结直肠吻合口漏的诊治进展.ppt

目录,壹,贰,叁,肆,基本概念,危险因素,诊断,治疗,伍,发生率及影响,PARTONE,基本概念,吻合口漏的定义(Anatomoticleakage),吻合口处肠壁连续性的缺陷，导致肠腔内外相连通(Anastomoticleakageshouldbedefinedasadefectoftheintestinalwallattheanastomoticsiteleadingtoacommunicationbetweentheintra-andextraluminalcompartments.)2010年国际直肠癌研究小组（ISGRC）,RahbariNN,etal.Definitionandgradingofanastomoticleakagefollowinganteriorresectionoftherectum:aproposalbytheInternationalStudyGroupofRectalCancer.Surgery.2010Mar;147(3):339-51.,漏和瘘的区别（LeakageandFistula),漏（Leakage）：空腔脏器吻合口出现的泄漏瘘（Fistula)：两个内脏器官之间的异常的通道（内瘘）；或从一个内脏器官达体表（外瘘）,两者根本区别在于有无瘘管,程邦昌等，吻合口“瘘”抑或吻合口“漏”.中华外科杂志，2000,38（1）.,PARTTWO,发生率及影响,吻合口漏的发生率,发生率1-24%，平均约11%包括无症状的漏，可以高达50%吻合口漏的发生率多年来并没有明显的改善,ShoganBD,etal.Dowereallyknowwhycolorectalanastomosesleak?JGastrointestSurg.2013;17(9):1698-707,吻合口漏的影响,增加并发症的发生率和死亡率,ALgroup-1.78%Non-ALgroup-0.74%,Mortality,KangCY,etal.Riskfactorsforanastomoticleakageafteranteriorresectionforrectalcancer.JAMASurg.2013;148(1):65-71.,吻合口漏的影响,增加肿瘤的局部复发率,WangS,etal.AdverseEffectsofAnastomoticLeakageonLocalRecurrenceandSurvivalAfterCurativeAnteriorResectionforRectalCancer:ASystematicReviewandMeta-analysis.WorldJSurg.2017;41(1):277-284.,吻合口漏的影响,降低长期生存率,WangS,etal.AdverseEffectsofAnastomoticLeakageonLocalRecurrenceandSurvivalAfterCurativeAnteriorResectionforRectalCancer:ASystematicReviewandMeta-analysis.WorldJSurg.2017;41(1):277-284.,吻合口漏的影响,其它影响延长住院时间增加了住院费用导致医疗纠纷的发生,PARTTHREE,危险因素,病人相关因素（Patient-relatedfactors),性别：男性,PommergaardHC,etal.Preoperativeriskfactorsforanastomoticleakageafterresectionforcolorectalcancer:asystematicreviewandmeta-analysis.ColorectalDis.2014Sep;16(9):662-71.,病人相关因素（Patient-relatedfactors),BMI,PommergaardHC,etal.Preoperativeriskfactorsforanastomoticleakageafterresectionforcolorectalcancer:asystematicreviewandmeta-analysis.ColorectalDis.2014Sep;16(9):662-71.,病人相关因素（Patient-relatedfactors),ASA分级,PommergaardHC,etal.Preoperativeriskfactorsforanastomoticleakageafterresectionforcolorectalcancer:asystematicreviewandmeta-analysis.ColorectalDis.2014Sep;16(9):662-71.,病人相关因素（Patient-relatedfactors),生活习惯,疾病相关因素（Disease-relatedfactors),肿瘤位置,PommergaardHC,etal.Preoperativeriskfactorsforanastomoticleakageafterresectionforcolorectalcancer:asystematicreviewandmeta-analysis.ColorectalDis.2014Sep;16(9):662-71.,疾病相关因素（Disease-relatedfactors),肿瘤大小,EberlT,etal.Riskfactorsforanastomoticleakageafterresectionforrectalcancer.AmJSurg.2008Oct;196(4):592-8.,肿瘤直径超过3cm，吻合口漏的发生率明显升高,疾病相关因素（Disease-relatedfactors),术前放化疗,PommergaardHC,etal.Preoperativeriskfactorsforanastomoticleakageafterresectionforcolorectalcancer:asystematicreviewandmeta-analysis.ColorectalDis.2014Sep;16(9):662-71.,QinC,etal.DoesPreoperativeRadio(chemo)therapyIncreaseAnastomoticLeakageinRectalCancerSurgery?AMeta-AnalysisofRandomizedControlledTrials.GastroenterolResPract.2014;2014:910956,疾病相关因素（Disease-relatedfactors),其它因素肠道炎性疾病伴有梗阻体重下降或营养不良水电解质酸碱平衡紊乱合并症：糖尿病，肝硬化，肾功能不全,手术相关因素（Surgery-relatedfactors）,术前因素,DahabrehIJ,etal.OralMechanicalBowelPreparationforColorectalSurgery:SystematicReviewandMeta-Analysis.DisColonRectum.2015Jul;58(7):698-707,肠道准备,手术相关因素（Surgery-relatedfactors）,vanRooijenSJ,etal.Intraoperativemodifiableriskfactorsofcolorectalleakage:whysurgronsandanesthesiologistsshouldacttogether.IntJSurg.2016Dec;36:183-200.,术中因素,高血糖、输血、手术时间、术中并发症、术中污染、中转,手术相关因素（Surgery-relatedfactors）,手术技巧,手工，器械开腹，腹腔镜端端，端侧,目前报道不一，暂无定论,吻合口张力、血供,PARTFOUR,诊断,诊断依据,CT、MRI：吻合口周围或腹盆腔积液；吻合口连续性中断血常规：白细胞升高,症状：腹痛、腹胀、发热体征：腹膜炎表现：腹膜刺激征引流管里有气体或肠内容物直肠指诊：吻合口破口,临床表现,辅助检查,吻合口漏的分级,A级：无症状的漏，不需要采取积极的治疗B级：需要采取保守治疗，但不需要再次手术。C级：需要再次手术治疗,RahbariNN,etal.Definitionandgradingofanastomoticleakagefollowinganteriorresectionoftherectum:aproposalbytheInternationalStudyGroupofRectalCancer.Surgery.2010Mar;147(3):339-51.,诊断进展,肠镜,IkedaT,etal.Endoscopicevaluationofclinicalcolorectalanastomoticleakage.JSurgRes.2015;193(1):126-34.,肠镜检查是安全可行能精确直观的判断吻合口漏的情况指导治疗方式的选择在内镜下进行相应的治疗,诊断进展,C-反应蛋白（CRP）,SinghPP,etal.Systematicreviewandmeta-analysisofuseofserumC-reactiveproteinlevelstopredictanastomoticleakaftercolorectalsurgery.BrJSurg.2014;101(4):339-46,诊断进展,降钙素原(PCT),GiaccagliaV,etal.ProcalcitoninRevealsEarlyDehiscenceinColorectalSurgery:ThePREDICSStudy.AnnSurg.2016May;263(5):967-72,诊断进展,腹腔引流液中细胞因子（TNF-a，IL-1，IL-6，MMP）,CiniC,etal.Peritonealfluidcytokinesandmatrixmetalloproteinasesasearlymarkersofanastomoticleakageincolorectalanastomosis:aliteraturereviewandmeta-analysis.ColorectalDis.2013;15(9):1070-7.,诊断进展,诊断指数,MartinG,etal.Validationofascorefortheearlydiagnosisofanastomoticleakagefollowingelectivecolorectalsurgery.JViscSurg.2015Feb;152(1):5-10.,大于3分，诊断AL的敏感性91.7%，特异性55.7%；常规评分，能早期诊断AL（比单纯的临床诊断早3.5天）,PARTFIVE,治疗,非手术治疗,体位：半卧位禁饮食抑制胃肠道分泌的药物：生长抑素等营养支持：肠内营养或肠外营养抗感染治疗保持引流的通畅,手术治疗,全身感染症状重腹膜炎范围较广漏口比较大，自行愈合较困难保守治疗效果不好,腹腔清理和引流横结肠造口或末端回肠造口吻合口处理：修补、拆除,适应症,手术方法,治疗进展,腹腔镜手术,术后并发症少术后死亡率低恢复快，住院时间短安全可行的手术方式,治疗进展,内镜下治疗-OTSC金属夹系统,适应症：破口最大经小于1.5cm;无肠腔外脓肿或肠壁硬化并发症少，安全可行成功率70-80%左右恢复快，住院时间缩短,MennigenR,etal.EndoscopicclosureofpostoperativegastrointestinalleakagesandfistulaswiththeOver-the-ScopeClip(OTSC).JGastrointestSurg.2013;17(6):1058-65.,治疗进展,内镜下治疗-支架植入,适应症及植入时机有争议目前报道病例数较少，成功率70%左右与其他治疗措施联合应用并发症：支架移位、肛门直肠疼痛、出血、穿孔、大便失禁,SevimY,etal.Minimallyinvasivemanagementofanastomoticleaksincolorectalsurgery.WorldJGastrointestSurg.2016;8(9):621-626.,治疗进展,内镜下治疗-负压引流系统,WeidenhagenR,etal.Endoscopicvacuum-assistedclosureofanastomoticleakagefollowinganteriorresectionoftherectum:anewmethod.SurgEndosc.2008Aug;22(8):1818-25.,StrangioG,etal.Endo-spongetherapyformanagementofanastomoticleak