腹腔镜和开腹直肠癌根治术的安全性及远期疗效比较

Comparison of safety and long-term outcomes of laparoscopic versus open radical resection for rectalcancer

目的探讨腹腔镜和开腹直肠癌根治术的安全性及远期疗效的差异。方法回顾性分析2000年1月至2008年12月福建医科大学附属协和医院收治的602例行直肠癌根治术患者的临床资料。根据手术方式将患者分为腹腔镜组（324例）和开腹组（278例）。比较两组患者淋巴结清扫数目、切除肿瘤标本的近端和远端切缘长度、局部复发率、远处转移率、生存率、无瘤生存率等。计数资料采用独立样本t检验，生存率采用寿命表法计算，采用Wileoxon（Gehan）检验进行比较，复发率和转移率的比较采用X2检验或Fisher确切概率法。结果腹腔镜组和开腹组平均淋巴结清扫数目分别为（21±8）枚和（21±9）枚，两组比较，差异无统计学意义（t=1．120，P〉0．05）；腹腔镜组和开腹组近端切缘长度分别为（15．1±1．3）em和（15．0±0．8）cm，两组比较，差异无统计学意义（t=1．452，P〉0．05）；远端切缘长度分别为（4．0±1．6）cm和（3．3±1．4）em，两组比较，差异有统计学意义（t=5．587，P〈0．05）。局部总体复发率为5．6％（34／602），无切口或戳孔种植。腹腔镜组与开腹组局部复发率分别为6．2％（20／324）和5．0％（14／278），两组比较，差异无统计学意义（X^2=0．363，P〉0．05）。总体远处转移率为11．5％（69／602），腹腔镜组和开腹组远处转移率分别为11．1％（36／324）和11．9％（33／278），两组比较，差异无统计学意义（X^2=0．085，P〉0．05）。腹腔镜组和开腹组3年生存率分别为87．8％和84．9％，5年生存率分别为83．0％和79．3％，两组比较，差异无统计学意义（P〉0．05）。两组3年无瘤生存率分别为79．4％和79．7％，5年无瘤生存率分别为69．2％和73．1％，两组比较，差异无统计学意义（P〉0．05）。本组随访率为81．2％（489／602），49例患者死亡，其中腹腔镜组20例，开腹组29例。结论腹腔镜直肠癌根治术不仅在肿瘤学安全性上是可靠的，而且可以达到和传统开腹手术同样的远期疗效。

Objective To compare the safety and the long-term outcomes of laparoscopic and open radicalresection for rectal cancer. Methods The clinical data of 602 patients who received radical resection at the Second Affiliated Hospital of Fujian Medical University from January 2000 to December 2008 were retrospectively analyzed. All patients were divided into the laparoscope group （324 patients） and the open group （278 patients）. The numbers of dissected lymph nodes, lengths of proximal and distal resection margins, local recurrence rate, distal metastasis rate, overall survival rates and disease-free survival rates of the 2 groups were compared. All data were analyzed by the independent t test, chi-square test or Fisher exact probability. The survival rates were calculated by the life table method and were analyzed by the Wilcoxon （Gehan） test. Results The number of lymph nodes dissected in the laparoscope group and the open group were 21 ± 8 and 21±9, with no significant difference between the 2 groups （t = 1. 120, P 〉 0.05 ）. The lengths of proximal resection margin were （15.1 ± 1.3） cm in the laparoscope group and （ 15.0 ± 0.8） cm in the open group, with no significant difference between the2groups （t = 1.452, P〉0.05）. The lengths of distal resection margin were （4.0 ± 1.6）cm in the laparoscope group and （3.3 ± 1.4） cm in the open group, with a significant difference between the 2 groups （t = 5. 587, P 〈 0.05 ）. The overall local recurrence rate was 5.6% （34/602）, and no tumor recurrence was detected in the incision and port-site. The local reccurence rates were 6.2% （20/324） in the laparoscope group and 5.0% （ 14/278 ） in the open group, with no significant difference between the 2 groups （ X^2 = 0. 363, P 〉 0.05 ）. The overall distal metastasis rate was 11.5% （69/602）, and the distal metastasis rates were 11.1% （36/324） in the laparoscope group and 11.9% （33/278） in the open group, with no significant difference between the 2 groups （X2 = 0.085, P 〉 0.05）. The 3- and 5-year survival rates were 87.8% and 83.0% in the laparoscope group, and 84.9% and 79.3% in the open group, with no significant difference between the 2 groups （P 〉 0.05 ）. The 3- and 5-year tumor-free survival rates were 79.4% and 69.2% in the laparoscope group, and 79.7% and 73. 1% in the open group, with no significant difference between the 2 groups （ P 〉 0.05 ）. The follow-up rate was 81.2% （489/602）. Forty-nine patients died, including 20 patients in the laparoscope group and 29 patients in the open group. Conclusion Laparoscopic radical resection for rectal cancer is reliable in the oncological efficacy, and is possible to achieve the similar long-term outcomes as that of open surgery.