| ObjectiveTo investigate the risk factors of anastomotic leakage after anastomotic leakage for ultra-low rectal cancer and its influence on long-term clinical and oncology results and postoperative anal function.MethodsFrom June 2011 to July 2022,A total of 317 patients with ultra-low rectal cancer who underwent intersphincteric resection(ISR)and terminal ileostomy in PLA rocket force characteristic medical center were included.There were 236 patients selcected in this study.Clinincal data of the patients was obtained from a prospectively collected database.Patients were regularly followed up to observe the anastomotic leakage.The patients were divided into non-AL group and AL group(early AL and delayed AL).The clinical data of the two groups of patients were analyzed to determine the risk factors of AL after ISR and the influence of AL on the longterm clinical and oncological results.Patients were followed up regularly after surgery.Wexner score,LARS score and VAS score and anorectal manometry were used to evaluate the functional result,which were compared between the two groups.ResultsA total of 236 patients with ISR surgery were included in this study,with a total of 236 cases,including 149 males(63.1%)and 87 females(36.9%),aged61(25-84)years old.There were 136 cases(57.6%)undergone partial ISR,63cases(26.7%)in subtotal ISR and 37 cases(15.7%)in total ISR.A total of 41(17.4%)of 236 patients with symptomatic AL after ISR,including 30(12.7%)early AL and 11(4.7%)delayed AL.Two(0.8%)patients with ISREC-C grade AL required reoperation,and one patient(0.4%)died during the perioperative period.Univariate analysis showed significant differences in BMI(P=0.006),diabetes(P=0.044)and operation time(P=0.035)between AL group and AL group.Multivariate logistic regression analysis showed that obesity(BMI≥30)(OR=3.16,P=0.02)and diabetes(OR=2.99,P=0.02)were independent risk factors for AL.A total of 29 patients included in this study had anastomotic stenosis(AS),accounting for 12.3%(29/236),29.3%(12/41)in the AL group and8.7%(17/195)in the non-AL group.The difference between the two groups was statistically significant(P=0.0001).In addition,the incidence of AS was significantly higher in the early AL and delay AL groups than in the non-AL group(33.3% vs 18.2% vs 8.7%,P=0.001).Among AL patients,there was an increasing trend of stenosis rate in AD subgroup,and there was a statistically significant difference between AD and non-AD group(60.0% vs 19.4%,P=0.04).Failure to return terminal ileostomy and AS problems were more common in AL patients with anastomotic dehiscence(AD).At the end of follow-up,a total of 22patients(9.3%)did ileostomy non-reverse,including 14 patients(34.1%)in the AL group and 4.1%(8/195)in the non-AL group,showing a statistically significant difference between groups(P < 0.0001).The median time of ileostomy reverse in AL group was significantly longer than that in AL group [4.6(3.1-11.1)months vs 3.7(2.7-19.9)months,P=0.001].At 1 year after surgery,the proportion of unrestored ostomy was 22.0%(9/41)in the AL group and 2.7%(5/195)in the AL group(P < 0.0001).The results of this study showed that a total of 24.4%(10/41)of AL patients developed AD,and the median diagnostic time was 11(3-17)days after surgery,among which 50%(5/10)of AD patients failed to return the terminal ileostomy,and 60%(6/10)of AD patients developed AS.The median follow-up time of 56(6-136)months.The results showed that15.7%(37/236)patients had tumor recurrence or metastasis,among which the rate of simple local recurrence was 2.5%(6/236)and the rate of simple distant metastasis was 9.7%(23/236).The rate of local recurrence with distant metastasis was 3.4%(8/236).The median diagnosis time of local recurrence was11(5-53)months and that of distant metastasis was 13(3-60)months.The results showed no significant difference in local recurrence(9.8% vs 5.1%,P=0.274)and distant metastasis(12.2% vs 13.3%,P=1.000)between AL and AL groups.There was no significant difference in 5-year DFS(77.5% vs 76.0%,P=0.52)and 5-year OS(84.7% vs 85.7%,P=0.37)between the two groups.A total of 214 out of 236 patients(90.7%)completed a follow-up of the anal function assessment questionnaire three months after the final ileostomy,including Wexner incontinence score,LARS score,and VAS score.Among them,there were 27 cases(12.6%)in the AL group and 187 cases(87.4%)in the nonAL group.The anal function scores of the two groups of patients at 3 months after admission showed statistically significant differences in WIS(13 vs 10,P=0.039),LARS(30 vs 27,P=0.041),and VAS(4 vs 5,P=0.043).Due to the inability of some patients to complete rectal and anal pressure testing after 3months of follow-up at local hospitals,we selected 114(48.3%)outpatient or inpatient follow-up patients who underwent routine rectal and anal pressure testing.The two groups of patients had rectal resting pressure(RRP)(12.3 ± 8.1vs 9.6 ± 6.1,P=0.031)and anal resting pressure(ARP)(38.9 ± 7.5 vs 33.6 ± 7.1,P=0.029),The anal maximum systolic pressure(AMSP)of the anal canal(71.4± 15.8 vs 87.4 ± 15.7,P=0.007)and the maximum rectal tolerance volume(RMTV)of the rectum(71.9 ± 22.6 vs 86.1 ± 26.1,P=0.044)indicate inter group differences,which are statistically significant.A total of 153 patients(64.8%)participated in the follow-up of the anal function questionnaire one year after the return of the final ileostomy,including 19 patients in the AL group(12.4%)and134 patients in the non-AL group(87.6%).The results of the anal function scores WIS(9 vs 8,P=0.11),LARS(29 vs 25,P=0.130),and VAS(5 vs 6,P=0.402)showed no statistically significant differences between the two groups one year after the return of the final ileostomy.A total of 66 patients underwent rectal and anal manometry during our outpatient or inpatient follow-up period.Among them,there were 13 cases(19.7%)in the AL group and 53 cases(80.3%)in the nonAL group.The results showed no statistically significant differences except for RMVT(74.2 ± 21.4 vs 88.7 ± 21.3,P=0.049),RRP(14.2 ± 7.1 vs 11.3 ± 7.3,P=0.122),ARP(40.1 ± 7.9 vs 37.6 ± 6.9,P=0.130),and AMSP(73.1 ± 14.2 vs89.1 ± 16.2,P=0.213).ConclusionsAL is one of the serious complications after ISR surgery.Our study suggested that obesity(BMI ≥ 30)and diabetes are independent risk factors for AL.The influence of AL after ISR on the long-term clinical results of patients with low rectal cancer is mainly manifested by the increased incidence of anastomotic stricture and the inability to return the prophylactic terminal ileostomy.AL had no effect on the long-term oncological results of patients,including local recurrence,distant metastasis,5-year DFS and 5-year OS.The occurrence of AL had negative impact on the anal function in short-term after surgery.However,there was no difference in function except for RMVT one-year after surgery.The results of WIS,LARS,VAS scores and anorectal manometry data 2 years after procedure showed that AL had no impact on the long-term anal function of patients.Therefore,for high-risk patients the occurrence of AL should be prevented through early accurate preoperative evaluation and careful operation during the surgery.If AL happens unfortunately,appropriate treatment should be actively given to reduce the occurrence of AD and AS.After the ileostomy is reversed,reasonable exercise should be carried out early to improve the anal function and quality of life. |
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