腹腔镜经肛门括约肌间直肠癌切除术治疗低位直肠癌

Laparoscopic intersphincteric resection for low rectal cancer

目的探讨腹腔镜经肛门括约肌问直肠癌切除术治疗低位直肠癌的手术技巧与疗效。方法采用回顾性描述性研究方法。收集2014年5—10月大连医科大学附属第一医院收治的12例腹腔镜低位直肠前切除联合经肛门括约肌间切除术患者的临床资料。首先进行腹腔操作（TME＋括约肌问游离），然后行经肛行肛门内括约肌切除，再施行结肠肛管吻合完成手术。观察患者手术时间、术中出血量、淋巴结清扫数目、术后并发症、肛门排气时间、住院时间、术后住院时间、病理学分期和随访情况。采用门诊及电话方式进行随访，分别于术后1、3、6个月进行随访，随访内容包括肿瘤学预后及肛门功能恢复情况的追踪，采用Wexner评分系统和Kirwan分级评价术后肛门的排便功能。随访时间截至2015年4月18日。正态分布的计量资料以x±s表示。结果12例患者均完成腹腔镜手术，无中转开腹。8例患者行部分内括约肌切除术，4例行次全内括约肌切除术。4例T3期的患者行侧方淋巴结廓清，均保留左结肠动脉、下腹神经和盆腔神经。手术时间为（290±35）min，术中出血量为（124±80）mL。淋巴结清扫数目为（17±8）枚，其中淋巴结阳性数目为0～4枚。远端切缘距离为（2．0±0．5）cm，切缘均为阴性。12例患者术后无感染、出血、吻合口漏、吻合口狭窄等并发症发生。患者术后肛门排气时间为（3±1）d，住院时间为（20±3）d，术后住院时间为（12±3）d。患者术后分期：pT1期3例，pT2期5例，pT3期4例；pN0期10例，pNl期1例，pN2期1例；Ⅰ期8例，Ⅱ期2例，Ⅲ期2例。12例患者均获得随访，随访时间为6～11个月。患者术后1、3、6个月大便次数分别为（12±7）次、（9±5）次和（5±3）次；Wexner评分分别为（15±3）分、（13±4）分、（10±3）分。12例患者术后1个月Kirwan分级满意1例、不能控制排气3例、偶尔排稀便8例，术后3个月上述指标分别为3例、3例、6例；术后6个月上述指标分别为10例、2例、0例。结论腹腔镜肛门内括约肌切除术是治疗低位直肠癌的有效选择。

Objective To investigate the surgical techniques and clinical efficacy of laparoscopic intersphincteric resection（ISR） in the treatulent of low rectal cancer. Methods A retrospective descriptive study was performed. The clinical data of 12 patients who underwent laparoscopic low rectal anterior resection combined with ISR at the First Affiliated Hospital of Dalian Medical University from May ：2014 to October 2014 were collected. The patients underwent abdominal operation including total mesorectal excision （TME） ＋ sphincter mobilization, then transanal intersphincteric resection, finally colinic anal-anal anastomosis. The operation time, volume of intraoperative blood loss, number of lymph node dissected, postoperative complications, time to anal exsufflation, duration of hospital stay, duration of postoperative hospital stay, pathological stage and follow-up were observed. The patients were followed up by outpatient examination and telephone interview at month 1, 3 and 6 after operation up to April 18, 2015. The follow-up included the prognosis of patients and the recovery of anal function. The function of defecation was evaluated by Wexner scoring system and Kirwan grading. Measurement data with normal distribution were presented as x±s. Results All the 12 patients were completed laparoscopic surgery without conversion to open surgery. Eight patients underwent partial internal anal sphincter resection, and 4 underwent subtotal resection. Four patients in T3 stage underwent lateral lymph node dissection preserving the left colonic artery, hypogastric nerve and pelvic nerve. The operation time was （290±35 ） minutes. The volume of intraoperative blood loss was （ 124 ± 80） mL. The number of lymph nodes dissected was 17 ± 8, and the number of positive lymph nodes was 0-4. The distance of the distal margin was （ 2.0±0.5 ） cm, and the margin was negative. All the 12 patients were not complicated with infection, bleeding, anastomotic leakage, anastomotic stenosis and other complications. The time to postoperative anal exsufflation was （ 3±1 ） days, duration of hospital stay was （20 ± 3） days, and duration of postoperative hospital stay was （ 12 ± 3） days. The results of TNM stage showed 3 cases of pT1 stage, 5 cases of pT2 stage, 4 cases of pT3 stage, 10 cases of pN0 stage, 1 case of pN1 stage, 1 case of pN2 stage, 8 cases of Ⅰ stage, 2 cases of Ⅱ stage and 2 cases of Ⅲ stage. All the 12 patients were followed up for 6-11 months. The defection frequency and the Wexner score at month 1, 3 and 6 after operation were 12±7, 15±3, 9±5 and 13±4, 5±3, 10±3, respectively. Of the 12 patients, the number of patients with satisfactory Kirwan score, flatus incontinence and loose stool was 1,3, 8 at month 1 after operation, 3, 3, 6 at month 3 after operation, 10, 2, 0 at month 6 after operation, respectively. Conclusion Laparoscopic ISR is effective in the treatment of low rectal cancer.