生物补片在低位进展期直肠癌肛提肌外腹会阴联合切除术盆底重建中的应用价值

Application value of biological mesh in the pelvic floor reconstruction of extralevator abdominoperineal excision for advanced low rectal cancer

目的：探讨生物补片在低位进展期直肠癌肛提肌外腹会阴联合切除术（ELAPE）盆底重建中的应用价值。方法：采用回顾性队列研究方法。收集2008年8月至2016年12月首都医科大学附属北京朝阳医院收治的228例行ELAPE治疗的低位进展期直肠癌患者的临床病理资料。228例患者中，174例术中采用生物补片重建盆底设为生物补片组，54例直接缝合关闭会阴切口设为直接缝合组。两组患者均行ELAPE。观察指标：（1）术中和术后情况。（2）术后并发症情况（包括近期并发症和远期并发症）。（3）随访和生存情况。采用门诊和电话方式进行随访，了解患者术后长期并发症，术后肿瘤复发、转移和总体生存情况。随访时间截至2017年12月。正态分布的计量资料以±s表示，两组比较采用独立样本t检验；偏态分布的计量资料以M（范围）表示，组间比较采用非参数检验。计数资料采用X2检验或Fisher确切概率法检验。结果：（1）术中和术后情况：生物补片组和直接缝合组患者均顺利完成ELAPE。两组患者会阴部手术时间、会阴引流管保留时间、住院费用分别为（60±50）min和（50±21）min、（11.6±2.4）d和（8.9±1.7）d、（57 781±11 337）元和（53 714±13 395）元，两组患者上述指标比较，差异均有统计学意义（t=3.327，7.691，-2.203，P〈0.05）。两组患者总体手术时间和术后住院时间分别为（242±53）min和（228±51）min、（13.0±5.0）d和（12.0±5.0）d，两组患者上述指标比较，差异均无统计学意义（t=1.701，1.309，P〉0.05）。（2）术后并发症情况：生物补片组和直接缝合组患者中分别有26例和19例发生会阴伤口并发症（同一患者可合并多种并发症），两组患者上述指标比较，差异有统计学意义（X2=10.660，P〈0.05）。两组患者会阴伤口感染、会阴疝、会阴伤口裂开分别为20例和12例、6例和7例、1例和3例，两组患者上述指标比较，差异均有统计学意义（X2=3.931，5.282，P〈0.05）。（3）随访和生存情况：生物补片组174例患者均获得随访，随访时间为64个月（13～112个月）；直接缝合组54例均获得随访，随访时间为51个月（23～76个月）。生物补片组患者局部复发率、远处转移率和总体生存率分别为5.17%（9/174）、20.11%（35/174）和77.59%（135/174）；直接缝合组分别为7.41%（4/54）、24.07%（13/54）和79.63%（43/54），两组患者上述指标比较，差异均无统计学意义（X2=0.080，0.389，0.101，P〉0.05）。结论：生物补片重建ELAPE盆底缺损安全可行，与直接缝合比较，虽然延长会阴手术时间、会阴引流管保留时间和增加住院费用，但不影响总体手术时间和术后住院时间，且有助于减少会阴伤口总体并发症的发生，尤其是会阴伤口感染、会阴疝、会阴伤口裂开。

Objective：To investigate the application value of biological mesh in the pelvic floor reconstruction of extralevator abdominoperineal excision （ELAPE） for advanced low rectal cancer （RC）. Methods： The retrospective cohort study was conducted. The clinicopathological data of 228 patients with advanced low RC who underwent ELAPE in the Beijing Chaoyang Hospital of Capital Medical University between August 2008 and December 2016 were collected. Of 228 patients, 174 using biological mesh closure and 54 using primary closure were respectively allocated into the biological mesh group and primary closure group. Observation indicators： （1） intra and postoperative situations; （2） postoperative complications （including shortterm and longterm complications）; （3） followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect postoperative longterm complications, tumor recurrence or metastasis and overall survival up to December, 2017. Measurement data with normal distribution were represented as ±s, and comparison between groups was analyzed using the independentsample t test. Measurement data with skewed distribution were described as M （range）, and comparison between groups was analyzed using the nonparametric test. Comparisons of count data were evaluated by the chisquare test or Fisher exact probability. Results：（1） Intra and postoperative situations： all the patients underwent successful ELAPE. The perineal operation time, time of indwelling perineal drainagetube and hospital expenses were respectively （60±50）minutes, （11.6± 2.4）days, （57 781±11 337）yuan in the biological mesh group and （50±21）minutes, （8.9±1.7）days, （53 714±13 395）yuan in the primary closure group, with statistically significant differences between groups （t=3.327, 7.691, -2.203, P〈0.05）. The total operation time and duration of postoperative hospital stay were respectively （242±53）minutes, （13.0±5.0）days in the biological mesh group and （228±51）minutes, （12.0±5.0）days in the primary closure group, with no statistically significant difference between groups （t=1.701, 1.309, P〉0.05）. （2） Postoperative complications： 26 and 19 patients in the biological mesh group and primary closure group had respectively perineal wound complications （1 patient combined with multiple complications）, showing a statistically significant difference between groups （X2=10.660, P〈0.05）. The perineal wound infection, perineal hernia and disruption of perineal wound were respectively detected in 20, 6, 1 patients in the biological mesh group and 12, 7, 3 patients in the primary closure group, showing statistically significant differences between groups （X2=3.931, 5.282, P〈0.05）. （3） Followup and survival situations： 174 patients in the biological mesh group were followed up for 64 months （range, 13-112 months）, and 54 patients in the primary closure group were followed up for 51 months （range, 23-76 months）. The local recurrence rate, distal metastasis rate and overall survival rate were respectively 5.17%（9/174）, 20.11%（35/174）, 77.59%（135/174） in the biological mesh group and 7.41%（4/54）, 24.07%（13/54）, 79.63%（43/54） in the primary closure group, with no statistically significant difference between groups （X2=0.080, 0.389, 0.101, P〉0.05）. Conclusions：The biological mesh in the pelvic floor reconstruction of ELAPE for advanced low RC is safe and feasible. Compared with primary closure, biological mesh closure will extend perineal operation time and time of indwelling perineal drainagetube, and increase hospital expenses, but doesn′t affect total operation time and duration of postoperative hospital stay, meanwhile, it can also reduce the overall perineal wound complications, especially in perineal wound infection, perineal hernia and disruption of perineal wound.