| Part I Anastomotic leakage in 1840 rectal cancer patients undergoing anterior resection in a single centerObjective : To compare the clinicopathological characteristics of patients with anastomotic leakage of different severity after anterior resection of rectal cancer.Methods:The clinicopathological data of 1840 rectal cancer patients who underwent anterior resection in the Department of Surgery of Union Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2014 to December 2019 were retrospectively collected.The patients were divided into three groups according to the severity of anastomotic leakage.The chi-square test and one-way analysis were used to compare the clinicopathological characteristics of patients with different severity anastomotic leakage.Results:1840 patients were included in the study.138 patients had postoperative anastomotic leakage.The incidence of anastomotic leakage was 7.5%.Among them,21(15.2%)were grade A anastomotic leakage cases,95(68.8%)were grade B,and 22(15.9%)were grade C.Most of the anastomotic leakage cases were diagnosed in 4-9 days after operation(89 cases,64.5%).In patients with grade C anastomotic leakage,the reoperation time was mainly within 2 days after diagnosis(15,68.2%).52.4% of the patients with grade A anastomotic leakage,40.0% of the patients with grade B anastomotic leakage and 4.5% of the patients with grade C anastomotic leakage had defunctioning stoma.The difference was statistically significant(P<0.05).Grade A,B,and C anastomotic leakage was diagnosed in 10.0±3.8 days,7.6±3.0 days and 7.5±4.7 days after operation respectively.The difference was statistically significant(P<0.05).Conclusion:The incidence of anastomotic leakage in our hospital was 7.5%.The most common anastomotic leakage of the patients undergoing anterior resection of rectal cancer in our hospital were grade B.Most of the anastomotic leakage cases were diagnosed in 4-9 days after operation,and the reoperation time caused by anastomotic leakage was mainly within 2 days after diagnosis.Grade C anastomotic leakage was less common in patients with defunctioning stoma,and the diagnosis of grade A anastomotic leakage was the latest.Part II Risk factors for anastomotic leakage after anterior resection for rectal cancer in patientsObjective:To investigate the risk factors for anastomotic leakage(AL)after anterior resection for rectal cancer in patients.Methods:From January 2014 to December 2019,a total of 1840 patients who underwent anterior resection for rectal cancer in Wuhan Union Hospital were included in the retrospective analysis.Univariate analysis,multivariate analysis and subgroup analysis were performed to determine the risk factors for AL.Results:Univariate analyses showed that AL was related with sex(P=0.004),tumor diameter(P=0.006),preoperative chemoradiotherapy(P=0.001),smoking history(P=0.022),alcohol intake history(P=0.007),surgical approach(P=0.033),defunctioning stoma(P=0.005),splenic flexure mobilization(P=0.036)and T stage(P=0.002).Multivariate analyses revealed that defunctioning stoma [odds ratio(OR),0.619] was a protective factor for AL in total patients.Male sex(OR,1.562),later T stage(T3 or T4 stage)(OR,1.729)were independent risk factors for total patients.Subgroup analysis suggested that sex(P=0.011),tumor diameter(P=0.020),preoperative chemoradiotherapy(P=0.007),Ligating IMA(P=0.038),defunctioning stoma(P=0.033)and T stage(P=0.002)were related with anastomotic leakage in Laparoscopic surgery.Multivariate analyses revealed that Male sex(OR,2.136),later T stage(T3 or T4 stage)(OR,2.425)were independent risk factors for total patients.Subgroup analysis suggested that the occurrence of anastomotic leakage in ultra-low rectal cancer patients was associated with sex(P=0.039),smoking history(P=0.028),alcohol intake history(P=0.007)and defunctioning stoma(P=0.002).Multivariate analyses showed that defunctioning stoma(OR = 0.286)was an independent protective factor of anastomotic leakage.Conclusion:The occurrence of AL after rectal cancer surgery could be affected by many factors.The risk factors for anastomotic leakage in different patient groups were not exactly the same.Defunctioning stoma reduced the risk of anastomotic leakage.Male sex,later T stage were independent risk factors for AL.Part III To assess the role of defunctioning stoma in the prevention of anastomotic leakage using propensity score matchingObjective:To assess the role of defunctioning stoma in the prevention of anastomotic leakage.Methods:From January 2014 to December 2019,patients who underwent anterior resection for rectal cancer in Wuhan Union Hospital were included in the retrospective analysis.Propensity score matching was performed to assess the role of defunctioning stoma in the prevention of anastomotic leakage.Results:A total of 1840 patients were included in the study.Among them,61(52.2%)patients had a defunctioning stoma.After propensity score matching,A total of 543 pairs of patients were matched.There was a significant difference in the incidence of grade B and C anastomosis leakage(P=0.001),grade B anastomosis leakage(P=0.003),and grade C anastomosis leakage(P<0.001).There was no difference in the incidence of grade A anastomosis leakage(P=1.000).Conclusion:Defunctioning stoma could reduce the incidence of grade B and C anastomotic leakage.And it could reduce the rate of reoperation caused by anastomotic leakage.Part IV Meta-analysis for the role of ileostomy in the anterior resection for rectal cancer patientsObjective:To systematically evaluate the role of ileostomy in the anterior resection for rectal cancer in patients by Meta-analysis.Methods : Randomized controlled trials(RCT)published before March 2021 regarding the correlation between ileostomy and anastomotic leakage after anterior resection were searched from Pub Med,Embase,Cochrane Library,Web of science,CNKI,Wanfang database,CCD,Sino Med.Associated data were screened and data were extracted according to the standards.Review manager 5.3 software was used to perform the Meta-analysis.The Z test was used to calculate the combined relative risk,and heterogenicity among trials was estimated with Q test.P<0.05 was considered the difference to be statistically significant.Results:850 patients from six studies were included in the Meta-analysis.The overall incidence of anastomotic leakage(AL)was 11.4%(97/850).The incidence of AL was 5.5%(24/459)and 17.3%(73/438)in the ileostomy group and no stoma group respectively.Meta-analysis showed that the incidence of AL in ileostomy group was significantly lower than that in no stoma group(RR=0.32,95%CI: 0.21~ 0.49,P<0.00001).The incidence of reoperation caused by AL in ileostomy group was significantly lower than that in no stoma group(RR=0.07,95%CI: 0.03~ 0.21,P<0.00001).Conclusion:Ileostomy can reduce the incidence of AL and reoperation caused by AL. |
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