新辅助化放疗对局部进展期直肠癌低位前切除后吻合口愈合的影响

Effect of neoadjuvant chemoradiotherapy on the healing of anastomosis following low anterior resection in locally advanced rectal cancer

目的探讨新辅助化放疗对局部进展期直肠癌低位前切除术后吻合口愈合的影响。方法收集2001年5月至2007年8月的低位直肠癌（距肛缘≤6cm）患者192例。全部病例均经术前化放疗。放疗40～46Gy／20～23次，每周5次，每次2Gy。放疗结束后休息六周。放疗同时进行化疗，口服卡培他滨1250mg／（m2·d），每日2次口服，直至手术。手术遵循TME原则进行。分析低位直肠癌术后吻合口漏发生情况。结果全部病例完成术前化放疗。17例术前复查肿瘤完全消失（8．9％），未再进行手术治疗。手术前复查无一例发现肿瘤有进一步发展或转移。24例术后病理提示肿瘤完全消失，故肿瘤完全消失者共41例（21．4％）。175例患者均按TME原则进行直肠癌根治术。保肛手术166例，保肛率为95．3％。其中低位直肠癌前切除术（LAR，双吻合器）134例，Parks术32例。腹会阴切除术6例。Hartmann术3例。在所有保肛患者中，发生吻合口漏9例，发生率为5．1％。IJAR（双吻合器）术后发生吻合口漏6例，发生率为4．4％，其中直肠阴道漏4例。Parks术后吻合口漏3例，发生率为9．4％，其中直肠阴道漏1例。两组保肛手术吻合口漏发生率无显著差异（P〉0．05）。吻合口漏发生时间为术后2—10d，均经相应处理后获得良好结果。结论合理运用新辅助化放疗不会明显增加低位直肠癌术后吻合口漏的发生。

Objective To investigate the effect of the neoadjuvant chemoradiotherapy （NCR） on the healing of anastomosis following low anterior resection in patients with locally advanced rectal cancer. Methods Between May 2001 and August 2007, 192 patients with T3 and T4 low rectal cancer （distance from the tumor to anal verge ≤ 6 cm ） enrolled in the study. All patients were subjected to preoperative radiotherapy to pelvis, with a total dose of 40-46 Gy in 20 days fractions of 2 Gy each in 4 weeks and simultaneously combined with oral eapeeitabine （CAP） of 1250 mg/m2 bid continuously for 10 weeks up to surgery. The patients were operated on 6 weeks after the end of radiotherapy according to the rule of TME technique. Results All patients fulfilled the study. Of the patients, 17 cases were diagnosed tumor free after the neoadjuvant therapy and were not operated on. Other 24 cases were found got complete tumor response with pathological examination after the operation. A total of 41 cases （21.4%） got complete tumor response with the neoadjuvant therapy. Surgery was performed in 175 patients, and 166 patients （95.3%） with sphincter-saving resection, 134 patients with low anterior resection （LAR, double stapling technique） and 32 patients with Park＇s endoanal anastomosis. Six patients were operated with abdominoperineal resection （APR） and 3 patients with Hartmann＇s procedure. Anastomotic leakage was found in 9 patients（5.1% ）, 6 patients （4 cases of rectovaginal leakage） with LAR（ double stapling technique）and 3 patients （1 case of rectovaginal leakage） with Parks technique（P 〉 0. 05）. Anastomotic leakage occurred in 2-10 days post operation, and were managed properly and got desirable results. Conclusion Neoadjuvant chemoradiotherapy would not affect the healing of anastomosis obviously if being applied reasonably in locally advanced low rectal cancer.