直肠癌保留肛门括约肌手术适应证选择及预后分析

Prognosis Analysis and Indication of Sphincter Preservation Operation for Rectal Carcinoma

目的:直肠癌保留肛门括约肌手术选择标准。探讨影响直肠癌保肛手术适应证选择因素。方法:回顾性分析1994年4月至2004年12月721例直肠癌外科治疗经验,肿瘤部位:直乙交界69例,直肠上段141例,直肠中段199例,直肠下段312例。经腹会阴切除手术(abdominoperinealresection,APR)227例,保留肛门括约肌(sphincterpreservationoperation,SPO)手术481例,其中Dixon手术449例;拖出保肛手术12例;“J”Pouch20例,Hartman手术13。SPO组与APR组比较:性别、年龄、肝脏转移、肿瘤长径、浸润深度、Dukes分期等无明显统计学差异;与有无合并低位肠梗阻、癌肿部位、组织学分化程度、侵犯周径、淋巴结转移以及根治程度差异有统计学意义。结果:根治性切除660例,根治性切除率为91·54%,SPO481例,保留肛门率为66·71%,低位直肠癌中SPO为135例,低位直肠癌保肛率43·69%(135/309)。手术死亡率0·42%(3/721),并发症发生率4·2%(30/721)。手术后局部复发率为5·41%(39/721),SPO组中位生存时间为(65·00±6·87)个月;5年生存率为59·26%;APR组中位生存时间为(42·23±5·63)个月,5年生存率为42·3%。Longrank检验Chi-Sqare为18·14;P<0·001,Overallcomparisons检验Wilcoxon为22·42;P<0·001。结论:直肠癌在确保根治前提下首选SPO,低位直肠癌根据肿瘤部位、浸润深度、分化程度、淋巴结转移状况及手术者经验选择SPO适应证。低位直肠癌中选择部分病例进行SPO是可行的。

Objective: To investigate the indication of sphincter preservation operation for rectal carcinoma (RC) and the factors that present relationships with prognosis of RC. Methods: The surgical treatment data of 721 cases of RC from April of 1994 to December 0f 2004 was analyzed retrospectively. Abdominoperineal resection (APR) was carried on 227 patients, the rest received sphincter preservation operation (SPO). The SPO procedure included Dixon, modified Bacon or Park, 'J' Pouch and Hartman (449, 12, 20 and 13 cases, respectively). The factors that showed statistical significance between SPO and APR group as follows: low ileus, site, differentiation, circumference of invasion, lymph node metastasis and radical cure degree. Results: In 660 radical resections, SPO were carried on 481 cases including 135 cases (43.69%) for low rectal carcinoma. Operation death and complication rate was 0.42 and 0.4%, respectively. High differentiated carcinoma was observed in 180 tissue samples, moderate differentiated carcinoma in 439 cases and poor differentiated carcinoma in the rest. The middle survival time of SPO group was 65.00 6.87 months and its 5 year survival was 59.26%, while in APR group, 42.23 5.63 months and 42.3% was met, respectively(P<0.001). Conclusion: The SPO is an idea surgical measure for RC radical resection. It is reasonable for low RC to accept a SPO procedure.