腹腔镜技术在不同分期直肠癌根治术中应用的安全性分析

Oncologic safety of laparoscopic surgery in radical resection for different stage rectal cancer

目的：探讨腹腔镜技术应用于早期和进展期直肠癌的安全性。方法回顾性分析从2009年6月至2013年12月间在广东省清远市人民医院接受腹腔镜直肠癌根治术的186例患者的临床资料，其中早期直肠癌（0～Ⅰ期）48例，进展期直肠癌（Ⅱ～Ⅲ期）138例。选取同期行开腹手术的37例早期直肠癌和275例进展期直肠癌作为对照组。比较腹腔镜组与开腹组患者的手术安全性、肿瘤学安全性及近期预后。结果无论是早期还是进展期直肠癌，腹腔镜组肿瘤学安全性（远切缘距离和淋巴结清扫数目）、手术安全性（术后并发症发生率）以及预后（局部复发率、远处转移率和3年生存率）均与开腹组相当（均P＞0．05），但对于进展期直肠癌，尽管差异未达到统计学意义，腹腔镜组患者平均淋巴结清扫数目有减少的趋势（13．5枚／例比15．0枚／例，P＝0．112），术后吻合口瘘发生率也有所增高[8．0％（11／138）比5．5％（15／275），P＝0．221）。进展期直肠癌腹腔镜手术的中转开腹率明显高于早期直肠癌[10．9％（15／138）比2．1％（1／48），P＝0．048]。结论对于早期直肠癌，腹腔镜手术无论是在肿瘤学安全性还是手术安全性方面，都可以达到与开腹手术相当的水平；而对于进展期直肠癌，由于其较高的中转开腹率，以及在淋巴结清扫和术后吻合口瘘方面的潜在风险，实施腹腔镜手术、尤其是在腹腔镜经验欠丰富的基层医院，需更为谨慎。

Objective To evaluate the oncologic safety and short-term outcomes of laparoscopic surgery in early and advanced rectal cancers. Methods Clinical and follow-up data of 186 cases with rectal cancer undergoing laparoscopic radical resection from June 2009 to December 2013 were analyzed retrospectively, including 48 early rectal cancer （stage 0-Ⅰ） and 138 advanced cancer （stage Ⅱ-Ⅲ）. Thirty-seven cases with early rectal cancer and 275 with advanced cancer undergoing open radical surgery were selected as control group. Surgical safety, oncologic safety and short-term outcomes were compared between two groups. Results As for either early or advanced rectal cancer, there were no significant differences in the number of harvested lymph nodes, length of distal resection margin, complication morbidity, rate of local recurrence, distant metastasis, and 3-year survival rate between the two groups （all P〉0.05）. Although the operation time was longer in laparoscopic group, the laparoscopic group presented less intra-operative blood loss, faster recovery of bowel function, and shorter postoperative hospital stay （all P〈0.05）. As for advanced rectal cancer, laparoscopic radical surgery tended to achieve less lymph nodes dissected （mean, 13.5 vs. 15.0） and develop more anastomotic leakage （8.0% vs. 5.5%） compared to open surgery, although neither reached statistical significance （P=0.112, P=0.221）. Moreover, the conversion rate in patients with advanced rectal cancer was significantly higher than that in those with early cancer （10.9% vs 2.1%, P=0.048）. Conclusions Laparoscopic surgery can obtain the＆nbsp;same oncologic and surgical safety for early rectal cancer as compared to open surgery. However , due to higher conversion rate, potential risk of decreased number of harvested lymph nodes and increased anastomotic leakage, laparoscopic surgery for advanced rectal cancer should be carried out prudently, especially in some hospitals with less laparoscopic experience.