腹腔镜手术治疗合并常见慢性病老年直肠癌患者的疗效评估

Efficacy of laparoscopic radical resection for rectal cancer in elderly patients with common chronic comor- bidities

目的 探讨腹腔镜手术治疗合并常见慢性病的老年直肠癌患者的可行性、安全性及疗效.方法 回顾性总结2003年1月至2008年12月南方医科大学南方医院收治的192例合并常见慢性病的老年直肠癌患者的临床资料.192例患者分为腹腔镜组（91例）和开腹组（101例）,比较两组患者的手术学指标、肿瘤学指标、预后指标.计量、计数资料分别采用t检验和x^2检验,患者生存情况采用寿命表法和Kaplan-Meier法.结果 腹腔镜组和开腹组患者保肛率、手术时间、术后住院时间、术后主要并发症发生率分别为85.7%（78/91）、（194±61）min、（14±8）d、24.2%（22/91）和85.1%（86/101）、（187±58）min、（14±8）d、28.7%（29/101）,其差异无统计学意义（x^2=0.012,t=0.874,-0.265,x^2=0.505,P＞0.05）;术中出血量、术后肛门排气时间、进流质饮食时间和下床活动时间分别为（108±78）ml、（3±1）d、（4±2）d、（3±1）d和（270±600）ml、（4±1）d、（5±2）d、（5±1）d,其差异有统计学意义（t=-2.650,-4.545,-4.587,-13.310,P＜0.05）.腹腔镜组和开腹组患者标本切除长度、淋巴结清扫数目分别为（18±5）cm、（9±7）枚和（18±5）cm、（9±8）枚,其差异无统计学意义（t=1.457,0.021,P＞0.05）;而腹腔镜组肠管远切缘长度（3.8±1.5）cm显著长于开腹组的（3.1±1.5）cm（t=0.283,P＜0.05）.腹腔镜组和开腹组患者3年累积生存率、总复发率、局部复发率、远处转移率分别为76%、12.1%（11/91）、2.2%（2/91）、9.9%（9/91）和82%、14.9%（15/101）、6.9%（7/101）、7.9%（8/101）,其差异无统计学意义（U=2.600,x^2=0.312,2.400,0.230,P＞0.05）;生存分析显示,两组TNM Ⅰ、Ⅱ、Ⅲ期和Ⅰ～Ⅲ期患者累积生存率比较,差异无统计学意义（P＞0.05）.结论 腹腔镜手术治疗合并常见慢性病的老年直肠癌患者是安全可行的,在术后恢复方面显示出明显的微创价值.

Objective To evaluate the feasibility, safety and clinical outcome of laparoscopic radical resection of rectal cancer in elderly patients with common chronic comorbidities. Methods The clinical data of 192 elderly patients with rectal cancer and common chronic comorbidities who were admitted to the Nanfang Hospital from January 2003 to December 2008 were retrospectively analyzed. All patients were divided into laparoscope group （n=91） and open group （n = 101）. The operative procedures, clinicopathological data and outcomes of the two groups were collected and compared. All data were analyzed using the t test and chi-square test, and the survival of patients was analyzed using the life table and Kaplan-Meier curves. Results The sphincter preservation rate,operation time, postoperative length of hospital stay, morbidity rate were 85.7% （78/91）, （194 ± 61） minutes,（14 ±8）days, 24.2% （22/91） in the laparoscope group, and they were 85.1% （86/101）, （187 ±58） minutes,（14 ±8）days and 28.7% （29/101） in the open group, with no significant difference between the two groups （x2=0.012, t=0.874,-0.265, x2 =0. 505 , P 〉 0. 05） . The intraoperative blood loss was （108 ±78）ml in the laparoscope group, which was significantly less than （270 ± 600） ml in the open group （t =-2. 650, P 〈0.05）. The time to first flatus, time to liquid diet, time to out-of-bed activity were （3 ± 1） days, （4 ± 2） days and （3 ± 1）days, which were significantly shorter than （4 ± 1）days, （5 ± 2）days and （5 ± 1）days in the open group,respectively （t =-4. 545,-4. 587,-13. 310, P 〈 0.05）. The length of rectum resected and the number of lymph node dissected were （18 ± 5）cm and 9 ± 7 in the laparoscope group, and （18 ± 5）cm and 9 ± 8 in the open group, respectively, with no significant difference between the two groups （t = 1. 457, 0. 021, P 〉 0.05）, while the distance of distal resection margin to the tumors was （3.8 ± 1.5） cm, which was significantly longer than （3.1 ± 1.5） cm of the open group （t = 0. 283, P 〈 0. 05）. The 3-year cumulative survival rate, overall recurrence rate, local recurrence rate and distal metastasis rate in the laparoscope group were 76%, 12. 1% （11/91）, 2.2% （2/91） and 9.9% （9/91）, and they were 82%, 14.9% （15/101）, 6.9% （7/101）, 7.9% （8/101） in the open group, respectively, with no significant difference between the two groups （U=2. 600, x2 =0. 312, 2.400,0. 230, P 〉 0.05）. There were no significant difference in the cumulative survival rate between patients in TNM stage Ⅰ, Ⅱ and Ⅲ in the two groups （P 〉 0.05）. Conclusion Laparoscopic radical resection of rectal cancer is safe and feasible for elderly patients with common chronic comorbidities, and it has the advantages in quick recovery of patients after operaion.