直肠癌行肛提肌外腹会阴联合切除术研究进展

Progress of extralevator abdominoperineal excision for advanced low rectal cancer

肛提肌外腹会阴联合切除术(ELAPE)是治疗低位进展期直肠癌的重要术式。近年来,ELAPE手术方式和技术在逐渐发展,其突出的优点是手术简单、精准、根治性有所提高。腹腔镜和机器人手术系统行ELAPE亦取得肯定效果。多数研究认为,ELAPE降低了环周切缘阳性率、肿瘤穿孔发生率,并可能进一步降低局部复发率和提高存活率。由于切除了更多的肿瘤周围组织,ELAPE可能会增加术后会阴部伤口并发症、泌尿生殖功能障碍和骶尾部慢性疼痛的发生,但有关生活质量研究认为,ELAPE术后病人总体生活质量与传统经腹会阴联合切除术(APR)无显著差别。个体化ELAPE手术可能降低术后并发症发生率。应用生物补片重建盆底有助于缩短住院时间,减少住院花费。笔者认为,ELAPE从理念上强调了沿肛门外括约肌-提肛肌外侧筋膜平面切除的重要性,尽可能保留坐骨直肠窝脂肪,以解剖学基础指导手术,符合肿瘤根治的精准原则。

Extralevator abdominoperineal excision （ELAPE）, has been described as a method for improving the outcome of advanced low rectal cancer, probably because of more pelvic dissection and less positive circumferential resection margin （CRM）. However, ELAPE might result in a significantly increased rate of perineal wound complications, urinary and sexual dysfunction and chronic perineal pain. Several studies suggest that ELAPE is not associated with deterioration in quality of life when compared with conventional APR. Individual ELAPE has the potential to reduce the risk of chronic perineal pain and sexual dysfunction without influenced the radical effect. Biologic meshes using in perineal reconstruction significantly reduce the operative time, length of stay in hospital and the cost per patient. Laparoscopic or robotic assistance enables ELAPE with acceptable perioperative and pathological outcomes. Although several studies show no benefit for ELAPE regarding oncological outcomes, ELAPE is still a milestone operation based on accurate surgery principle.