近紅外線螢光顯影用於大腸直腸癌手術中偵測腸吻合端血循之效率分析

Efficacy of Assessing Intraoperative Anastomosis Site Bowel Perfusion with Near-Infrared Camera in Colorectal Cancer Surgery

陳威佑(Wei-Yu Chen)

指導教授 ： 周明智

中山醫學大學/醫學院/醫學研究所/碩士(2021年)

https://doi.org/10.6834/csmu202100011

摘要

前言：對於大腸手術患者而言，最嚴重的併發症就是術後腸吻合端癒合不良而產生滲漏，根據過去研究顯示，患者在接受根除性大腸直腸癌手術後，較易造成腸吻合端滲漏的原因，最重要的就是腸吻合端的血液循環不良，而過去傳統手術針對吻合端血流，都是藉由手術醫師目測吻合端腸壁顏色或斷端血流速度來判斷，主觀因素過多，沒有充分的科學方式來評估，因此，過去用於評估皮辦血流的靛氰綠(indocyanine green；ICG)近紅外線螢光顯影測試，近幾年來開始被直腸外科醫師用於術中評估腸吻合端血流，但近幾年文獻個案數都不多，對於促進術後腸接口吻合是否有正面意義，目前還是無法確定，因此我們希望研究本院接受術中ICG近紅外線螢光顯影測試並完成根除性結直腸切除手術的大腸直腸癌患者，追蹤其術後腸吻合端情況，來統計術中ICG近紅外線螢光顯影測試與術後腸吻合端滲漏的相關性。
研究目的：對於接受術中ICG近紅外線螢光顯影測試並完成根除性大腸切除手術患者，追蹤其術後腸吻合端滲漏的情況，統計術中ICG紅外線螢光顯影測試與術後腸吻合端滲漏之間的相關性，以及造成腸吻合端滲漏相關危險因子分析。
方法：我們從2016年3月至2020年3月彰化基督教醫院手術記錄中，檢索了所有大腸惡性腫瘤腹腔鏡手術，且無論是否於術中接受ICG近紅外線螢光顯影測試患者皆納入討論，排除術前已知有復發、轉移、資料不全、傳統開腹、緊急手術以及ASA score≧4的病人，對於術後60天內腸道吻合端滲漏的患者進行分析。
結果：共收錄802位大腸直腸癌患者手術患者，其中400(49.8%)位患者有接受術中ICG近紅外線螢光顯影測試，402(50.2%)位患者沒有接受術中ICG近紅外線螢光顯影測試。我們發現在有接受術中近紅外線螢光顯影劑組別腸吻合端滲漏比例為3.2%，而未接受術中近紅外線螢光顯影劑組別腸吻合端滲漏比例為4.2% (p=0.466)。 單變數分析顯示，術前接受放射治療(p<0.001)、低位直腸手術(p<0.001)，統計學上與腸吻合端滲漏有明顯關聯。
討論：接受術中近紅外線螢光顯影測試腸吻合端血流組別，相較於未接受術中近紅外線螢光顯影測試組別，並無明顯降低術後腸吻合端滲漏的比例。吻合端血流量只是影響術後接口滲漏的其中一項因素，或許需要更大型的研究來檢測這項新科技對於預防腸吻合端滲漏是否有其益處。

關鍵字

近紅外線螢光顯影 ； 大腸直腸癌手術 ； 腸吻合端血循 ； 腸吻合端滲漏

並列摘要

Background: Anastomotic leaks after colorectal surgery result in significant morbidity and mortality. Insufficient blood supply to the site of anastomosis is the most important factor that contributes to anastomotic leakage. During surgery, the surgeon select an optimal site for anastomosis is dependent on subjective clinical indicators. During traditional surgery we observe the change in color of the colonic wall with the surgeon’s naked eye and to observe the pulsation of colonic bowel wall artery to evaluate the blood perfusion. During these years, Near-infrared fluorescence (NIRF) imaging allows surgeons to visualize the tissue perfusion and had been adapted in several surgical fields.With the development of indocyanine green (ICG)-enhanced fluorescence-guided imaging system capable of real-time monitoring, objective assessment of blood flow to the colon has become possible.It had been adopted during colorectal surgery in these years to evaluate the anastomosis site bowel wall perfusion. But,it is still unclear whether intraoperative fluorescence angiography offers a benefit in colorectal resections to prevent anastomotic leak .For now, the literature which was published were less of case numbers. So, our purpose was to determine whether the use of intraoperative fluorescence angiography can effected the anastomotic leak rate in colon and rectal cancer surgery patients with large case numbers in one single institute.
Purpose: The main purpose was to determine the relationship between intraoperative angiography usage and colorectal anastomotic leaks in colorectal cancer patients. And to evaluate other risk factors which related to anastomotic leakage.
Patients and methods: We performed a retrospective review of all of the patients who underwent colon and rectal cancer surgery with primary anastomosis from March 2016 through March 2020 by colorectal surgeons at our hospital. No matter if they had received ICG test or not were all included. Patient with Stage IV colorectal cancer, incomplete data,who received open or emergency surgery and ASA score greater or equal to IV were all be excluded. The primary outcome was anastomotic leak occurring within 60 days of the initial operation.
Results: 802 patients were diagnosed with colorectal cancer and received colorectal surgery were studied. Of these patients who underwent elective resections, 400 (49.8%) had evaluated the anastomosis site with intraoperative fluorescence angiography and 402 (50.2%) did not undergo intraoperative angiography. The anastomotic leak rate was no significant difference in patients with intraoperative angiography and those in whom it had not been used (3.2% vs 4.2%; p = 0.466).Univariate analysis revealed that preoperative pelvic radiation (p<0.001)and lower rectal anastomosis (p<0.001)were positively associated with anastomotic leak.
Conclusion: Our study revealed that there was no strong relationship between the use of intraoperative fluorescence angiography to detect the perfusion of the colon anastomosis with prevent postoperative anastomotic leak. Many factors may effect the result of anastomosis and not only anastomosis site perfusion.Therefore, large prospective, randomized controlled trial are required to show if ICG test can really help to prevent anastomotic leak.

並列關鍵字

Anastomotic leak ； Laparoscopic colorectal cancer surgery ； ICG fluorescence angiography

參考文獻

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