腹腔镜结直肠手术前钛夹标记定位的指征探讨

The indication for preoperative localization of colorectal tumor with endoscopic clip placement for laparoscopic resection

目的:探讨腹腔镜结直肠手术前钛夹标记辅助病灶定位的应用指征。方法:2013年7月1日至2014年6月30日共行367例腹腔镜结直肠切除术,其中86例(23.4%)因病灶定位不确切行术中肠镜定位,分析并归纳其原因。结果:造成病灶定位不确切的因素包括肛检阴性、术前肠镜定位肿瘤位于非回盲部或升结肠、术前影像学检查未发现原发病灶或原发病灶T分期≤2期、肠镜下评估病灶直径≤3 cm、大体类型为隆起型(各因素均为强烈相关,P=0.000)。上述因素即为术前钛夹标记定位的初步指征,将其表述为流程图。应用此流程图预测367例研究对象是否需行术前钛夹标记定位,取得良好的效果,其灵敏度为94.2%,特异度为90.0%,阳性似然比9.42,Youden指数0.842,准确率91.0%,阳性预测值74.3%,阴性预测值98.1%。结论:应用此指征判断病灶是否需行术前钛夹标记定位方法简便且有效,可避免对无需定位的病灶进行额外操作,降低了术中肠镜定位的使用频率。但术前钛夹标记辅助定位的实际使用效果仍需大样本前瞻性研究确定。

Objective： To investigate the indication for preoperative localization of colorectal tumor with endoscopic clip placement for laparoscopic resection. Methods： Retrospective analysis was performed on the clinical data of 367 patients who underwent laparoscopic colorectal resection from Jul. 2013 to Jun. 2014. Intra-operative colonoscopy was performed in 86 patients（ 23. 4%） to localize the colorectal tumor due to the failure of laparoscopic exploration and the inaccuracy of preoperative localization by colonoscopy and CTScan / MRI,the reasons were analyzed and generalized. Results： The risk factors for inaccuracy of localization of colorectal tumor were as follows： rectal examination was negative; tumor wasn＇t localized in ileocecus or ascending colon; CT-Scan / MRI didn＇t demonstrate primary tumor; T stage of primary tumor by CT-Scan / MRI was less than T2,diameter of tumor was less than 3 cm under colonoscopy;Tumor was protruded type. All factors were strongly correlated（ P = 0. 000）. The indication for preoperative localization of colorectal tumor with endoscopic clip placement was expressed as a flow chart with all these factors. The prediction for inaccuracy of localization of colorectal tumor with this flow chart showed a satisfactory success： sensitivity = 94. 2%,specificity = 90. 0%,positive likelihood ratio =9. 42,Youden index = 0. 842,accuracy rate = 91. 0%,positive predictive value = 74. 3%,negative predictive value = 98. 1%. Conclusions： This indication makes the preoperative localization of colorectal tumor with endoscopic clip placement more targeted and effective,can avoid additional operation for lesion which does not need localization,and decrease the frequency of intraoperative colonoscopic localization. The actual effect of preoperative titanium clip labeling for assistant localization still need large-sample prospective study.