腹腔镜低位直肠癌部分、次全和完全经括约肌间切除术式的肿瘤学结果及肛门功能比较

Comparison of oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection for low rectal cancers

目的 比较部分、次全和完全腹腔镜经括约肌间切除术式（ISR）应用于低位直肠癌的肿瘤学结果与肛门功能。 方法 回顾性分析2011年6月至2016年2月期间在火箭军总医院结直肠肛门外科接受腹腔镜ISR治疗的79例低位直肠癌患者的临床资料。术中判断肿瘤下缘距离肛门括约肌环〈1 cm，采用部分ISR（28例，自齿状线附近环形切除部分内括约肌进入括约肌间隙）；肿瘤远切缘位于齿状线与肛门括约肌间沟之间，采用次全ISR（34例，在齿状线与括约肌间沟之间垂直于肛管长轴环形切除大部分内括约肌全层）；若肿瘤下缘位于肛管内，则选择完全ISR（17例，经括约肌间沟环形切除全部内括约肌）；3种术式均采用2-0可吸收缝线间断行结肠肛管手工吻合。比较3组患者的肿瘤学结果，并采用标准胃肠功能问卷调查、Wexner失禁评分和Kirwan失禁分级对术后肛门功能进行评估。结果 除肿瘤下缘与肛缘的距离（P= 0.000）和术前癌胚抗原水平（P= 0.040）外，3组患者其他基线资料的差异均无统计学意义（均P 〉 0.05）。术后中位随访时间为21（8~61）月，部分、次全和完全ISR组患者术后3年无病生存率分别为91.1%、72.9%和80.2%（P= 0.658），3年无局部复发生存率分别为91.1%、88.9%和88.2%（P= 0.901），差异均无统计学意义。对38例未接受新辅助治疗且回肠造口还纳术后至少24月的患者完成肛门功能评估，其中部分ISR组14例，次全ISR组15例，完全ISR组9例。28例（73.7%）患者术后肛门功能良好（Wexner失禁评分≤10分），无一例因为术后严重肛门失禁（Kirwan 5级）行永久性乙状结肠造口。3组患者Wexner失禁评分和Kirwan分级的差异均无统计学意义（均P 〉 0.05）。然而，术后出现慢性狭窄的患者肛门功能明显劣于无狭窄患者[Wexner失禁评分：18（9~20）比6（0~18），P= 0.000；Kirwan分级：3（2~4）比2（1~4），P= 0.002]。结论 腹腔镜ISR作为低位直肠癌患者的极限保肛术式，能够获得较好的肿瘤学结果和较为满意的肛门功能。不同ISR手术方式可能并不影响患者术后的肿瘤学结果和肛门功能，但吻合口慢性狭窄患者术后排粪控制功能欠佳。

Objective To compare the oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection （ISR） for low rectal cancers. Methods From June 2011 to February 2016, a total of 79 consecutive patients with low rectal cancers underwent laparoscopic ISR with hand-sewn coloanal anastomosis at our department. According to the distal tumor margin, partial ISR （internal sphincter resection at the dentate line） was used to treat tumors with distance 〈 1 cm from the anal sphincter （n= 28） , subtotal ISR was adopted for the tumors locating between the dentate line and intersphincteric groove （n= 34） , and total ISR （resection at the dentate line） was applied in the treatment of intra-anal tumors （n= 17） . Anal function was evaluated by a standardized gastrointestinal questionnaire, Wexner incontinence score and Kirwan′s classification. Metaphase oncological results and postoperative anal function were compared among three groups, and.Results Other than the distance of tumor low margin to dentate line （P= 0.000） and serum CEA level （P= 0.040） , no significant differences were noted in baseline data among 3 groups （all P 〉 0.05） . The median follow up was 21 （8-61） months. The 3-year disease-free survival rates in laparoscopic partial, subtotal and total ISR groups were 91.1%, 88.9%, 88.2% （P= 0.901） and the 3-year local relapse-free survival rates were 91.1%, 72.9%, 80.2% （P= 0.658） , whose all differences were not significant. Thirty-eight patients who did not receive neoadjuvant chemoradiotherapy and underwent ileostomy closure for at least 24 months completed the evaluation of anal function, including 14 cases in partial group, 15 cases in subtotal group and 9 cases in total group. Of 38 patients, 73.7% （28/38） was classified as good function （Wexner incontinence score ≤ 10） and no patient adopted a colostomy because of severe fecal incontinence （Kirwan classification=grade 5） . Furthermore, there were no significant differences in Wexner incontinence score and Kirwan classification among 3 groups （all P 〉 0.05） . However, patients with chronic anastomotic stoma stenosis showed worse anal function than those without stenosis[Wexner incontinence score： 18 （9-20） vs 6 （0-18） , P= 0.000; Kirwan grading： 3 （2-4） vs. 2 （1-4） , P= 0.002]. Conclusions As the ultimate sphincter-saving technique, laparoscopic ISR can result in better oncologic outcomes and better anal function for patients with low rectal cancers. The different procedures of ISR may not affect the efficacy, but chronic anastomotic stoma stenosis deteriorates incontinence status.