直肠癌术后吻合口漏相关危险因素及诊疗进展
Risk Factors and Advances in the Management of Anastomotic Leakage Following Rectal Cancer Surgery
DOI: 10.12677/acm.2025.15113324, PDF,   
作者: 吴文飞：暨南大学第二临床医学院，深圳市人民医院胃肠外科，广东 深圳；钟克力*：深圳市人民医院(南方科技大学第一附属医院，暨南大学第二临床医学院)胃肠外科，广东 深圳
关键词: 直肠肿瘤；吻合口漏；危险因素；诊疗方案；预防措施；Rectal Cancer； Anastomotic Leakage； Risk Factors； Management； Prevention
摘要: 吻合口漏是腹腔镜直肠癌术后常见且严重影响患者康复的并发症。明确其危险因素有助于加强预防和早期识别，从而改善患者预后。在腹腔镜直肠癌手术中，吻合口的良好愈合依赖于充足的组织血供与无张力吻合技术，围绕这两方面的技术优化与精准评估已成为降低吻合口漏风险的关键路径。本文系统综述直肠癌术后吻合口漏的危险因素、预防策略及治疗进展，旨在为临床实践提供理论支持与实践参考。
Abstract: Anastomotic leakage is a common complication following laparoscopic rectal cancer surgery that significantly impacts patient recovery. The identification of its associated risk factors is crucial for enhancing preventive strategies and facilitating early detection and intervention, thereby playing a key role in improving patient outcomes. In laparoscopic rectal cancer surgery, successful anastomotic healing relies primarily on adequate blood supply and the application of tension-free anastomotic techniques. Ongoing technical optimization and precise evaluation focused on these two aspects have become important approaches to reducing the incidence of anastomotic leakage. This article provides a systematic review of the risk factors, preventive measures, and recent advances in the management of anastomotic leakage after rectal cancer surgery, with the aim of offering theoretical foundations and clinical strategies for practice.
文章引用：吴文飞, 钟克力. 直肠癌术后吻合口漏相关危险因素及诊疗进展[J]. 临床医学进展, 2025, 15(11): 2096-2105. https://doi.org/10.12677/acm.2025.15113324

参考文献

[1] Sung, H., Ferlay, J., Siegel, R.L., Laversanne, M., Soerjomataram, I., Jemal, A., et al. (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 71, 209-249. [Google Scholar] [CrossRef] [PubMed]
[2] Galandiuk, S. (2023) Rectal Cancer: New Challenges. Diseases of the Colon & Rectum, 66, 863-864. [Google Scholar] [CrossRef] [PubMed]
[3] Platell, C., Barwood, N., Dorfmann, G. and Makin, G. (2007) The Incidence of Anastomotic Leaks in Patients Undergoing Colorectal Surgery. Colorectal Disease, 9, 71-79. [Google Scholar] [CrossRef] [PubMed]
[4] 中华医学会外科学分会结直肠外科学组. 中国直肠癌手术吻合口漏诊断、预防及处理专家共识(2019版) [J]. 中华胃肠外科杂志, 2019, 22(3): 201-206.
[5] Rahbari, N.N., Weitz, J., Hohenberger, W., Heald, R.J., Moran, B., Ulrich, A., et al. (2010) Definition and Grading of Anastomotic Leakage Following Anterior Resection of the Rectum: A Proposal by the International Study Group of Rectal Cancer. Surgery, 147, 339-351. [Google Scholar] [CrossRef] [PubMed]
[6] Lim, S.‐B., Yu, C.S., Kim, C.W., Yoon, Y.S., Park, I.J. and Kim, J.C. (2016) Late Anastomotic Leakage after Low Anterior Resection in Rectal Cancer Patients: Clinical Characteristics and Predisposing Factors. Colorectal Disease, 18, O135-O140. [Google Scholar] [CrossRef] [PubMed]
[7] Shinji, S., Ueda, Y., Yamada, T., Koizumi, M., Yokoyama, Y., Takahashi, G., et al. (2018) Male Sex and History of Ischemic Heart Disease Are Major Risk Factors for Anastomotic Leakage after Laparoscopic Anterior Resection in Patients with Rectal Cancer. BMC Gastroenterology, 18, Article No. 117. [Google Scholar] [CrossRef] [PubMed]
[8] 李干斌, 韩加刚, 王振军, 等. 新辅助放化疗治疗局部进展期直肠癌疗效分析[J]. 中国实用外科杂志, 2021, 41(2): 144-149.
[9] Suzuki, N., Yoshida, S., Tomochika, S., Nakagami, Y., Shindo, Y., Tokumitsu, Y., et al. (2020) Determining the Protective Characteristics and Risk Factors for the Development of Anastomotic Leakage after Low Anterior Resection for Rectal Cancer. Surgery Today, 51, 713-720. [Google Scholar] [CrossRef] [PubMed]
[10] Xu, H. and Kong, F. (2020) Malnutrition‐Related Factors Increased the Risk of Anastomotic Leak for Rectal Cancer Patients Undergoing Surgery. BioMed Research International, 2020, Article ID: 5059670. [Google Scholar] [CrossRef] [PubMed]
[11] Kawada, K. and Sakai, Y. (2016) Preoperative, Intraoperative and Postoperative Risk Factors for Anastomotic Leakage after Laparoscopic Low Anterior Resection with Double Stapling Technique Anastomosis. World Journal of Gastroenterology, 22, 5718-5727. [Google Scholar] [CrossRef] [PubMed]
[12] 陶凯雄, 高金波. 直肠癌术后吻合口漏发生的危险因素[J]. 中华胃肠外科杂志, 2018, 21(4): 384-387.
[13] Krysa, J., Patel, V., Taylor, J., Williams, A.B., Carapeti, E. and George, M.L. (2008) Outcome of Patients on Renal Replacement Therapy after Colorectal Surgery. Diseases of the Colon & Rectum, 51, 961-965. [Google Scholar] [CrossRef] [PubMed]
[14] Degiuli, M., Elmore, U., De Luca, R., De Nardi, P., Tomatis, M., Biondi, A., et al. (2021) Risk Factors for Anastomotic Leakage after Anterior Resection for Rectal Cancer (RALAR Study): A Nationwide Retrospective Study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group. Colorectal Disease, 24, 264-276. [Google Scholar] [CrossRef] [PubMed]
[15] Borstlap, W.A.A., Westerduin, E., Aukema, T.S., Bemelman, W.A. and Tanis, P.J. (2017) Anastomotic Leakage and Chronic Presacral Sinus Formation after Low Anterior Resection: Results from a Large Cross-Sectional Study. Annals of Surgery, 266, 870-877. [Google Scholar] [CrossRef] [PubMed]
[16] Li, J., An, Y., Wu, G., et al. (2018) Incidence and Risk Factors for Anastomotic Leakage after Anterior Resection for Rectal Cancer. Chinese Journal of Gastrointestinal Surgery, 21, 413-418.
[17] Katsuno, H., Shiomi, A., Ito, M., Koide, Y., Maeda, K., Yatsuoka, T., et al. (2016) Comparison of Symptomatic Anastomotic Leakage Following Laparoscopic and Open Low Anterior Resection for Rectal Cancer: A Propensity Score Matching Analysis of 1014 Consecutive Patients. Surgical Endoscopy, 30, 2848-2856. [Google Scholar] [CrossRef] [PubMed]
[18] Planellas, P., Cornejo, L., Pigem, A., Gómez-Romeu, N., Julià-Bergkvist, D., Ortega, N., et al. (2022) Challenges and Learning Curves in Adopting Tatme and Robotic Surgery for Rectal Cancer: A Cusum Analysis. Cancers, 14, Article 5089. [Google Scholar] [CrossRef] [PubMed]
[19] Kawada, K., Hasegawa, S., Hida, K., Hirai, K., Okoshi, K., Nomura, A., et al. (2014) Risk Factors for Anastomotic Leakage after Laparoscopic Low Anterior Resection with DST Anastomosis. Surgical Endoscopy, 28, 2988-2995. [Google Scholar] [CrossRef] [PubMed]
[20] Nikolian, V.C., Kamdar, N.S., Regenbogen, S.E., Morris, A.M., Byrn, J.C., Suwanabol, P.A., et al. (2017) Anastomotic Leak after Colorectal Resection: A Population-Based Study of Risk Factors and Hospital Variation. Surgery, 161, 1619-1627. [Google Scholar] [CrossRef] [PubMed]
[21] 中国医师协会结直肠肿瘤专业委员会, 中国抗癌协会大肠癌专业委员会, 北京整合医学学会结直肠肿瘤分会. 吲哚菁绿近红外荧光血管成像技术应用于腹腔镜结直肠手术中吻合口血供判断中国专家共识(2023版) [J]. 中华结直肠疾病电子杂志, 2023, 12(6): 441-447.
[22] Song, M., Liu, J., Xia, D., Yao, H., Tian, G., Chen, X., et al. (2020) Assessment of Intraoperative Use of Indocyanine Green Fluorescence Imaging on the Incidence of Anastomotic Leakage after Rectal Cancer Surgery: A Prisma-Compliant Systematic Review and Meta-Analysis. Techniques in Coloproctology, 25, 49-58. [Google Scholar] [CrossRef] [PubMed]
[23] Alekseev, M., Rybakov, E., Shelygin, Y., Chernyshov, S. and Zarodnyuk, I. (2020) A Study Investigating the Perfusion of Colorectal Anastomoses Using Fluorescence Angiography: Results of the FLAG Randomized Trial. Colorectal Disease, 22, 1147-1153. [Google Scholar] [CrossRef] [PubMed]
[24] Chan, D.K.H., Lee, S.K.F. and Ang, J.J. (2020) Indocyanine Green Fluorescence Angiography Decreases the Risk of Colorectal Anastomotic Leakage: Systematic Review and Meta-Analysis. Surgery, 168, 1128-1137. [Google Scholar] [CrossRef] [PubMed]
[25] Watanabe, J., Ishibe, A., Suwa, Y., Suwa, H., Ota, M., Kunisaki, C., et al. (2020) Indocyanine Green Fluorescence Imaging to Reduce the Risk of Anastomotic Leakage in Laparoscopic Low Anterior Resection for Rectal Cancer: A Propensity Score-Matched Cohort Study. Surgical Endoscopy, 34, 202-208. [Google Scholar] [CrossRef] [PubMed]
[26] Blanco-Colino, R. and Espin-Basany, E. (2018) Intraoperative Use of ICG Fluorescence Imaging to Reduce the Risk of Anastomotic Leakage in Colorectal Surgery: A Systematic Review and Meta-Analysis. Techniques in Coloproctology, 22, 15-23. [Google Scholar] [CrossRef] [PubMed]
[27] 申占龙, 鲍予頔, 叶颖江, 等. 直肠癌根治术中肠系膜下动脉高位和低位结扎的争议与思考[J]. 中华外科杂志, 2020, 58(8): 596-599.
[28] 黄永, 陈小军, 杨永国, 等. 保留左结肠动脉对腹腔镜下中低位直肠癌根治术疗效的影响[J]. 实用临床医药杂志, 2022, 26(8): 91-94.
[29] Kong, M., Chen, H., Xin, Y., Jiang, Y., Han, Y. and Sheng, H. (2021) High Ligation of the Inferior Mesenteric Artery and Anastomotic Leakage in Anterior Resection for Rectal Cancer: A Systematic Review and Meta‐Analysis of Randomized Controlled Trial Studies. Colorectal Disease, 23, 614-624. [Google Scholar] [CrossRef] [PubMed]
[30] Luo, Y., Yu, M., Huang, Y., Jing, R., Qin, J., Qin, S., et al. (2021) Lymphadenectomy around Inferior Mesenteric Artery in Low-Tie vs High-Tie Laparoscopic Anterior Resection: Short-and Long-Term Outcome of a Cohort of 614 Rectal Cancers. Cancer Management and Research, 13, 3963-3971. [Google Scholar] [CrossRef] [PubMed]
[31] 刘鹏飞, 钱正海, 吴云云, 等. 双荷包单吻合技术在腹腔镜辅助直肠癌前切除术中的临床应用价值[J]. 中国冶金工业医学杂志, 2023, 40(4): 395-396.
[32] Shiomi, A., Ito, M., Maeda, K., Kinugasa, Y., Ota, M., Yamaue, H., et al. (2015) Effects of a Diverting Stoma on Symptomatic Anastomotic Leakage after Low Anterior Resection for Rectal Cancer: A Propensity Score Matching Analysis of 1,014 Consecutive Patients. Journal of the American College of Surgeons, 220, 186-194. [Google Scholar] [CrossRef] [PubMed]
[33] 李东明, 宋建宁, 杨鋆, 等. 直肠癌根治术预防性回肠造口术后还纳失败的预后因素分析[J]. 中华外科杂志, 2022, 60(8): 756-761.
[34] Qu, H., Liu, Y. and Bi, D. (2015) Clinical Risk Factors for Anastomotic Leakage after Laparoscopic Anterior Resection for Rectal Cancer: A Systematic Review and Meta-Analysis. Surgical Endoscopy, 29, 3608-3617. [Google Scholar] [CrossRef] [PubMed]
[35] Karrasch, T. and Jobin, C. (2009) Wound Healing Responses at the Gastrointestinal Epithelium: A Close Look at Novel Regulatory Factors and Investigative Approaches. Zeitschrift für Gastroenterologie, 47, 1221-1229. [Google Scholar] [CrossRef] [PubMed]
[36] Anderson, D.I., Keskey, R., Ackerman, M.T., Zaborina, O., Hyman, N., Alverdy, J.C., et al. (2021) Enterococcus Faecalis Is Associated with Anastomotic Leak in Patients Undergoing Colorectal Surgery. Surgical Infections, 22, 1047-1051. [Google Scholar] [CrossRef] [PubMed]
[37] Hyoju, S.K., Klabbers, R.E., Aaron, M., Krezalek, M.A., Zaborin, A., Wiegerinck, M., et al. (2018) Oral Polyphosphate Suppresses Bacterial Collagenase Production and Prevents Anastomotic Leak Due to Serratia Marcescens and Pseudomonas Aeruginosa. Annals of Surgery, 267, 1112-1118. [Google Scholar] [CrossRef] [PubMed]
[38] Hajjar, R., Gonzalez, E., Fragoso, G., Oliero, M., Alaoui, A.A., Calvé, A., et al. (2022) Gut Microbiota Influence Anastomotic Healing in Colorectal Cancer Surgery through Modulation of Mucosal Proinflammatory Cytokines. Gut, 72, 1143-1154. [Google Scholar] [CrossRef] [PubMed]
[39] Albert, J.G., Friedrich-Rust, M., Woeste, G., Strey, C., Bechstein, W.O., Zeuzem, S., et al. (2011) Benefit of a Clipping Device in Use in Intestinal Bleeding and Intestinal Leakage. Gastrointestinal Endoscopy, 74, 389-397. [Google Scholar] [CrossRef] [PubMed]
[40] Liu, S., Jacobsen, G.R., Sandler, B.J., Savides, T.J., Fehmi, S., Fuchs, H., et al. (2018) Preventing Rescue Surgeries by Endoscopic Clipping: A Valuable Resource in the Surgeon’s Toolbox. Journal of Laparoendoscopic & Advanced Surgical Techniques, 28, 439-444. [Google Scholar] [CrossRef] [PubMed]
[41] Weidenhagen, R., Gruetzner, K.U., Wiecken, T., Spelsberg, F. and Jauch, K. (2008) Endoscopic Vacuum-Assisted Closure of Anastomotic Leakage Following Anterior Resection of the Rectum: A New Method. Surgical Endoscopy, 22, 1818-1825. [Google Scholar] [CrossRef] [PubMed]
[42] Kollmann, C., Kusnezov, B., Kollmann, L., Schmitt, J., Germer, C., Lock, J.F., et al. (2025) The Effects of Endoscopic Vacuum Therapy for Non-Operative Treatment of Anastomotic Leakage on Oncological Outcomes in Rectal Cancer Patients. Langenbeck’s Archives of Surgery, 410, Article No. 107. [Google Scholar] [CrossRef] [PubMed]
[43] Kumar, N. and Thompson, C.C. (2013) Endoscopic Therapy for Postoperative Leaks and Fistulae. Gastrointestinal Endoscopy Clinics of North America, 23, 123-136. [Google Scholar] [CrossRef] [PubMed]
[44] DiMaio, C.J., Dorfman, M.P., Gardner, G.J., Nash, G.M., Schattner, M.A., Markowitz, A.J., et al. (2012) Covered Esophageal Self-Expandable Metal Stents in the Nonoperative Management of Postoperative Colorectal Anastomotic Leaks. Gastrointestinal Endoscopy, 76, 431-435. [Google Scholar] [CrossRef] [PubMed]
[45] Hatamori, H., Yoshio, T., Tokai, Y., Namikawa, K., Yoshimizu, S., Horiuchi, Y., et al. (2021) Efficacy of Endoscopic Filling with Polyglycolic Acid Sheets and Fibrin Glue for Anastomotic Leak after Esophageal Cancer Surgery: Identification of an Optimal Technique. Esophagus, 18, 529-536. [Google Scholar] [CrossRef] [PubMed]
[46] 孙孝文, 徐竟益, 朱志东, 等. 直肠癌术后吻合口漏蛋白胶精准封堵治疗[J]. 中国现代普通外科进展, 2024, 27(3): 234-235.
[47] 肖明明, 孙璇, 王大广, 等. 医用生物胶致十二指肠穿孔1例报告[J]. 中国实用外科杂志, 2018, 38(6): 694-695.
[48] Zhang, M., Sha, H., Xue, H., Qin, Y., Dong, F., Zhang, L., et al. (2024) Treatment of Anastomotic Stricture after Rectal Cancer Operation by Magnetic Compression Technique: A Case Report. World Journal of Gastrointestinal Surgery, 16, 1443-1448. [Google Scholar] [CrossRef] [PubMed]
[49] Blumetti, J., Chaudhry, V., Cintron, J.R., Park, J.J., Marecik, S., Harrison, J.L., et al. (2014) Management of Anastomotic Leak: Lessons Learned from a Large Colon and Rectal Surgery Training Program. World Journal of Surgery, 38, 985-991. [Google Scholar] [CrossRef] [PubMed]

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