Search

Uvod: Dehiscencija kolo-rektalne anastomoze (DKRA) je najteža komplikacija u hirurgiji karcinoma rektuma (KR) i direktno utiče na rane postoperativne ishode, prognozu i stopu preživljavanja. Cilj: ispitati povezanost godišnjeg volumena procedure hirurga i ranih postoperativnih ishoda i analizirati odnos uticajnih faktora rizika za nastanak DKRA u kontekstu iskustva hirurga. Materijal i metode: Retrospektivna,klinička studija jednog centra sa kohortom od 546 bolesnika oba pola sa KR. Kod svih je učinjena klasična (otvorena) prednja resekcija rektuma sa kreiranjem kolo-rektalne anastomoze (KRA) šavnom ili stepler tehnikom, u 10-godišnjem periodu. Bolesnici su podeljeni u tri grupe, shodno godišnjem volumenu procedura 18. ordinirajućih hirurga u kolorektalnoj hirurgiji. Analizirano je sedam ranih postoperativnih ishoda, kao i druga 22 faktora rizika (nezavisne, zavisne i „zbunjujuće“ varijable) od značaja za ishode operativnog lečenja i objašnjenje razlika između grupa hirurških volumena i njihovog uticaja na rane ishode lečenja. Sve operacije su izvedene u Klinici za opštu i abdominalnu hirurgiju KC Banja Luka (RS). Rezultati: Većina hirurga (77,7%) pripadala je grupi sa niskim i srednjim volumenom procedura. DKRA je nastala kod 53 (9,7%) bolesnika sa statistički značajnom razlikom između grupa hirurških volumena. Intrahospitalna smrtnost iznosila je 4,8% (26/546), bez statistički značajne razlike između grupa. Dužina hospitalizacije (> 8 dana, 65,4%) bila je u signifikantnoj korelaciji sa učestalošću DKRA. Grupa hirurga sa visokim volumenom imala je signifikantno bolje rezultate u četiri ranih ishoda. Zaključak: Signifikantni faktori rizika za nastanak DKRA su: T3 N1-2 M0 stadijum KR, nivo anastomoze do 12sm od analnog ruba, Charlson-ov indeks komorbiditeta ≥3, znatan fekalni sadržaj u kolonu (82,5%), preoperativna radioterapija, intraoperativni gubitak krvi >200ml., intraoperativna fekalna kontaminacija (30,8%), protektivna stoma (62,5%) i niski godišnji volumen procedura hirurga. Ovi faktori rizika obeležavaju posebnu „high-risk“grupu bolesnika sa KR, predisponiranu za nastanak DKRA. Visoki godišnji volumen hirurga je najvažniji prediktor uspešnih ranih ishoda u lečenju bolesnikasa KR. Introduction: Dehiscence of the colorectal anastomosis (AD) is the most severe complication of rectum cancer surgery which directly influences early postoperative outcome, prognosis and survival rate. Aim. To examine the connection between the annualvolume of the surgeon and early postoperative outcomes, as well as to analyze risk factors for the development of AD in the context of the surgeon individual experience. Method: Retrospective study performed in a single center, with a cohort of 546 patients of both sexeswith rectal cancer (RC), over a 10-year period.In all patients a classical (open) anterior resection of the rectum with a colorectal anastomosis (CRA), created viasuture or stapler,was performed. Patients were divided into three groups, according to the annual volume of their attending surgeon. Seven early postoperative outcomes were analyzed, as well as 22 other risk factors (independent, dependent, and “confusing” variables) of significance for surgical outcome. The risk factors were analyzed to explain the difference between the groups of surgeons and their influence on the outcomes. All surgeries were performed in the Clinic for general and abdominal surgery, Banja Luka (Republic of Srpska). Results: The majority of surgeons (77.7%) belonged to the low and medium annual volume groups. AD developed in 53 (9.7%) patients, with significant difference between the annual volume groups. The in-hospital death rate was4.8% (26/546), without significant difference between the groups. The length of stay in the hospital (> 8 days in 65.4%) was in significant correlation with the incidence of AD. The high annual volume surgeon group was associated with significantly better results in four of the outcomes. Conclusion: Risk factors for the development of AD were: T3N1-2M0 stadium of RC, anastomosis level up to 12 cm from the anal edge, Charlson comorbidity index of ≥3, significant fecal load of colon (82.5%), preoperative radiotherapy, intraoperative blood loss of more than 200 ml, intraoperative fecal contamination (30.8%), protective stoma (62.5%) and low annual volume of surgeons. These factors mark the particular high risk group of patients with RC predisposed to develop AD. The high annual volume surgeon was the most important predictor of success of the RC surgery.