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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) ›› 2023, Vol. 17 ›› Issue (05) : 326 -331. doi: 10.3877/cma.j.issn.1674-0793.2023.05.002

论著

腹腔镜辅助直肠癌前切除术端侧吻合对肛门功能影响的随机对照研究
杨自杰, 归明彬, 屈莲平, 高华, 邹敏, 杨康, 王得晨, 杨增强, 高峰†()   
  1. 730050　兰州，中国人民解放军联勤保障部队第九四〇医院结直肠肛门外科；750000　银川，宁夏医科大学
    730050　兰州，中国人民解放军联勤保障部队第九四〇医院结直肠肛门外科
    730050　兰州，甘肃省中心医院普通外科
  • 收稿日期:2022-10-11 出版日期:2023-10-01
  • 通信作者: 高峰
  • 基金资助:
    甘肃省卫生行业计划项目(GSWSKY2018-03); 甘肃科技计划项目(20YF8FA098)

Effect of end-to-side anastomosis in laparoscopic assisted anterior resection of rectal cancer on anal function: A randomized controlled study

Zijie Yang, Mingbin Gui, Lianping Qu, Hua Gao, Min Zou, Kang Yang, Dechen Wang, Zengqiang Yang, Feng Gao†()   

  1. Department of Colorectal Anal Surgery, the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, China; Ningxia Medical University, Yinchuan 750000, China
    Department of Colorectal Anal Surgery, the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, China
    Department of General Surgery, Central Hospital of Gansu Province, Lanzhou 730050, China
  • Received:2022-10-11 Published:2023-10-01
  • Corresponding author: Feng Gao
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引用本文：

杨自杰, 归明彬, 屈莲平, 高华, 邹敏, 杨康, 王得晨, 杨增强, 高峰. 腹腔镜辅助直肠癌前切除术端侧吻合对肛门功能影响的随机对照研究[J]. 中华普通外科学文献(电子版), 2023, 17(05): 326-331.

Zijie Yang, Mingbin Gui, Lianping Qu, Hua Gao, Min Zou, Kang Yang, Dechen Wang, Zengqiang Yang, Feng Gao. Effect of end-to-side anastomosis in laparoscopic assisted anterior resection of rectal cancer on anal function: A randomized controlled study[J]. Chinese Archives of General Surgery(Electronic Edition), 2023, 17(05): 326-331.

目的

探讨腹腔镜下直肠癌前切除术端侧吻合方式的安全性及其对肛门功能的影响。

方法

采用前瞻性随机对照研究，纳入2021年7月至2022年7月在联勤保障部队第九四〇医院行腹腔镜下直肠前切除术的46例中低位直肠癌患者，按随机数字表法1∶1原则分组，并剔除3例预防性造口未还纳，最终端端吻合组（SCA组）23例，端侧吻合组（SEA组）20例。观察并比较两组患者的一般资料及围手术期并发症，使用汉化版的低位前切除综合征（LARS）评分表评估术后1、3、6个月时的肛门排便功能。

结果

43例均顺利完成手术，无中转开腹或死亡。两组患者在手术指标和术后病理指标比较，差异无统计学意义。SCA组发生吻合口瘘3例（13.0%），SEA组发生1例（5.0%），差异无统计学意义（χ2=2.223，P=0.329）；两组术后总并发症发生率比较，差异无统计学意义（17.4% vs 25.0%，χ2=0.064，P=0.081）。两组术后1、3个月时发生LARS的严重程度及评分差异均无统计学意义；术后6个月时，SEA组的LARS发生率低于SCA组（50.0% vs 82.6%，χ2=5.180，P=0.023），LARS评分更低[（21.15±6.75）分vs （26.48±7.76）分，t=-2.146，P=0.036]，LARS严重程度更轻（Z=2.569，P<0.01）。

结论

SEA是一种简单、安全且不增加并发症的吻合方式，在近期内可以改善直肠低位前切除术患者的排便功能。

关键词: 直肠肿瘤, 低位前切除综合征, 端侧吻合, 肛门功能
Objective

To investigate the safety of side-to-end anastomosis in laparoscopic anterior rectum resection and its effect on anal function.

Methods

A prospectively randomized controlled study was conducted. From July 2021 to July 2022, a total of 46 patients with middle and low rectal cancer who underwent laparoscopic anterior rectal resection in the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army were included and divided into two groups according to the 1∶1 random number table method, except for 3 cases with unreturned preventive ostomy. There were 23 cases in the straight coloretal anastomosis group (SCA group) and 20 cases in the side-to-end anastomosis group (SEA group). General data and perioperative complications were observed and compared between the two groups. The anal defecation function at 1, 3, and 6 months after surgery was evaluated using the Chinese-version scale of low anterior resection syndrome (LARS).

Results

43 cases completed the operation successfully, without any conversion to laparotomy or death. There were no statistically significant differences between the two groups in surgical indicators and postoperative pathological indicators. Anastomotic fistula occurred in 3 cases (13.0%) in SCA group and 1 case (5.0%) in SEA group, with no statistical difference (χ2=2.223, P=0.329). In terms of the incidence of postoperative complications between the two groups, there was no statistically significant difference (17.4% vs 25.0%, χ2=0.064, P=0.081). There were no significant differences in the severity and score of LARS between the two groups at 1 and 3 months after operation. At 6 months after operation, the incidence of LARS in SEA group was lower than that in SCA group (50.0% vs 82.6%, χ2=5.180, P=0.023), LARS score was lower [(21.15±6.75) vs (26.48±7.76), t=-2.146, P=0.036], the severity of LARS was lighter (Z=2.569, P<0.01).

Conclusion

SEA is a simple and safe anastomotic method without increasing perioperative complications, which can improve anal function of rectal cancer patients undergoing laparoscopic assisted anterior resection in a short term.

Key words: Rectal neoplasms, Low anterior resection syndrome, End-to-side anastomosis, Anal function
图1 裸化肠管远端约3 cm处将吻合器抵钉座置入
图2 吻合器中心杆自远端肠管后壁戳出同抵钉座对接，旋紧吻合器击发，完成吻合
表1 两组中低位直肠癌患者一般基线资料比较
项目 SCA组 SEA组 统计值 P值
例数 23 20    
性别[例(%)]     2.386 0.122
男 12(52.2) 15(75.0)    
女 11(47.8) 5(15.0)    
年龄(岁)a 59.78±11.18 62.45±6.21 0.947 0.068
体质指数(kg/m2)a 22.62±2.42 23.85±3.30 1.375 0.087
ASA分级[例(%)]     1.329 0.514
Ⅰ 5(21.8) 3(15.0)    
Ⅱ 15(65.2) 16(80.0)    
Ⅲ 3(13.0) 1(5.0)    
肿瘤距肛缘长度(cm)a 7.04±3.24 6.75±3.04 -0.305 0.762
肿瘤分期[例(%)]     4.148 0.186
Ⅰ 1(4.3) 5(25.0)    
Ⅱ 8(34.8) 8(40.0)    
Ⅲ 10(43.5) 5(25.0)    
Ⅳ 4(17.4) 2(10.0)    
腹部手术史[例(%)]     2.412 0.120
有 0(0) 2(10.0)    
无 23(100.0) 18(90.0)    
MRI分期[例(%)]     1.491 0684
T1 3(13.0) 4(20.0)    
T2 11(47.8) 8(40.0)    
T3 6(26.1) 7(35.0)    
T4 3(13.0) 1(5.0)    
核磁MRF侵犯[例(%)]     0.673 0.425
有 11(47.8) 12(60.0)    
无 12(52.2) 8(40.0)    
血红蛋白(g/L)a 138.09±22.13 134.30±20.32 0.581 0.564
白蛋白(g/L)a 40.01±3.55 40.03±7.61 0.010 0.992
癌胚抗原(μg/L)b 3.89(2.18,11.42) 2.27(1.54,11.00) -0.828 0.408
CA19-9(μg/L)b 5.9(3.4,17.6) 6.2(3.82,11.76) 0.268 0.788
甲胎蛋白(μg/L)b 1.80(1.53,2.40) 2.19(1.78,4.51) -1.826 0.068
高血压史[例(%)] 2(8.7) 2(10.0) 0.022 0.883
糖尿病史[例(%)] 5(21.7) 3(15.0) 0.321 0.571
冠心病史[例(%)] 3(13.0) 1(5.0) 0.820 0.365
新辅助化疗[例(%)] 3(13.0) 2(10.0) 0.096 0.756
表2 两组中低位直肠癌患者手术资料比较
组别 例数 手术时间(min)a 术中出血量(ml)a 合并脏器切除[例(%)] 吻合口距肛缘长度(cm)a 住院时间(d)a
SCA组 23 180.50±43.13 61.00±36.54 1(4.3) 5.09±1.98 11.17±4.20
SEA组 20 181.09±45.07 66.09±51.05 4(20.0) 4.55±1.31 12.80±4.16
统计值   t=-0.043 t=-0.370 χ2=1.439 t=-1.023 t=1.230
P值   0.652 0.364 0.230 0.467 0.684
表3 两组中低位直肠癌患者术后病理资料特征比较[例(%)]
组别 例数 大体类型 分化程度 组织学类型
隆起型 溃疡型 低 中 高 腺癌 黏液腺癌
SCA组 23 3(13.0) 20(87.0) 1(4.3) 21(91.3) 1(4.3) 22(95.7) 1(4.3)
SEA组 20 9(45.0) 11(55.0) 1(5.0) 19(95.0) 0(0) 19(95.0) 1(5.0)
χ2值   5.430 0.895 1.010
P值   0.020 0.639 0.919
图3 两组中低位直肠癌患者术后LARS量表评分比较
表4 两组中低位直肠癌患者LARS量表评分比较（分，±s）
组别 例数 术后1个月 术后3个月 术后6个月
SCA组 23 31.65±8.44 26.22±9.79 26.48±7.76
SEA组 20 30.04±8.50 26.70±7.89 21.15±6.75
t值   0.620 -0.120 -2.146
P值   0.539 0.905 0.036
表5 两组中低位直肠癌患者LARS严重程度比较[例(%)]
项目 1个月 3个月 6个月
SCA组(23例)      
重度LARS 16(69.7) 13(56.5) 10(43.5)
轻度LARS 3(13.0) 6(26.1) 9(39.1)
无LARS 4(17.3) 4(17.4) 4(17.4)
SEA组(20例)      
重度LARS 13(65.0) 10(50.0) 2(10.0)
轻度LARS 5(25.0) 7(35.0) 8(40.0)
无LARS 2(10.0) 3(15.0) 10(50.0)
Z值 0.073 0.231 2.569
P值 0.719 0.817 <0.01
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