腹腔镜辅助电凝钩法直肠癌根治术的疗效分析

Clinical effects of laparoscopic electrocoagulating hook＇ method in treatment of rectal cancer

目的探讨腹腔镜辅助电凝钩法直肠癌根治术的临床疗效。方法采用回顾性队列研究方法。收集2004年6月至2009年6月广西壮族自治区第二人民医院收治的237例直肠癌患者的临床资料。237例患者均行直肠癌根治术，其中120例患者行腹腔镜辅助电凝钩直肠癌根治术设为电凝钩组；117例患者行腹腔镜超声刀直肠癌根治术设为超声刀组。观察指标：（1）治疗情况：手术时间、术中出血量、淋巴结清扫数目、术后肛门排气时间、术后下床活动时间、术后住院时间、治疗费用以及术后并发症情况如术后吻合口瘘、肠梗阻、术后排尿困难、性功能障碍情况。（2）随访情况。采用门诊或电话方式随访，随访内容为肿瘤复发、转移情况，如怀疑肿瘤局部或远处复发者行肠镜、胸部X线片、腹部CT等检查证实。随访时间截至2014年12月18日。正态分布的计量资料以面±s表示，组间比较采用t检验；计数资料比较采用，或Fisher确切概率法检验；Kaplan—Meier绘制生存曲线，Log—Rank检验进行生存分析。结果（1）治疗情况：两组患者均顺利完成腹腔镜手术，无中转开腹患者。电凝钩组和超声刀组患者手术时间分别为（156±33）rain和（175±21）min，两组比较，差异无统计学意义（t=25．324，P〉0．05）；术中出血量分别为（116±12）mL和（149±25）mL，两组比较，差异有统计学意义（t=212．740，P〈0．05）；淋巴结清扫数目分别为（18±2）枚和（16±4）枚，两组比较，差异无统计学意义（t=20．117，P〉0．05）。电凝钩组和超声刀组患者术后肛门排气时间、术后下床活动时间、术后住院时间分别为（1．5±0．6）d和（1．6±0．5）d、（1．5±0．5）d和（1．4±0．5）d、（7．5±2．5）d和（8．0±1．8）d，两组上述指标比较，差异均无统计学意义（t=21．477，1．617，1．770，P〉0．05）。治疗费用分别为（2．4±0．3）万元和（2．8±0．2）万元，两组比较，差异有统计学意义（t=211．071，P〈0．05）。电凝钩组和超声刀组患者术后发生吻合口瘘分别为6例和7例，肠梗阻均为3例，两组上述指标比较，差异均无统计学意义（x^2=0．110，P〉0．05）；排尿困难或性功能障碍分别为0和5例，两组比较，差异有统计学意义（P〈0．05）。两组患者术后均行FOLFOX方案化疗6个疗程。（2）随访情况：226例患者获得随访，中位随访时间为52个月（11—121个月）。11例患者失访，其中电凝钩组5例，超声刀组6例，失访患者均以截尾数据纳入分析。随访期间67例患者死亡，其中肿瘤复发或转移患者58例、脑出血4例、心肌梗死3例、肾衰竭2例。患者总体生存率为70．36％，总体生存时间为51个月。电凝钩组患者肿瘤局部复发率和远处转移率分别为8．33％（10／120）和25．83％（31／120），超声刀组分别为7．69％（9／117）和29．06％（34／117），两组上述指标比较，差异均无统计学意义（x^2=0．033，0．310，P〉0．05）。电凝钩组和超声刀组患者5年生存率分别为71．7％和72．4％，两组比较，差异无统计学意义（x^2=0．002，P〉0．05）。结论腹腔镜辅助电凝钩法直肠癌根治术可达到传统腹腔镜手术的安全性和临床疗效，同时可降低自主神经相关并发症发生率和治疗费用。

Objective To explore the clinical effect of laparoscopic electrocoagulating hook＇ method in treatment of rectal cancer. Methods The retrospective cohort study was adopted. The clinical data of 237 patients with rectal cancer who were admitted to the Second People＇s Hospital of Guangxi Zhuang Autonomous Region from June 2004 to June 2009 were collected. Among 237 patients undergoing radical resection of rectal cancer, 120 using laparoseopic eleetrocoagulating hook＇ method were allocated into the laparoscopic electrocoagulating hook＇ group and 117 using laparoscopic ultrasound knife＇s method were allocated into the laparoscopic ultrasound knife＇s group. Observation indicators included ： （ 1 ） treatment situations ： operation time, volume of intraoperative blood loss, number of lymph node dissected, time to anal exsufllation, time for out-of-bed activity, duration of hospital stay, treatment expenses and occurrence of complications （anastomotic leakage, intestinal obstruction, postoperative dysuresia and sexual dysfunction） , （2） follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis up to December lg, 2014. The colonoscopy, chest X-ray and abdominal computed tomography （CT） were applied to suspected patients with local or distal tumor recurrence. Measurement data with normal distribution were represented asx ± s and comparison between groups was analyzed using t test. Count data were analyzed using chi-square test or Fisher exact probability. The survival curve was drawn by Kaplan-Meier method, and the survival rate was analyzed using the Log-rank test. Results （1） Treatment situations： all the patients underwent successful laparoscopic surgery, without conversion to open surgery. Operation time, number of lymph node dissected, time to anal exsufflation, time for out-of-bed activity and duration of hospital stay were respectively （ 156 ± 33） minutes, 18 ± 2, （ 1.5 ± 0.6） days, （ 1.5 ± 0.5 ） days, （ 7.5 ± 2.5 ） days in the laparoscopic electroeoagulating hook＇ group and （ 175 ± 21 ） minutes, 16 ± 4, （ 1.6 ± 0. 5 ） days, （ 1.4 ± 0.5 ） days, （ 8.0 ± 1.8 ） days in the laparoscopic ultrasound knife＇ s group, with no statistically significant difference in the above indexes between the 2 groups （ t = 25. 324, 20. 117, 21. 477, 1. 617, 1. 770, P 〉 0.05 ）. Volume of intraoperative blood loss and treatment expenses were respectively （ 116 ± 12 ） mL, （2.4 ± 0.3） × 10^4 yuan in the laparoscopic electrocoagulating hook＇ group and （ 149 ± 25） mL, （2.8 ± 0.2） × 10^4 yuan in the laparoscopic ultrasound knife＇s group, with statistically significant differences in the above indexes between the 2 groups （ t = 212. 740, 211. 071, P 〈 0.05 ）. Anastomotic leakage, intestinal obstruction and dysuresia or sexual dysfunction were respectively detected in 6, 3, 0 in the laparoscopic electrocoagulating hook＇ group and 7, 3, 5 in the laparoscopic ultrasound knife＇s group, with no statistically significant difference in the anastomotic leakage and intestinal obstruction between the 2 groups （x^2 = 0. 110, P 〉 0.05 ） and with a statistically significant difference in the dysuresia or sexual dysfunction between the 2 groups （ P 〈 0.05 ）. All the patients received postoperative chemotherapy of FOLFOX regimens for 6 cycles. （2） Followup situations： 226 patients were followed up for a median time of 52 months （range, 11-121 months） , and 11 patients lost to tollow-up were included in the study as censored data, including 5 in the laparoscopic electrocoagulating hook＇ group and 6 in the laparoseopic ultrasound knife＇s group. During the follow-up, 67 patients were dead, including 58 died of tumor recurrence and metastasis, 4 died of cerebral hemorrhage, 3 died of myocardial infarction and 2 died of renal failure. The overall survival rate and overall survival time were 70.36% and 51 months. The overall local tumor recurrence rate, distal tumor recurrence rate and 5-year survival rate were 8.33% （10/120） , 25.83% （31/120） , 71.7% in the laparoscopic electrocoagulating hook＇ group and 7.69% （9/117）, 29.06% （34/117）, 72.4% in the laparoscopic ultrasound knife＇s group, with no statistically significant difference between the 2 groups （x^2 = 0. 033, 0. 310, 0. 002, P 〉 0.05）. Conclusion The laparoscopic electrocoagulating hook＇ method in treatment of rectal cancer is safe and effective compared with traditional laparoscopic surgery, and it could also reduce the incidence of autonomic nerve-related complications and treatment expenses.