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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2017, Vol. 11 ›› Issue (05) : 298 -304. doi: 10.3877/cma.j.issn.1674-0793.2017.05.002

所属专题： 文献；

论著

单中心腹腔镜与开腹直肠癌根治术近远期临床疗效对比研究
黄跃明1, 张信华2, 陈剑辉2, 陈创奇2,†()   
  1. 1. 510080　广州，中山大学附属第一医院胃肠外科中心结直肠外科（现在中山市人民医院普外科，528403）
    2. 510080　广州，中山大学附属第一医院胃肠外科中心结直肠外科
  • 收稿日期:2016-08-07 出版日期:2017-10-01
  • 通信作者: 陈创奇
  • 基金资助:
    广东省科技计划项目(2009B030801144、2010B080701106、2013B021800131)

Comparison on the short- and long-term clinical efficacy between laparoscopic and open radical resection of cectal rancer in a single centre

Yueming Huang1, Xinhua Zhang2, Jianhui Chen2, Chuangqi Chen2,†()   

  1. 1. Department of Colorectal Surgery, Gastrointestinal Surgery Center, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China (Present address: Department of General Surgery, Zhongshan People’s Hospital, Zhongshan 528403, China)
  • Received:2016-08-07 Published:2017-10-01
  • Corresponding author: Chuangqi Chen
  • About author:
    Corresponding author: Chen Chuangqi, Email:
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引用本文：

黄跃明, 张信华, 陈剑辉, 陈创奇. 单中心腹腔镜与开腹直肠癌根治术近远期临床疗效对比研究[J]. 中华普通外科学文献(电子版), 2017, 11(05): 298-304.

Yueming Huang, Xinhua Zhang, Jianhui Chen, Chuangqi Chen. Comparison on the short- and long-term clinical efficacy between laparoscopic and open radical resection of cectal rancer in a single centre[J]. Chinese Archives of General Surgery(Electronic Edition), 2017, 11(05): 298-304.

目的

比较腹腔镜与开腹直肠癌根治术的近远期疗效，探讨腹腔镜直肠癌手术的可行性、肿瘤学安全性及优缺点。

方法

回顾性分析2008年1月至2014年12月收治的949例直肠癌病例，根据手术方式不同分为腹腔镜组（行腹腔镜下直肠癌根治术）以及开腹组（行开腹直肠癌根治术），对比两组患者的临床基本资料、手术相关数据、肿瘤病理学结果和术后随访情况并行统计学分析。

结果

（1）腹腔镜组394例，开腹组555例，两组在临床基本资料上差异无统计学意义。（2）腹腔镜组在术中出血量、预防性肠造口率、术后肛门恢复排气和排便时间、拔除腹腔引流管时间、术后住院天数和总住院天数少于开腹组，而手术时间和住院总费用则高于开腹组，差异均有统计学意义（P<0.05）；腹腔镜组除术中大出血发生率低于开腹组外，在总并发症发生率和其他各并发症发生率上与开腹组相当。（3）两组在肿瘤病理学方面差异无统计学意义。（4）两组在术后肿瘤复发情况，3、5年无瘤生存率和总生存率上差异均无统计学意义，两组pTNM分期亚组分析显示远期生存情况差异亦无统计学意义。

结论

腹腔镜下直肠癌根治术安全、可行，其近远期临床疗效与开腹手术相当。

关键词: 直肠肿瘤, 腹腔镜, 剖腹术, 治疗结果
Objective

To discuss the surgical feasibility, oncological safety, advantages and disadvantages of laparoscopic radical resection of rectal cancer (RC) by comparing the short- and long-term clinical efficacy between laparoscopic and open surgery.

Methods

From January 2008 to December 2014, nine hundred and forty-nine RC cases were divided into laparoscopic group (undergoing laparoscopic radical resection) and open group (undergoing open radical resection). The basic clinical data, surgical parameters, oncological pathology indicators and the postoperation follow-up data were analyzed retrospectively.

Results

(1) There was no statistical difference on the basic clinical data between the laparoscopic group (394 cases) and the open group (555 cases). (2) Compared with the open group, the laparoscopic group had less surgical blood loss, preventive colostomy rate, time of fart recovery, defecation recovery and pulling out the abdominal cavity drainage tube, and took shorter time in hospital both of postoperation and the total (P<0.05). However, the laparoscopic group took more surgical time and hospitalized costs. Except for the lower incidence of surgical massive bleeding, the laparoscopic group were statistically similar to the incidence of other complications. (3) There was no statistical difference in oncology pathology indicators, tumor recurrence, disease free survival rate and overall survival rate between the two groups. (4) In the subgroup analysis by pTNM stages, the long-term survival between the two groups also had no significant difference.

Conclusion

The laparoscopic radical resection of rectal cancer is feasible and safe, with similar clinical efficacy as the open surgery.

Key words: Rectal neoplasms, Laparoscopes, Laparotomy, Treatment outcome
表1 两组直肠癌患者的临床资料对比
临床资料 腹腔镜组(394例) 开腹组(555例) 统计值 P值
性别(例) χ2=1.215 0.270
男 236 352
女 158 203
年龄(岁，例) 58.64±11.94 59.17±13.04 t=0.642 0.521
≤60 220 281 χ2=2.507 0.113
>60 174 274
术前合并基础疾病(例) χ2=0.394 0.544
无 309 426
有 85 129
BMI (kg/m2) 22.61±3.35 22.37±3.02 t=1.158 0.247
术前血CEA水平(μg/L,例) χ2=1.241 0.265
<5 272 364
≥5 122 191
肿瘤所在部位(例) χ2=0.060 0.807
腹膜反折以上 202 289
腹膜反折以下 192 266
肿瘤下缘离肛缘距离(cm) 6.96±3.84 6.64±3.50 t=1.307 0.191
住院总天数(d) 20.94±12.40 22.75±9.71 t=2.519 0.012
住院总费用(万元) 6.36±1.74 5.19±1.42 t=11.394 <0.001
术前cTNM分期(例) χ2=5.607 0.061
Ⅰ 63 89
Ⅱ 136 231
Ⅲ 195 235
术后辅助化疗率[例(%)] 237/281(83.34) 358/421(85.04) χ2=0.063 0.802a
表2 两组直肠癌患者的手术相关资料对比
组别 手术方式(例) 手术时间(min, ±s) 术中出血量(ml, ±s) 预防性肠造口率[例(%)]
Dixon术 Miles术
腹腔镜组(394例) 351 43 240.89±91.15 102.99±128.59 8/351(2.28)
开腹组(555例) 488 67 208.48±55.89 201.95±222.46 28/488(5.74)
统计值 0.302a 6.774 7.937 5.946 a
P值 0.583 <0.001 <0.001 0.015 b
组别 术后恢复排气时间(d,±s) 恢复排便时间(d,±s) 术后拔除引流管时间(d, ±s) 术后住院天数(d, ±s)
腹腔镜组(394例) 3.10±1.51 4.05±2.35 6.07±4.02 11.24±11.31
开腹组(555例) 3.95±1.65 5.38±2.33 7.42±4.94 12.63±8.41
统计值 8.053 8.639 4.484 2.185
P值 <0.001 <0.001 <0.001 0.029
表3 两组直肠癌患者的术中、术后并发症发生情况对比[例(%)]
组别 例数 并发症总发生率 术中大出血(≥1 000 ml) 输尿管损伤 肺部感染 腹腔内感染 泌尿系感染
腹腔镜组 394 73 (18.53) 1(0.25) 1(0.25) 6(1.52) 15(3.81) 9(2.28)
开腹组 555 85 (15.32) 12(2.16) 4(0.72) 10(1.80) 10(1.80) 5(0.90)
χ2值 1.714 6.211 0.275 0.108 3.612 3.034
P值 0.191 0.011 0.600 a 0.804 0.065 0.102
组别 尿潴留 腹腔内出血 深静脉血栓形成 肠梗阻 切口感染 吻合口出血c 吻合口瘘c
腹腔镜组 10 (2.54) 3(0.76) 0(0) 8(2.03) 14(3.55) 8(2.28) 29(8.26)
开腹组 12 (2.16) 5(0.90) 2(0.36) 13(2.34) 15(2.70) 7(1.43) 27(5.53)
χ2值 0.144 0.000 - 0.144 0.563 0.830 2.441
P值 0.827 1.000 a 0.514 b 0.748 0.452 0.362 0.118
表4 两组直肠癌患者的肿瘤病理学资料对比
组别 肿瘤长径(cm) 近端切缘长度(cm) 远端切缘长度(cm) 标本肠管总长度(cm) 清扫淋巴结数目(个) 阳性淋巴结数目(个)
腹腔镜组(394例) 4.15±1.50 12.27±6.53 4.16±1.93 20.57±6.74 15.25±9.59 1.76±4.52
开腹组(555例) 4.34±1.82 12.70±3.74 3.95±2.09 20.99±4.49 15.69±10.23 1.45±3.20
统计值 1.735a 1.298 a 1.538a 1.068 a 0.679 a 1.205 a
P值 0.083 0.194 0.124 0.286 0.497 0.228
组别 淋巴结阳性率(%) TME完整率[例(%)] CRM阳性率(≤1mm) [例(%)]c 术后pTNM分期[例(%)]
Ⅰ Ⅱ Ⅲ
腹腔镜组(394例) 11.06±26.71 265/394(67.26) 61/308(19.80) 113 132 149
开腹组(555例) 9.69±19.0 368/555(66.31) 40/210(19.05) 134 209 212
统计值 0.922 a 0.094 b 0.046 b 2.938 b
P值 0.357 0.759 0.831 0.230
表5 两组直肠癌患者的肿瘤复发情况对比[例(%)]
指标 腹腔镜组 开腹组 χ2值 P值
总体情况 394 (100.00) 555 (100.00)
总复发情况 48 (12.18) 82 (14.77) 1.310 0.252
局部复发 13 (3.30) 25 (4.50) 0.870 0.351
远处转移 35 (8.88) 57 (10.27) 0.506 0.477
TNM Ⅰ期 113 (28.68) 134 (24.14)
总复发情况 4 (3.54) 12 (8.96) 2.968 0.085
局部复发 2 (1.77) 3 (2.24) 0 1.000 a
远处转移 2 (1.77) 9 (6.72) 2.458 0.117a
TNM Ⅱ期 132 (33.50) 209 (37.66)
总复发情况 15/ (11.36) 29 (13.88) 0.454 0.500
局部复发 3 (2.27) 8 (3.83) 0.228 0.633a
远处转移 12 (9.09) 21 (10.05) 0.085 0.771
TNM Ⅲ期 149 (37.82) 212 (38.20)
总复发情况 29 (19.46) 41 (19.34) 0.001 0.977
局部复发 8 (5.37) 14 (6.60) 0.233 0.629
远处转移 21 (14.09) 27 (12.74) 0.140 0.708
图1 949例直肠癌总体及各pTNM分期亚组内腹腔镜组与开腹组无瘤生存情况对比，显示两组的无瘤生存情况差异无统计学意义
图2 949例直肠癌总体及各pTNM分期亚组内腹腔镜组与开腹组生存情况对比，显示两组生存情况差异无统计学意义
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