摘要
目的探讨既往腹部手术史(PAS)对腹腔镜结直肠癌切除术的影响。方法采用回顾性队列研究疗法,收集2010—2015年间,在中国医学科学院肿瘤医院接受腹腔镜结肠癌手术且有PAS病史(既往患者至少有1次PAS,排除既往手术为腹股沟疝修补术、单纯腹腔镜探查手术、右下腹小切口的阑尾切除术以及内镜治疗术的患者)的病例资料,并按照年龄、性别、体质指数、美国麻醉师协会评分、肿瘤位置、外科手术类型及肿瘤分期的匹配标准与无PAS病史的结直肠癌患者进行1∶1匹配,共匹配成功464对。比较两组患者的术中和术后情况、围手术期并发症发生情况以及预后。结果PAS组464例患者中,男341例(73.5%),女123例(26.5%),中位年龄62(24~85)岁;既往腹部手术次数仅1次者317例(68.3%),〉 1次者147例(31.7%);有389例(83.8%)行腹正中切口,37例横切口(8.0%),右肋下切口34例(7.3%)以及左肋下切口4例(0.9%);手术类型包括妇科手术(146例,31.5%)、胆囊切除术(84例,18.1%)、胃十二指肠手术(52例,11.2%)、结直肠手术(89例,19.2%)、小肠手术(11例,2.4%)、肝切除术(23例,5.0%)、胰腺手术(16例,3.4%)、泌尿外科手术(8例,1.7%)、腹膜后肿瘤切除术(18例,3.9%)、其他类手术(1例,0.2%)。无PAS组男328例(70.7%),女136(29.3%)例,中位年龄62(24~86)岁。两组患者基线资料的比较差异无统计学意义(均P 〉 0.05)。相比无PAS组,PAS组手术平均时间较长(208.0 ± 27.0比179.0 ± 15.3,t = 4.695,P = 0.003),中转开腹率更高[18.1%(84/464)比11.6%(54/464),χ^2 = 7.217,P = 0.003];PAS组因粘连反应致中转开腹更常见[8.8%(41/464)比4.5%(21/464),χ^2 = 4.886,P = 0.007]。两组的术中出血和输血情况、清扫淋巴结情况、环周切缘和手术切缘情况以及术后首次进食时间和术后住院天数的比较,差异均无统计学意义(均P 〉 0.05)。PAS组和无PAS组发生术中及术后并发症的差异亦无统计学意义[3.7%(17/464)比2.8%(13/464),P = 0.346;20.3%(94/464)比18.5%(86/464),P = 0.739]。全组中位随访32.0(0.5~79.0)月,其中PAS组31.0(0.5~79.0)月,无PAS组为33.0(1.0~75.0)月,两组比较,差异无统计学意义(P = 0.391)。PAS组和无PAS组3年无病生存率[68.1%(95%CI:62.0%~74.2%)比68.5%(95%CI:63.0%~74.0%),P = 0.764]和3年总生存率[78.5%(95%CI:72.8%~81.4%)比80.2%(95%CI:74.3%~86.1%),P = 0.528]的差异均无统计学意义。结论除因粘连导致中转开腹的风险有所增高外,腹腔镜手术应用于PAS结直肠癌患者总体安全可行,PAS并不会影响患者预后。
ObjectiveTo investigate the effect of previous abdominal surgery (PAS) on laparoscopic resection of colorectal cancer.MethodsThe retrospective cohort study was adopted. Clinical data of consecutive colorectal cancer patients with PAS history (past history of at least one abdominal surgery, exclusion of previous inguinal hernia repair, simple laparoscopic approach, appendectomy of the right lower quadrant and endoscopic therapy) undergoing laparoscopic surgery at the Cancer Hospital of Chinese Academy of Medical Sciences between 2010 and 2015 were collected, meanwhile other colorectal cancer patients without PAS history were selected according to 1∶1 match in age, sex, body mass index, American Society of Anesthesiologists score, tumor location, type of surgery, and staging of tumor. A total of 464 pairs were successfully matched. Intraoperative and postoperative conditions, perioperative complications and prognosis were compared between the two groups.ResultsIn PAS group, there were 341 males (73.5%) and 123 females (26.5%) with a median age of 62 (24-85) years; 317 (68.3%) cases with only one previous abdominal surgery and 147 (31.7%) with more than one; 389 (83.8%) cases with abdominal midline incisions, 37 (8.0%) with transverse incisions, 34 (7.3%) with right subcostal incision and 4 (0.9%) with left subcostal incision; 146 (31.5%) cases undergoing gynecologic surgery, 84 (18.1%) cholecystectomy, 52 (11.2%) gastroduodenal surgery, 89 (19.2%) colorectal surgery, 11 (2.4%) small intestine surgery, 23 (5.0%) hapatectomy, 16 (3.4%) pancreatic surgery, 8 (1.7%) urological surgery, 18 (3.9%) retroperitoneal tumor resection and 1 (0.2%) other surgery. In no PAS group, there were 328 males (70.7%) and 136 females (29.3%) with a median age of 62 (24-86) years. No significant differences in baseline data were found between the two groups (all P 〉 0.05) . As compared to no PAS group, PAS group had longer mean operative time [ (208.0 ± 27.0) minutes vs. (179.0 ± 15.3) minutes, t = 4.695, P = 0.003] and higher rate of conversion to laparotomy [18.1% (84/464) vs. 11.6% (54/464) , χ^2= 7.217, P = 0.003]. In the PAS group, conversion to laparotomy was more common due to adhesion reaction [8.8% (41/464) vs. 4.5% (21/464) , χ^2= 4.886, P = 0.007]. There were no significant differences between the two groups in intraoperative bleeding and transfusion, lymph node dissection, circumferential margin and surgical margin, time to the first diet and postoperative hospital stay (all P 〉 0.05) . No significant differences in intraoperative and postoperative morbidity of complication were found between PAS group and no PAS group [3.7% (17/464) vs. 2.8% (13/464) , P = 0.346; 20.3% (94/464) vs. 18.5% (86/464) , P = 0.739]. Median follow-up of the whole patients was 32.0 (0.5-79.0) months, and there was no significant difference between the two groups [PAS group 31.0 (0.5-79.0) months vs. no PAS group 33.0 (1.0-75.0) months, P = 0.391]. In PAS and no PAS group, the 3-year disease-free survival rate was 68.1% (95% CI: 62.0%-74.2%) and 68.5% (95%CI: 63.0%-74.0%) (P = 0.764) , and 3-year overall survival rate was 78.5% (95% CI: 72.8%-81.4%) and 80.2% (95% CI: 74.3%-86.1%) (P = 0.528) respectively, whose differences were not significant.ConclusionExcept higher risk of conversion to laparotomy due to adhesion reaction, laparoscopic resection of colorectal cancer is safe and feasible in patients with PAS, and the prognosis is not affected by PAS.
作者
陶金华
王锡山
刘正
姜争
郭春光
陈佳楠
王治杰
刘骞
Tao Jinhua;Wang Xishan;Liu Zheng;Jiang Zheng;Guo Chunguang;Chen Jianan;Wang Zhijie;Liu Qian(Department of Colorectal Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of MedicalSciences and Peking Union Medical College, Beijing 100021, China;Department of Pancreatic Stomach Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2018年第3期292-298,共7页
Chinese Journal of Gastrointestinal Surgery
基金
国家重点研发计划精准医学专项(2016YFC905301)
中国癌症基金会北京希望马拉松专项基金(LC2017L03)
中国医学科学院医学与健康科技创新工程项目(2017-12M-1-006)
关键词
结直肠肿瘤
腹腔镜
外科手术
腹部手术史
Colorectal neoplasms
Laparoscopes
Surgery
Previous abdominal surgery