直肠癌保肛手术的安全下切缘

Safe Distal Margin of Curative Sphincter-Saving Procedure for Rectal Carcinoma

目的：探讨直肠癌保肛手术的安全下切缘。方法：对１９８３年１月～１９９２年１２月１０年间完成的４０２例直肠癌保肛手术，按性别、年龄、Ｄｕｋｅ’ｓ分期、细胞分化程度、病理类型、肿瘤占据肠周的周径、术式和手术下切缘等变量进行分组。回顾性分析了对局部复发，远处转移和１、３、５年生存率的影响。结果：局部复发率２３．９％。其影响因素有：Ｄｕｋｅ’ｓ Ｂ，Ｃ期（Ｐ＜０．０１），肿瘤占据肠周径＞１／２（Ｐ＜０．０１），细胞中分化（Ｐ＜０．０１）和低分化（Ｐ＜０．０５），溃疡型（Ｐ＜０．０５）和浸润型（Ｐ＜０．０１）肿瘤及下切缘距离（２～３ｃｍ）（Ｐ＜０．０１）。远处转移率为４４．８％，影响因素有：Ｄｕｋｅ’ｓ Ｂ期（Ｐ＜０．０１）和Ｃ期（Ｐ＜０．０５），细胞中低分化（Ｐ＜０．０５），肿瘤占据肠周径＞１／２（Ｐ＜０．０５）及溃疡型肿瘤（Ｐ＜０．０１）。１、３、５年生存率为８４．３％、７８．４％和 ５９．７％。下切缘距离仅对 １年生存率有影响（Ｐ＜０．０５），对 ３、５年生存率无影响（Ｐ＞０．０５）。肿瘤分期、细胞分化、大体类型、肿瘤大小对生存率均有影响。结论：对于直肠癌保肛手术，传统的２～３ｃｍ的下切缘是不安全的。

Aim The purpose of this study is to probe into the safe distal margin of curative sphincter-saving procedure for rectal carcinoma. Methods: From 1983 to 1992, four hundred and two patients with rectal cancer treated by curative sphincter-saving procedure were divided into groups by gender, age, Duke's stage, histological differentiation, pathological type, circumference of the involved bowel segment, operation mode and the distal resected 'safe margin'. The relationship between the local recurrence, distal metastasis, survival rates of the tumor and this operation was analysed retrospectively. Results: The local recurrence rate was 23.9%, the influencing factors included Duke's stage B and C (p<0.01), the invasion of the rectal circumference more than l/2 (p<0.01), differentiation of the tumor cells: moderately (p<0.01) and poorly (P<0.05) differentiated, pathological type: ulcerative (P<0.05) and invasive (p<0.01) type and the distal resected 'safe margin' was 2-3cm (P<0.01). The metastatic rate was 44.8% and the influencing factors included: Duke's stage B (p<0.01) and C (P<0.05), moderately and poorly differentiated (P<0.05), invasion of the bowel circumference more than 1/2 (P<0.05), ulcerative type (P< 0.01) and the 1-, 3-, 5-yeasr survival rates were 84.3%, 78.4% and 59.7% respectively. The distal resected 'safe margin' only affected the 1-year survival rate (P<0.05) but not the 3-, 5- year survival rate (P>0.05) Other factors were the Duke's stage, histological differentiation, pathologic type and tumor invasion of the bowel circumference. Conclusion: The traditional concept of 2-3cm distal 'safe margin' is not safe for curative sphincter-saving procedure for rectal cancer.