不翻转体位腹腔镜肛提肌外腹会阴联合切除术治疗低位直肠癌的临床疗效

Clinical efficacy of laparoscopic extralevator abdominoperineal excision for low rectal cancer without turning position

目的：探讨采用改良Lloyd-Davies截石位，不翻转体位行腹腔镜肛提肌外腹会阴联合切除术（ELAPE）治疗低位直肠癌的临床疗效。方法：采用回顾性横断面研究方法。收集2013年9月至2015年1月四川大学华西医院收治的27例行不翻转体位腹腔镜ELAPE的低位直肠癌患者的临床病理资料。行会阴部切除术时，不翻转患者体位为俯卧折刀位，而采用改良Lloyd-Davies截石位。观察指标：（1）手术情况。（2）术后恢复情况。（3）术后病理学检查情况。（4）随访和生存情况。采用门诊和电话方式进行随访，了解患者出院后并发症、生存和肿瘤复发、转移情况。随访时间截至2017年3月。正态分布的计量资料采用x^-±s表示，偏态分布的计量资料采用M（范围）表示。结果：（1）手术情况：27例患者均完成不翻转体位腹腔镜ELAPE，手术时间为（198±51）min，术中出血量为（85±66）mL。27例患者中，5例发生术中并发症，其中肠穿孔1例，术中成功修补；骶前出血1例，术中采用纱布压迫，成功止血；左、右侧盆丛神经损伤1例，未予特殊处理；左侧盆丛神经＋左侧髂内静脉损伤1例，神经损伤未予特殊处理，血管损伤术中成功修补；右侧血管神经束损伤1例，神经损伤未予特殊处理，血管损伤采用超声刀成功止血。术中无肿瘤部位穿孔发生。27例患者术中中位淋巴结清扫数目为14枚（9～22枚），其中≥12枚 15例，〈12枚12例。（2）术后恢复情况：27例患者术后肛门首次排气时间为（78±21）h，术后首次进流质食物时间为（83±21）h。27例患者中，8例发生术后并发症，其中ClavienDindoⅠ级1例（会阴部渗液〉100 mL），Ⅱ级7例（肺部感染3例、乳糜漏2例、会阴部切口感染1例、血尿1例），均予保守治疗好转。全组术后30 d内无患者死亡。27例患者术后中位住院时间为7 d（6～8 d）。（3）术后病理学检查情况：27例患者中，环周切缘阳性1例，阴性26例；环周切缘中位距离为0.7 cm（0.1～1.1 cm）；肿瘤病理学T分期：T2期14例、T3期12例、T4期1例，N分期： N0期18例、N1期6例、N2期3例。（4）随访和生存情况：27例患者中，25例获得术后随访，随访时间为2～32个月，中位随访时间为24个月。随访期间，5例患者出院后发生并发症，其中持续肛周疼痛2例，未予特殊处理，无明显缓解；性功能障碍3例，未予特殊处理，随访观察。25例患者中，发生肿瘤相关死亡2例，非肿瘤相关死亡1例，其余22例患者均生存；无肿瘤局部复发患者；肿瘤远处转移8例， 其中肺转移4例，肝转移3例，脑转移1例。结论：采用改良Lloyd-Davies截石位，不翻转体位行腹腔镜ELAPE治疗低位直肠癌安全可行，可一期关闭盆底腹膜。

Objective：To explore the clinical efficacy of laparoscopic extralevator abdominoperineal excision （laparoscopic ELAPE） for low rectal cancer with modified Lloyd-Davies lithotomy position and without turning position. Methods：The retrospective crosssectional study was conducted. The clinicopathological data of 27 patients with low rectal cancer who underwent laparoscopic ELAPE without turning position in the West China Hospital of Sichuan University from September 2013 to January 2015 were collected. The modified Lloyd-Davies lithotomy position was used in perineal resection. Observation indicators： （1） surgical situation; （2） postoperative recovery situation; （3） postoperative pathological examination situation; （4） followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect postoperative complications,survival of patients and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were represented as x^-±s. Measurement data with skewed distribution were described as M （range）. Results：（1） Surgical situation： A total of 27 patients received laparoscopic ELAPE without turning position, and operation time and volume of intraoperative blood loss were （198±51）minutes and （85±66）mL. Among 5 of 27 patients with intraoperative complications, 1 with intestinal perforation received successful intraoperative repair, 1 with presacral haemorrhage received successful hemostasis by intraoperative gauze pressing, 1 with left and right pelvic plexus injury didn′t receive special treatment, 1 with left pelvic plexus injury ＋ left internal iliac vein injury didn′t receive special treatment and were repaired in vascular injury repair, 1 with right neurovascular bundle injury didn′t receive special treatment of nerve injury and received successful hemostasis by ultrasonic scalpel. There was no perforation in the site of the tumor. Number of lymph node dissected was 14 （range, 9-22）, and number of lymph node dissected ≥12 and 〈12 were detected in 15 and 12 patients, respectively. （2） Postoperative recovery situation： time to anal exsufflation and time for fluid diet intake in 27 patients were respectively （78±21）hours and （83±21）hours. Of 27 patients, 8 with postoperative complications were improved by conservative treatment, including 1 in ClavienDindo Ⅰ （volume of perineal exudation 〉100 mL） and 7 in ClavienDindoⅡ （3 with pulmonary infection, 2 with chylous fistula, 1 with perineal incision infection and 1 with hematuria）. There was no death within 30 days postoperatively. The median duration of hospital stay of 27 patients was 7 days （range, 6-8 days）. （3） Postoperative pathological examination situation： of 27 patients, 1 and 26 had respectively positive and negative circumferential margins and median distance of circumferential margin was 0.7 cm （range, 0.1-1.1 cm）. T stage： 14, 12 and 1 patients were respectively detected in T2, T3 and T4. N stage： 18, 6 and 3 patients were respectively found in N0, N1 and N2. （4） Followup and survival situations： 25 of 27 patients were followed up for 2-32 months, with a median time of 24 months. During the followup, 5 had complications after discharge from hospital. Of 5 patients, 2 with persistent anal pain didn′t receive special treatment and were not relieved, and 3 with sexual dysfunction didn′t receive special treatment and were followed up or observed. Of 25 patients, 2 died of tumorrelated diseases, 1 died of non-tumor-related disease and other 22 had survival. No local tumor recurrence was detected. Eight patients had tumor distant metastases, including 4 with pulmonary metastases, 3 with hepatic metastases and 1 with brain metastasis. Conclusion： Laparoscopic ELAPE by modified Lloyd-Davies lithotomy position without turning position is safe and feasible, with closing pelvic floor peritoneum in stage Ⅰ.