumApoorviewduetodistendedbowelshasbeenreportedasthemostfrequentcausesofconversiontoopensurgeryduringlaparoscopicsurgeryforperitonitis.However,duringthisoperation,thebowelshadnotdistendedandtheviewwasgood.Wethinkthepromptnessisthekeytosuccessfullaparoscopicreoperation.Laparoscopicreoperationofan30ChronicsinustractFailureofhealingresultsinpersistenceofthedehiscence,withformationofachronicsinustract.Somemayappeartohavehealedonsubsequentcontraststudies,butotherspersist.Thepatientthereforecontinuestosufferthesignificantmorbidityofanileostomyasreversalmaybringabouttheundesiredconsequenceofpelvicsepsis,requiringsurgery.Managementofthechronicsinusisdifficult.Manymethodshavebeendescribedforitstreatment,includingderoofingmucosaladvancement,resectionandanastomosis,resectionandpermanentstoma,andsealingofthetrackwithtissueglueChronicsinustractFailureof31医学ppt课件直肠癌术后吻合口瘘32医学ppt课件直肠癌术后吻合口瘘33Chronicanastomoticsinusafterlowanteriorresection:whencanthedefunctioningstomabereversed?ManagementofasymptomaticisolatedanastomoticleakInpatientswithasymptomaticAL,closureoftheprotectiveileostomyat11andat15months,respectively,didnotresultinsepticcomplications.Limetal.reporteda100%rateofileostomyclosureforasymptomaticALbutthesuccessratewasonly30%forsymptomaticALChronicanastomoticsinusafte34Managementofanastomoticleakswithchronicsepsisand/orstrictureManagementofanastomoticleak35Re-doanastomosisDelayedcoloanalanastomosisbythetechniqueofBaulieuxColoanalanastomosisthroughtherectalstumpRe-doanastomosisDelayedcoloa36ManagementofisolatedanastomoticstrictureShortanastomoticstricturesSimplelocaltreatment;fingerdilatationExcisionofashortstricturecanalsobeperformedusingacircularstapler.EnteroplastytoenlargethestenosisEndoscopichydrostaticballoondilatationPlacementofacolonicstentforPlacementofacolonicstentresultsinarectalsyndrome,makingthisapproachinadvisable.LonganastomoticstrictureManagementofisolatedanastom37LonganastomoticstricturethereisnoroleforlocaltreatmentandabdominalsurgicalrevisionisneededcoloanalanastomosisthroughtherectalstumporpreferablyadelayedcoloanalanastomosisbythetechniqueofBaulieuxLonganastomoticstricture38