3D与2D腹腔镜手术治疗新辅助放化疗后直肠癌的疗效分析

Effects of three-dimensional and two-dimensional laparoscopic surgeries for rectal cancer after neoadjuvant chemoradiation therapy

目的：比较3D与2D腹腔镜手术治疗行新辅助放化疗（nCRT）后直肠癌的临床疗效。方法：采用回顾性队列研究方法。收集2013年1月至2014年1月辽宁省肿瘤医院收治的126例行nCRT后直肠癌患者的临床病理资料。126例患者中，63例行3D腹腔镜直肠癌根治术设为3D组，63例同期行2D腹腔镜直肠癌根治术设为2D组。两组患者手术均由同一手术团队施行。nCRT结束后6～8周施行手术，手术遵循全直肠系膜切除术原则。观察指标：（1）术中及术后恢复情况。（2）术后病理学检查情况。（3）随访及生存情况。采用门诊和电话方式进行随访。术后第1年每3个月随访1次，术后2～3年每6个月随访 1次，了解患者肿瘤局部复发情况和生存情况。随访时间截至2017年1月。正态分布的计量资料以x±s表示，两组比较采用t检验。计数资料比较采用χ^2检验。等级资料比较采用非参数检验。采用KaplanMeier法绘制生存曲线并计算生存率，Logrank检验比较生存情况。结果：（1）术中及术后恢复情况：两组患者均顺利完成腹腔镜直肠癌根治术，无中转开腹，无围术期死亡患者。3D组和2D组患者手术时间、术中出血量、术后肛门首次排气时间、术后排尿功能障碍例数分别为（125±10）min和（137±12）min、（54± 23）mL和（62±20）mL、（44±5）h和（46±5）h、0和5例，两组患者上述指标比较，差异均有统计学意义（t=5.777，2.038，2.575， χ^2=7.138，P〈0.05）。3D组和2D组患者保肛例数、淋巴结清扫数目、术后吻合口瘘例数、术后住院时间分别为60例和58例、（14.9±2.1）枚和（14.3±1.7）枚、2例和4例、（9.5±0.8）d和（9.9±2.0）d，两组患者上述指标比较，差异均无统计学意义（χ^2=0.133，t=1.606， χ^2=0.175，t=1.329，P〉0.05）。3D组2例和2D组4例术后吻合口瘘患者均行预防性造口术，最终吻合口瘘均愈合，未发生吻合口狭窄。2D组5例术后排尿功能障碍患者中， 4例经留置导尿管3周后拔除，可自行排尿，1例留置导尿管3个月后拔除，自行排尿，均未行膀胱造瘘术。（2）术后病理学检查情况：3D组和2D组患者环周切缘阳性例数分别为 0和4例，两组比较，差异有统计学意义（χ^2=5.676，P〈0.05）。两组患者远切缘阳性例数分别为1例和 2例，两组比较，差异无统计学意义（χ^2=1.606，P〉0.05）。3D组患者术后肿瘤病理学分期Ⅱ、Ⅲ期分别为30、33例，2D组分别为32、31例，两组比较，差异无统计学意义（χ^2=0.127，P〉0.05）。（3）随访及生存情况：126例患者均获得术后随访，随访时间为36.0～48.0个月，中位随访时间为39.5个月。随访期间，3D组和2D组分别有0、3例患者发生肿瘤局部复发，两组比较，差异有统计学意义（χ^2= 4.232，P〈0.05）。3D组患者1、3年总体生存率分别为98.4%、82.5%，2D组患者分别为96.8%、79.4%，两组患者总体生存情况比较，差异无统计学意义 （χ^2=0.206，P〉0.05）。3D组患者1、3年无病生存率为92.7%、77.8%，2D组患者分别为90.5%、73.0%，两组患者无病生存情况比较，差异无统计学意义（χ^2=0.421，P〉0.05）。结论：3D与2D腹腔镜手术治疗行nCRT后直肠癌均安全可行，且3D腹腔镜能缩短手术时间，减少术中出血量，减轻肠道蠕动功能影响，改善盆腔神经保护，提高手术质量。

Objective：To compare the clinical effects of threedimensional （3D） and twodimensional （2D） laparoscopic surgeries for rectal cancer （RC） after neoadjuvant chemoradiation therapy （nCRT）. Methods：The retrospective cohort study was conducted. The clinicopathological data of 126 patients with RC who received laparoscopic surgery after nCRT in the Liaoning Cancer Hospital from January 2013 to January 2014 were collected. Of 126 patients, 63 undergoing 3D laparoscopic surgery and 63 undergoing 2D laparoscopic surgery were respectively allocated into the 3D and 2D groups. Surgery was performed by the same doctors′ team. Patients received surgery at 6-8 weeks after nCRT, and surgery followed the principle of total mesorectal excision. Observation indicators： （1） intra and postoperative situations; （2） postoperative pathological examination; （3） followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect local tumor recurrence and patients′ survival up to January 2017. Patients received reexaminations once every 3 months within 1 year postoperatively and once every 6 months after 2-3 years postoperatively. Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using the t test. Comparisons of count data were analyzed using the chisquare test. Comparison of ordinal data was done by the nonparametric test. Survival curve was drawn using the KaplanMeier method. Survival was analyzed using the Logrank test. Results：（1） Intra and postoperative situations： all the patients underwent successful laparoscopic surgery for RC, without conversion to open surgery and perioperative death. Operation time, volume of intraoperative blood loss, time to anal exsufflation and number of patients with postoperative urinary dysfunction were （125±10）minutes, （54±23）mL, （44±5）hours, 0 in the 3D group and （137±12）minutes, （62±20）mL, （46±5）hours, 5 in the 2D group, respectively, with statistically significant differences between the 2 groups （t=5.777, 2.038, 2.575, χ^2=7.138, P〈0.05）. Number of patients with preserving anus, number of lymph node dissected, number of patients with anastomotic fistula and duration of hospital stay were 60, 14.9±2.1, 2, （9.5±0.8）days in the 3D group and 58, 14.3±1.7, 4, （9.9±2.0）days in the 2D group, respectively, with no statistically significant difference between the 2 groups （χ^2=0.133, t=1.606, χ^2=0.175, t=1.329, P〉0.05）. Two and 4 patients with anastomotic leakage in the 3D and 2D groups received defunctioning stoma, and finally anastomotic leakage healed, without anastomotic stenosis. Of 5 patients with urinary dysfunction in the 2D group, 4 received indwelling catheter for 3 weeks and then can micturate autonomously after indwelling catheter removal, 1 received indwelling catheter for 3 months and then can micturate autonomously after indwelling catheter removal, without suprapubic cystostomy. （2） Postoperative pathological examination： 0 and 4 patients in the 3D and 2D groups had positive circumferential margin, with a statistically significant difference （χ^2=5.676, P〈0.05）. One and 2 patients in the 3D and 2D groups had positive distal margin, with no statistically significant difference （χ^2=1.606, P〉0.05）. Number of patients with stage Ⅱ and Ⅲ of postoperative pathological staging were 30, 33 in the 3D group and 32, 31 in the 2D group, respectively, with no statistically significant difference between the 2 groups （χ^2=0.127, P〉0.05）. （3） Followup and survival situations： 126 patients were followed up for 36.0-48.0 months, with a median time of 39.5 months. During the followup, 0 and 3 patients in the 3D and 2D groups were complicated with local tumor recurrence, with a statistically significant difference between the 2 groups （χ^2=4.232, P〈0.05）. One and 3year overall survival rates were 98.4%, 82.5% in the 3D group and 96.8%, 79.4% in the 2D group, respectively, with no statistically significant difference between the 2 groups （χ^2=0.206, P〉0.05）. One and 3year diseasefree survival rates were 92.7%, 77.8% in the 3D group and 90.5%, 73.0% in the 2D group, respectively, with no statistically significant difference between the 2 groups （χ^2=0.421, P〉0.05）. Conclusion：Compared with 2D laparoscopic surgery, 3D laparoscopic surgery for RC after nCRT is safe and feasible, it can also shorten operation time, reduce intraoperative bleeding, alleviate the influence of intestinal peristalsis function, protect pelvic nerves better and improve operation quality.