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中华普通外科学文献(电子版) ›› 2019, Vol. 13 ›› Issue (02) : 119 -124. doi: 10.3877/cma.j.issn.1674-0793.2019.02.007

所属专题: 文献

论著

腹腔镜辅助括约肌间切除保肛术治疗超低位直肠癌的远期疗效
黄辉宏1, 林志远1, 庄潮平1,(), 陈耿臻1, 张智1   
  1. 1. 515000 汕头大学医学院第二附属医院普外科
  • 收稿日期:2018-09-13 出版日期:2019-04-01
  • 通信作者: 庄潮平
  • 基金资助:
    汕头大学医学院临床提升计划项目(201427)

Long term efficacy of laparoscopic intersphincteric resection as sphincter preserving surgery for ultra-low rectal cancer

Huihong Huang1, Zhiyuan Lin1, Chaoping Zhuang1,(), Gengzhen Chen1, Zhi Zhang1   

  1. 1. Department of General Surgery, the Second Affiliated Hospital, Medical College of Shantou University, Shantou 515000, China
  • Received:2018-09-13 Published:2019-04-01
  • Corresponding author: Chaoping Zhuang
  • About author:
    Corresponding author: Zhuang Chaoping, Email:
引用本文:

黄辉宏, 林志远, 庄潮平, 陈耿臻, 张智. 腹腔镜辅助括约肌间切除保肛术治疗超低位直肠癌的远期疗效[J/OL]. 中华普通外科学文献(电子版), 2019, 13(02): 119-124.

Huihong Huang, Zhiyuan Lin, Chaoping Zhuang, Gengzhen Chen, Zhi Zhang. Long term efficacy of laparoscopic intersphincteric resection as sphincter preserving surgery for ultra-low rectal cancer[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2019, 13(02): 119-124.

目的

分析腹腔镜辅助括约肌间切除保肛术(ISR)治疗超低位直肠癌的远期疗效,以探讨该术式的可行性。

方法

选择2009年1月至2011年12月汕头大学医学院第二附属医院38例施行腹腔镜辅助ISR保肛手术的超低位直肠癌患者为腹腔镜组,32例同期行开腹ISR超低位直肠癌保肛术患者为开腹组,于术后1、3、6、12、24个月时对患者肛门括约肌功能进行评价,随访比较两组患者的手术情况、长期生存及远期疗效。

结果

与开腹组比较,腹腔镜组术中出血量较少,住院时间更短(U=4.992,t=4.608,均P<0.001)。随访72(61~96)个月,腹腔镜组术后16~33个月有6例(15.8%)发生局部复发,3例(7.9%)发生远处转移;开腹组中5例(15.6%)发生局部复发,2例(6.3%)发生远处转移,两组局部复发率和远处转移率比较,差异无统计学意义(χ2=0.096、0.071,P=0.985、0.790),术后病理提示淋巴结有转移的患者,其远处转移发生率明显升高(χ2=6.412,P=0.011)。腹腔镜组患者的5年累积生存率和5年无瘤生存率分别为84.2%和81.6%,开腹组分别为81.3%和78.1%,两组5年累积生存率和5年无瘤生存率比较,差异无统计学意义(χ2=4.167、1.776;P=0.794、0.768),其中腹腔镜组Ⅲ期患者的5年无瘤生存率明显低于Ⅰ期、Ⅱ期患者(χ2=0.107、0.130;P=0.028、0.041)。两组患者随着病情恢复及康复训练的进行,排便功能逐渐改善,术后肛门功能比较,差异无统计学意义(P=0.413)。

结论

超低位直肠癌行腹腔镜ISR保肛手术技术上是可行的,远期疗效满意,是一种微创的、可供选择的保肛手术方法。

Objective

To evaluate the long term outcome and feasibility of laparoscopic intersphincteric resection (ISR) as a way of the sphincter preserving surgery to treat ultra-low rectal carcinoma.

Methods

From January 2009 to June 2011, thirty-eight patients with ultra-low rectal cancer (less than 5 cm from the anal verge) received laparoscopic ISR (laparoscopic group), while 32 patients with similar conditions received laparotomy (open group) in the Second Affiliated Hospital of Shantou University Medical College. The function of anal sphincter was evaluated at 1, 3, 6, 12 and 24 months after operation. The operation condition, long-term survival and outcome were compared between the two groups.

Results

Compared with the open group, the laparoscopic group had less bleeding and shorter hospital stay (U=4.992, t=4.608, all P<0.001). After follow-up of 72 (61-96) months, there were 6 cases (15.8%) of local recurrence and 3 cases (7.9%) of distant metastasis in the laparoscopic group, 5 cases (15.6%) had local recurrence and 2 cases (6.3%) had distant metastasis in the open group. There were no significant differences in the local recurrence rate and distant metastasis rate between the two groups (χ2=0.096, 0.071; P=0.985, 0.790). The incidence of distant metastasis was significantly higher in patients with lymph node metastasis (χ2=6.412, P=0.011). The rate of 5-year overall survival (OS) and disease-free survival (DFS) in the laparoscopic group were 84.2% and 81.6%, and those of open group were 81.3% and 78.1%, respectively. There were no significant differences in 5-year OS and DFS between the two groups (χ2=4.167, 1.776; P=0.794, 0.768). The 5-year DFS of laparoscopic group with stage III patients was significantly lower than that with stage I and II patients (χ2=0.107, 0.130; P=0.028, 0.041). With the progress of recovery and rehabilitation, patients in both groups experienced similar improvement in defecation (P=0.413).

Conclusion

With a satisfactory long term outcome, ISR, as a means of the sphincter preserving surgery, is a feasible, minimal invasive and reasonable option for ultra-low rectal carcinoma.

表1 70例超低位直肠癌保肛术患者资料
表2 两组行腹腔镜辅助括约肌间切除的超低位直肠癌患者围手术期资料比较
表3 38例腹腔镜组超低位直肠癌患者术后复发和转移情况[例(%)]
表4 32例开腹组超低位直肠癌患者术后复发和转移情况[例(%)]
图1 腹腔镜组不同TNM分期患者的5年累积生存率比较Ⅰ期、Ⅱ期及Ⅲ期分别93.3%、84.6%和70.0%,差异均无统计学意义
图2 腹腔镜组不同分期患者的5年无瘤生存率比较Ⅰ期、Ⅱ期及Ⅲ期分别93.3%、84.6%和60.0%,Ⅰ期和Ⅱ期差异无统计学意义(P=0.414),Ⅰ期和Ⅲ期差异有统计学意义(P=0.028),Ⅱ期和Ⅲ期差异有统计学意义(P=0.041)
图3 腹腔镜组和开腹组5年累积生存率比较 腹腔镜组为84.2%,开腹组为81.3%(P=0.794)
图4 腹腔镜组和开腹组5年无瘤生存率比较,腹腔镜组为81.6%,开腹组为78.1%(P=0.768)
表5 两组超低位直肠癌术后大便失禁评分情况(Williams标准)
[1]
庄潮平,蔡高阳,李廷汉, 等. 低位直肠癌括约肌间切除超低位吻合的疗效评估[J]. 中华胃肠外科杂志, 2009, 12(4): 364-367.
[2]
Williams NS,Patel J,George BD, et al. Development of an electrically stimulated neoanal sphincter[J]. Lancet, 1991, 338(8776): 1166-1169.
[3]
Rullier E,Zerbib F,Laurent C, et al. Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer[J]. Dis Colon Rectum, 1999, 42(9): 1168-1175.
[4]
Chamlou R,Parc Y,Simon T, et al. Long-term results of intersphincteric resection for low rectal cancer[J]. Ann Surg, 2007, 246(6): 916-921; discussion 921-922.
[5]
Yamada K,Ogata S,Saiki Y, et al. Long-term results of intersphincteric resection for low rectal cancer[J]. Dis Colon Rectum, 2009, 52(6): 1065-1071.
[6]
Köhler A,Athanasiadis S,Ommer A, et al. Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients[J]. Dis Colon Rectum, 2000, 43(6): 843-850.
[7]
Schiessel R,Novi G,Holzer B, et al. Technique and long-term results of intersphincteric resection for low rectal cancer[J]. Dis Colon Rectum, 2005, 48(10): 1858-1865; discussion 1865-1867.
[8]
Akasu T,Takawa M,Yamamoto S, et al. Incidence and patterns of recurrence after intersphincteric resection for very low rectal adenocarcinoma[J]. J Am Coll Surg, 2007, 205(5): 642-647.
[9]
王振军,梁小波,杨新庆, 等. 经肛门内外括约肌间切除直肠的直肠癌根治术疗效评价[J]. 中华胃肠外科杂志, 2006, 9(2): 111-113.
[10]
姜金波,戴勇,刘涛, 等. 超低位直肠癌内括约肌切除的根治效果及肛门功能评估[J]. 中华普通外科杂志, 2006, 21(4): 304-305.
[11]
Lacy AM,García-Valdecasas JC,Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial[J]. Lancet, 2002, 359(9325): 2224-2229.
[12]
杨阳,魏东,赵艇, 等. 腹腔镜与开腹内外括约肌间切除术治疗低位直肠癌的长期疗效比较[J]. 腹腔镜外科杂志, 2016, 17(5): 373-378.
[13]
郑民华,毛志海. 腹腔镜手术在胃肠外科的应用现状[J]. 中华胃肠外科杂志, 2005, 8(5): 389-391.
[14]
Akasu T,Takawa M,Yamamoto S, et al. Incidence and patterns of recurrence after intersphincteric resection for very low rectal adenocarcinoma[J]. J Am Coll Surg, 2007, 205(5): 642-647.
[15]
Tsukamoto S,Kanemitsu Y,Shida D, et al. Comparison of the clinical results of abdominoperanal intersphincteric resection and abdominoperineal resection for lower rectal cancer[J]. Int J Colorectal Dis, 2017, 32(5): 683-689.
[16]
郭志刚,周仕海,陈宏,等.腹腔镜超低位直肠癌经括约肌间切除术后肛门控便机制变化的研究[J/CD]. 中华普通外科学文献(电子版), 2018, 12(3): 200-203.
[17]
徐昶,宋华羽,左志贵, 等. 根治性经括约肌间切除术治疗低位直肠癌的远期疗效观察[J].浙江医学, 2015, 37(2): 87-90, 97.
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