超低位直肠癌保肛术的临床应用价值

Clinical efficacy of anus-preserving operation for ultra low rectal cancer

目的 探讨超低位直肠癌保肛术的临床应用价值.方法 回顾性分析2009年1月至2013年9月皖南医学院弋矶山医院收治的226例超低位直肠癌患者的临床资料.117例患者行超低位直肠癌保肛术设为保肛组,109例患者行腹会阴联合直肠癌根治术设对照组.保肛组行直肠低位前切除术或改良直肠低位前切除术;对照组行常规腹会阴联合直肠癌根治术.分析两组患者手术时间、术中出血量、术中清扫淋巴结数目、肠道功能恢复时间以及术后短期并发症、局部肿瘤复发、远处转移、生存率及生命质量.计数资料采用x2检验,正态分布的计量资料以哥（x）±s表示,采用t检验,采用Kaplan-Meier法计算生存率,Logrank检验进行生存分析.采用定期门诊和电话进行随访,随访时间截至2014年9月.结果 117例保肛组患者行传统的直肠低位前切除术108例,直肠翻转肛门内拖出切割缝合改良直肠低位前切除术9例;109例对照组患者均行腹会阴联合直肠癌根治术.保肛组患者的手术时间及术中出血量分别为（117±12）min、（110±51）mL,与对照组患者的（122±8）min和（155 ±44） mL比较,差异有统计学意义（t=3.80,7.09,P＜0.05）.保肛组和对照组患者术中清扫淋巴结数目和肠道功能恢复时间分别为（13±4）枚和（13±4）枚、（2.8±0.8）d和（2.7 ±0.7）d,两组比较,差异均无统计学意义（t=0.90,0.83,P＞0.05）.术后184例患者行化疗,其中19例因化疗反应严重终止治疗,17例化疗结束后继续放疗,9例化疗结束后继续行肝脏介入治疗;42例患者未行化疗.保肛组患者肛周湿疹的发生率为15.38％ （18/117）较对照组3.67％（4/109）明显增高（x2=8.81,P＜0.05）.保肛组和对照组发生吻合口漏、腹腔内出血、腹腔内感染、术后尿潴留、切口感染、切口裂开的患者例数分别为4例和0、3例和2例、5例和4例、10例和11例、7例和8例、9例和5例,两组比较,差异无统计学意义（x2=1.86,0.14,0.05,0.16,0.19,0.94,P＞0.05）.190例患者获得随访,中位随访时间为34.5个月（12.0～ 57.0个月）.保肛组与对照组患者术后肿瘤的局部复发率、远处转移率、1、3年生存率分别为8.55％（10/117）和8.26％（9/109）、5.98％（7/117）和5.50％（6/109）、94.8％和95.7％、76.2％和76.1％,两组比较,差异均无统计学意义（x2=0.01,0.02,0.08,0.00,P＞0.05）.保肛组患者生命质量评分为（66±14）分,高于对照组的（49±11）分,两组比较,差异有统计学意义（t=10.13,P＜0.05）.结论 严格把握手适应证,超低位直肠癌保肛术安全可行,能够改善患者术后的生命质量.

Objective To investigate the clinical value of anus-preserving operation for ultra low rectal cancer.Methods The clinical data of 226 patients with ultra low rectal cancer who were admitted to the Yijishan Hospital between January 2009 and September 2013 were retrospectively analyzed.All the patients were divided into the anus-preserving group （117 patients underwent traditional or modified Dixon operation） and the control group （109 patients underwent Miles operation）.The operation time,volume of intraoperative blood loss,number of lymph node dissection,recovery time of intestinal function,postoperative short-term amplications,local recurrence and distal metastasis of tumors,survival rate and quality of life in the 2 groups were analyzed.The measurement data with normal distribution were presented as （x） ± s and analyzed using t test,count data were analyzed using Pearson chi-square test.The survival curve was drawn by Kaplan-Meier method,and the survival rate was analyzed using the Log-rank test.The patients were followed up by regular out-patient examination and telephone interview up to September 2014.Results The traditional Dixon operation was performed on 108 patients,modified Dixon operation on 9 patients and Miles operation on 109 patients in the control group.The operation time and volume of blood loss were （117 ± 12） minutes and （110 ± 51） mL in the anus-preserving group,which were significantly different from （122 ± 8） minutes and （155 ± 44） mL in the control group （t =3.80,7.09,P 〈 0.05）.The number of lymph node dissected and time of intestinal function recovery were 13 ±4 and （2.8 ± 0.8）days in the anus-preserving group and 13 ±4 and （2.7 ± 0.7）days in the control group,respectively,with no significant difference （t =0.90,0.83,P 〉 0.05）.Among the 184 patients receiving postoperative chemotherapy,19 patients terminated the chemotherapy due to serious response to chemotherapy,17 patients received radiotherapy after chemotherapy,9 patients received interventional treatment for liver after chemotherapy and 42 patients didn＆#39;t receive the chemotherapy.The incidence of perianal eczema were 15.38% （18/117） in the anus-preserving group and 3.67% （4/109） in the control group,with a significant difference between the 2 groups （x2=8.81,P 〈0.05）.The cases of anastomotic leakage,intra-abdominal bleeding,intra-abdominal infection,postoperative urinary retention,infection of incision and incision dehiscence were 4,3,5,10,7 and 9 in the anus-preserving group,which were not significantly different from 0,2,4,11,8 and 5 in the control group （x2=1.86,0.14,0.05,0.16,0.19,0.94,P 〉 0.05）.One-hundred and ninety patients were followed up for a median time of 34.5 months （range,12.0-57.0 months）.The rate of local tumor recurrence,rate of distant metastasis and 1-and 3-year survival rate were 8.55% （10/117）,5.98% （7/117）,94.8% and 76.2% in the anus-preserving group and 8.26% （9/109）,5.50% （6/109）,95.7% and 76.1% in the control group,with no significant difference between the 2 groups （x2 =0.01,0.02,0.08,0.00,P 〉 0.05）.The score of life quality was 66 ± 14 in the anus-preserving group,which was significantly higher than 49 ± 11 in the control group （t =10.13,P 〈 0.05）.Conclusion The anus-preserving operation for ultra low rectal cancer is safe and feasible based on strictly grasping operative indications,meanwhile,it can improve the postoperative life quality of patients.