全直肠系膜切除术安全远切端距离的临床研究

Clinical study of the safe distal margin length in total mesorectal excision for rectal cancer

目的探讨全直肠系膜切除术(TME)原则下直肠癌低位前切除术的安全远切端距离。方法回顾性分析5年间412例TME原则下直肠癌低位前切除术患者的临床资料,比较不同远切端距离(DML)分组间并发症发生率、远处转移率、复发率和生存率的差异。结果DML<2 cm组,2～3 cm(含2 cm和3 cm)组,>3 cm组患者术后并发症发生率和远处转移率差异均无统计学意义(P=0.494和P=0.906)。DML<2 cm组局部复发率(19.30%)显著高于DML2～3 cm组(8.37%,P=0.015)和DML>3 cm组(7.69%,P=0.029),后两组局部复发率差异无统计学意义(P=0.833)。DML<2 cm组,2～3 cm组,>3 cm组3年生存率依次为69.4%,86.5%,89.9%;5年生存率依次为63.0%,70.7%,71.1%。DML<2 cm组总生存率显著低于2～3 cm组和>3 cm组,差异有统计学意义(P=0.030和P=0.040)。DML2～3 cm组和>3 cm组总生存率之间差异无统计学意义(P=0.707)。结论遵循TME原则下的直肠癌低位前切除术,<2 cm的远切端距离是不足够的;对于分化较好的直肠腺癌,≥2 cm是可接受的远切端安全距离。

Objective To study the safe distal resection margin in low anterior resection with total mesorectal excision for rectal cancer. Methods Between January 2003 and December 2007 , 412 patients with rectal cancer ≤ 10 cm from the anal verge underwent low anterior resection with total mesoreetal excision, and the rates of pstoperative complications, distal metastasis, tumor recurrence and survival in different distal resection margin lengths were compared. Results The rates of post-operative complications and distant metastasis were similar and no significantly differentin in patients with distal margins 〈 2 cm, 2 -3 cm or 〉 3 cm. Distal margins 〈 2 cm had significantly higher local recurrence rate （ 19. 30 % ） when compared with 2 - 3 cm （8.37% , P=0.015） or 〉3 cm （7.69% , P=0.029）. Kaplan-Meier estimates of survival rates at 3 years for the 〈2 cm, 2 -3 cm and 〉3 em groups were 69.4% , 86.5% and 89.9% , respectively, and those at 5years were 63. 0% , 70. 7% and 71. 1% , respectively. Survival was significantly worse when distal margins were 〈 2 cm compared with 2 - 3 cm （ P = 0. 030 ） and 〉 3 em （ P = 0. 040 ） .Survival for the 2 - 3 cm versus 〉 3 cm groups was not significantly different （ P = 0. 707 ）. Conclusions Our data suggest that for patients undergoing low anterior resection with total mesorectal excision for rectal cancer, distal margins less than 2 cm are associated with compromising oncological outcome, and at least 2 cm distal margin seems to be acceptable.