Abstract:
Objective:To investigate the influencing factors of anastomotic leakage after anuspreserving operation for rectal cancer and analyze the prognosis of patients.
Methods:The retrospective casecontrol study was adopted. The clinical data of 931 patients with rectal cancer who underwent anuspreserving operation at the Union Hospital of Fujian Medical University between January 2000 and October 2012 were collected. Patients in stage cT3-4 and (or) N1-2 underwent surgery within 6-8 weeks after neoadjuvant chemoradiation. Patients underwent anuspreserving operation for rectal cancer based on the principle of total mesorectal excision, and partial patients underwent enterostomy. Observation indicators included: (1) surgical situation, (2) postoperative anastomotic leakage, (3) risk factors analysis affecting anastomotic leakage, (4) followup and prognostic analysis. Followup using telephone interview, correspondence and outpatient examination was conducted once every 3 months within postoperative 2 years, once every 6 months at postoperative 3 years and once every 1 year at postoperative 4 years up to August 31, 2015. Followup included the physical examination, serum carcinoembryonic antigen (CEA), CA19-9, lung computed tomography (CT), abdominal magnetic resonance imaging (MRI), colonoscopy and postoperative adjuvant chemotherapy, and the end of followup was tumor recurrence and metastasis or death. Measurement data with normal distribution was presented as
±s, and comparisons between groups were evaluated with an independent sample t test . Measurement data with skewed distribution were presented as M (range), and comparisons between groups were evaluated with the MannWhitney U test. Count data were analyzed using the chisquare test or Fisher exact probability. The univariate analysis and multivariate analysis were respectively done using the least significant difference (LSD) and Logistic regression model. The survival curve was drawn by KaplanMeier method, and the survival rate was analyzed using the Logrank test.
Results:(1) Surgical situation: of 931 patients undergoing anuspreserving operation for rectal cancer, 422 underwent low anterior resection of rectal cancer (open surgery in 66 patients and laparoscopic surgery in 356 patients), 286 underwent ultralow anterior resection of rectal cancer (open surgery in 79 patients and laparoscopic surgery in 207 patients), 223 underwent anterior resection of rectal cancer (open surgery in 105 patients and laparoscopic surgery in 118 patients). Among 931 patients, 78 underwent laparoscopyassisted intersphincteric resection. Among 931 patients, 307 received preventive enterostomy, 624 unreceived preventive enterostomy. Operation time and volume of intraoperative blood loss were (183±52)minutes and (112±30)mL. (2) Postoperative anastomotic leakage situation: anastomotic leakage that was confirmed in 42 patients was occurred at postoperative 7 days (range,
2-14 days), anastomotic leakage in patients with laparoscopic surgery and open surgery was respectively occurred at postoperative 4 days (range,2-6days) and 10 days (range, 7- 14 days), with a statistically significant difference (Z=0.034, P<0.05). Incidences of anastomotic leakage in patients with and without preventive enterostomy were respectively 2.61%(8/307) and 5.45%(34/624), with a statistically significant difference (χ
2=3.860, P<0.05). Severity of anastomotic leakage: 2 patients in grade A were improved by themselves without special treatment, 19 in grade B were improved after symptomatic treatment, and 21 in grade C, including 1 undergoing simplex leaking stoma repair, 1 undergoing Hartmenn, 2 undergoing peritoneal lavage and drainage, 2 undergoing leaking stoma repair combined with enterostomy and 15 undergoing enterostomy. (3) Risk factors analysis affecting anastomotic leakage: univariate analysis showed that anastomotic leakage after anuspreserving operation for rectal cancer was associated with age, preoperative serum albumin (Alb), distance from the distal margin of tumor to anal verge, neoadjuvant chemoradiation and preventive enterostomy (χ
2=4.018, 3.969, 5.767, 6.585, 3.860, P<0.05). Multivariate analysis showed that distance from the distal margin of tumor to anal verge≤5 cm and neoadjuvant chemoradiation were independent risk factors affecting anastomotic leakage after anuspreserving operation for rectal cancer ［OR=1.264, 2.459, 95% confidence interval (CI): 1.149-1.457, 1.181-5.123, P<0.05］, and preventive enterostomy was a protective factor for anastomotic leakage after anuspreserving operation for rectal cancer (OR=0.407, 95% CI: 0.182- 0.912, P<0.05). (4) Followup situation and prognostic analysis: eight hundred and thirtythree patients were followed up with a median time of 84 months (range, 34-179 months), of whom 721 received postoperative adjuvant chemotherapy, and 98 was loss to followup, including 5 with anastomotic leakage and 93 without anastomotic leakage, showing no statistically significant difference (P>0.05). The 5year tumorfree survival rate, distant metastasis rate and local recurrent rate were 75.7%, 21.4%, 7.1% in patients with anastomotic leakage and 79.6%, 15.2%, 5.1% in patients without anastomotic leakage, respectively, with no statistically significant difference (χ
2=0.504, 0.447, 0.076, P>0.05).
Conclusions:The distance from distal margin of tumor to anal verge≤5 cm and neoadjuvant chemoradiation are independent risk factors affecting anastomotic leakage after anuspreserving operation for rectal cancer, and selective preventive enterostomy is an effective measure of preventing anastomotic leakage. Anastomotic leakage cannot affect the longterm tumorfree survival rate, distant metastasis rate and local recurrent rate.
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