直結腸癌手術後吻合滲漏與低存活率有關


  Aug. 6, 2004 - 一項發表於8月號外科學誌(Annals of Surgery)的前瞻性試驗結果顯示,直結腸癌手術後吻合滲漏是總體與癌症特定存活率降低,為除了立即臨床結果外獨立的預測因子。
  
  澳洲新德里大學Concord醫院直結腸外科部Kennth G. Walker醫師與他的同事們表示,直結腸癌切除後的吻合滲漏是項嚴重併發症;滲漏可能以需要接受腹部重新手術的廣泛性腹膜炎、或是僅能在對比顯影放射技術上顯現的局部滲出物或是亞臨床滲漏來表現。
  
  為了要確認吻合滲漏是不是存活率癒後顯著性獨立因素,研究人員回顧前瞻性紀錄的1,722位接受切除病患的病歷,追蹤時間從1971到1999年;這些病患中,76位病患因未確認的死亡原因,而被排除在分析之外。
  
  27位(1.6%;95%信賴區間,1.0%-2.3%)病患發生廣泛性需要緊急手術的吻合滲漏;61位(3.5%;95%信賴區間,2.7%-4.5%)病患發生局部滲漏,接受排出或經皮下引流治療;滲漏盛行率與男性、直腸而非結腸腫瘤、以及侵入靜脈的腫瘤有關。
  
  整體來說,相較於沒有發生滲漏的病患(64.0%;95%信賴區間,61.5%-66.3%),廣泛性或局部滲漏病患的5年存活率顯著地較低(44.3%;95%信賴區間,33.5%-54.6%)。
  
  吻合滲漏被發現與整體存活率(風險比,1.6;95%信賴區間,1.3-2.1),及利用比例性風險回歸控制年齡、性別、緊急切除位置、大小、分期、等級、侵入靜脈與否、頂端淋巴結轉移、以及牽涉漿膜表面等因素後的癌症特定存活率(風險比,1.8;95%信賴區間,1.3-2.6)有獨立負面的關聯。
  
  除此之外,局部滲漏被發現與整體存活率(風險比,1.7;95%信賴區間,1.3-2.3)及癌症特定存活率(風險比,2.2;95%信賴區間,1.4-3.2)有獨立負面的關聯;至於廣泛性滲漏組的數據,則不足以分析。
  
  研究人員指出,即使局部滲漏也與存活率有關是令人驚訝的,但至今仍鮮少與長期臨床顯著性是歸因於局部或亞臨床的吻合滲漏,因此這項試驗的結果與長期以來觀點相抵觸。
  
  研究人員總結指出,這項試驗強調採取避免吻合滲漏的措施是重要的,提出需要對手術細節更多的需求,如無張力吻合與良好的血流供應等。

Anastomotic Leak After Colorec

By Yael Waknine
Medscape Medical News

Aug. 6, 2004 — Anastomotic leakage after surgery for colorectal cancer is an independent predictor of diminished overall and cancer-specific survival, aside from immediate clinical consequences, according to the results of a prospective study published in the August issue of the Annals of Surgery.

"Anastomotic leakage is a serious complication following restorative resection for colorectal cancer," explains Kenneth G. Walker, MD, and colleagues, from the Department of Colorectal Surgery at the University of Sydney's Concord Hospital in Australia. "Leakage may be present as generalized peritonitis requiring abdominal reoperation, as a more localized collection that may discharge, or as a subclinical leak detected merely on contrast radiology."

To determine whether anastomotic leakage is an independent factor with prognostic significance for survival, investigators reviewed database records of 1,722 resection patients prospectively recorded and followed from 1971 to 1999. Of these, 76 were excluded from analysis due to unidentified cause of death.

General anastomotic leak requiring emergency operation occurred in 27 patients (1.6%; 95% confidence interval [CI], 1.0% - 2.3%). Localized leak in 61 patients (3.5%; 95% CI, 2.7% - 4.5%) was treated expectantly or percutaneously drained. Leakage prevalence was associated with male sex, rectal rather than colonic tumors, and tumors with venous invasion.

Overall, the five-year survival rate was significantly lower in patients with generalized or local leakage (44.3%; 95% CI, 33.5% - 54.6%) compared with patients who did not have a leak (64.0%; 95% CI, 61.5% - 66.3%).

Anastomotic leakage was found to have an independent negative association with overall survival (hazard ratio [HR], 1.6; 95% CI, 1.3 - 2.1) and cancer-specific survival (HR, 1.8; 95% CI, 1.3 - 2.6) after proportional hazards regression adjustments for age, sex, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis, and serosal surface involvement.

In addition, local leak was found to be independently negatively associated with both overall (HR, 1.7; 95% CI, 1.3 - 2.3) and cancer-specific (HR, 2.2; 95% CI, 1.4 - 3.2) survival. Data from the general leakage group were insufficient for analysis.

"The fact that even localized leakage is negatively associated with survival was surprising," the authors write. "Hitherto, little long-term clinical significance has been attributed to localized or subclinical anastomotic leakage. The results of this study contradict that long-held view."

The authors conclude, "This study emphasizes the importance of taking measures to avoid anastomotic leakage," noting the need for attention to surgical details such as a tension-free anastomosis with good blood supply.

The authors report no pertinent financial conflicts of interest.

Ann Surg. 2004;240:255-259

Reviewed by Gary D. Vogin, MD

    
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