多学科协作诊治模式下新辅助化疗对直肠癌术后近期并发症影响的临床对照研究

Influence of Neoadjuvant Chemotherapy to Rectal Cancer Early Postoperative Complications in Multi-Disciplinary Team:A Case-Control Study

目的探讨在多学科协作（multi—disciplinaryteam，MDT）诊治模式下，应用新辅助化疗联合手术治疗的直肠癌患者术后近期并发症发生的情况。方法研究四川大学华西医院2007年4月至2007年10月期间最终诊断明确、未进行过MDT模式下的新辅助治疗且首次发现并行外科治疗的直肠癌患者。研究观察此组患者术后1个月以内并发症发生的情况，并和非MDT诊治组进行比较。结果根据条件纳入研究的直肠癌病例数为189例。其中，肿瘤位置〈3cm者38例，3～7cm者86例，≥7cm者65例；肿瘤病理学TNM分期Ⅰ期5例，Ⅱ期122例，Ⅲ期50例，Ⅳ期12例。开腹手术181例，腹腔镜手术8例；造口手术者33例，非造口手术者156例。术后并发症总发生率为27．0％（51／189），其中，切口出血1例，腹腔内（深部）出血4例，吻合口出血5例；肺部感染1例，伤口感染7例，尿路感染3例，腹腔内（深部）感染1例，不明原因发热19例；伤口浅层裂开1例，伤口液化15例；吻合口漏3例，直肠阴道瘘2例；肠梗阻7例，尿潴留7例，应激性溃疡2例。随访时间为术后2～10个月，平均5．8个月，无死亡病例。MDT组和非MDT组之间基线一致。MDT组术后无输血史的构成比明显高于非MDT组（P〈0．05）。此外，MDT组手术时间明显比非MDT组更短（P〈0．05）。而开腹手术和腹腔镜手术的构成比、造口手术和非造口手术的构成比以及直肠癌根治性切除手术类型的构成比2组间比较差异无统计学意义（P〉0．05）。患者术后排气时间、术后排便时间、术后进食时间2组间比较差异亦无统计学意义（P〉0．05）。而MDT组患者术后下床活动时间和术后住院时间明显短于非MDT组（P〈0．05）。MDT组术后总并发症发生率明显小于非MDT组（P〈0．05）。其中，伤口感染、伤口液化以及尿潴留的发生率明显小于非MDT组（P〈0．05）。采用多因素Logistic回归分析，发现MDT组内影响术后并发症发生率的危险因素有术后进食时间和术后住院时间；而在非MDT组内，影响术后并发症发生率的危险因素仅为术后住院时间。结论进行MDT诊治的直肠癌患者，具体手术方式和是否联合应用新辅助化疗，并不会导致术后并发症发生率的增加，也没有增加术后并发症发生的风险；可以认为这样的一套综合治疗方案在术后近期内具有一定的可行性和安全性，但对于中长期临床效果的评估，还有赖于研究的进一步观察。

Objective To discuss incidence of the complications in the rectal cancer patients＇ early postoperative being treated with neoadjuvant chemotherapy combined with surgical intervention. Methods The rectal cancer patients under surgical therapy being diagnosed definitely, with neoadjuvant chemotherapy under multi-disciplinary team （MDT） or without and firstly being discovered from April to October of 2007 were studied. The complication conditions of these patients 1 month after operation were studied and observed, and the differences between MDT group and non-MDT group were compared. Results According to the condition, 189 rectal cancer patients were internalized. Among all the patients, the distance of tumor to the dentate line were 〈3 cm 38 cases, 3-7 cm 86 cases, ≥7 cm 65 cases; pathological stage were Ⅰ stage 5 cases, Ⅱ stage 122 cases, Ⅲ stage 50 cases, IV stage 12 cases. There were 181 cases laparotomy, 8 cases laparoscopic operation; 33 cases stoma operation, 156 cases non-stoma operation. The total incidence of postoperative complication was 27.0% （51/189）. Of all, incision bleeding was 1 case, abdominal （deep） bleeding were 4 cases, anastomosis bleeding were 5 cases, pulmonary infection was 1 case, wound infection were 7 cases, urinary tract infection were 3 cases, abdominal （deep） infection was 1 case, unknown fever were 19 cases, superficial layer wound dehiscence was 1 case, wound co-liquation were 15 cases, anastomosis leakage were 3 cases, rectovaginal fistula were 2 cases; intestinal obstruction were 7 cases, urinary retention were 7 cases, stress ulcer were 2 cases. Follow-up in 2--10 months after operation, there was no death case. The baseline between MDT group and non-MDT group was equal. The ratio of postoperative blood transfusion of MDT group was obviously less than that of non-MDT group （P〈0.05）. Moreover, the operation time of MDT group was obviously shorter than that of non-MDT group, and the difference was statistically significant （P〈0.05）. But the ratio of laparotomy and laparoscopic operation, of stoma operation and non-stoma operation, as well as the types of radical excision operation of rectal cancer didn＇t show any statistical difference between two groups （P〉0.05）. The postoperative venting time, defecation time, intake time didn＇t show any statistical difference between two groups too. But the postoperative out-of-bed activity time and the postoperative in-hospital days of MDT group was obviously shorter than that of non-MDT group, and the difference was statistically significant （P〈0. 05）. In MDT group the postoperative total complication rate was less than non-MDT group, and the difference was statistically significant （P〈0.05）. Among all the complications, the MDT group had a lower rate of wound infection, wound co-liquation and urinary retention （P〈0.05）. Using multifactorial logistic regression analysis, the risk factor which influenced the postoperative complication rate in MDT group were： postoperative intake time and postoperative hospitalization time. But the risk factor in non-MDT group was only according to postoperative hospitalization time. Conclusion The patients who were treated by MDT, definite operative method combining neoadjuvant chemothera- py or not didn＇t increase the postoperative complication rate and risk. So it could be believed that such a composite treatment was feasible and safe in early postoperative stage. But it needs further studies to evaluate the medium- and long-term clinical effect.