经肛门微创手术治疗直肠肿瘤的可行性分析

The feasibility analysis of tranasnal minimally invasive surgical treatment for rectal cancer

目的 评价经肛门微创手术（transanalminimallyinvasivesurgery，TAMIS）临床疗效，以期为患者提供更好的手术方式选择。方法 回顾性分析2012年7月至2014年9月间在哈尔滨医科大学附属第二医院结直肠肿瘤外科接受直肠肿物局部切除术患者52例，其中TAMIS组30例，传统经肛门切除组（TAE）22例，对患者进行系统随访，并详细记录其临床资料。结果 TAMIS组手术患者平均手术时间41.5（25~90）分钟。平均住院时间3（1~4）天。SILSPort平均安装时间3（1~5）分钟，TAE组手术患者平均手术时间55（25~110）分钟。平均住院时间3（1~4）天。52例患者手术均获得完整切除，未见切缘阳性患者。共发生术后短期内肛门括约肌功能异常1例，术后尿潴留1例，术后肛门出血1例。两组患者肿物距离肛缘距离方面差异有显著的统计学意义，TAMIS术能够获得更为广泛的手术范围；TAMIS组手术时间更短（41.5分钟，P＜0.05）；在肛门功能影响方面，TAMIS组患者便失禁严重程度评分下降明显（P=0.002），肛门功能恢复良好；患者术后疼痛强度评分低于TAE手术组（P=0.001），经过数学分析得到TAMIS曲线公式为Y=-13.15ln（x）＋79.563。根据手术时间二次求导曲线图，第12例为拐点，提示前12例为学习阶段。结论 经肛门微创可通过常规腹腔镜器械完成，手术学习曲线平滑，易于掌握，肛门功能损伤小，术后疼痛轻微，手术范围广，术野清晰，在直肠良性肿物或早期直肠癌的局部切除中具有良好的疗效。

Objective To evaluate the clinical curative effect of the transanal minimally invasivesurgery (TAMIS), is aiming to provide a better surgical procedure for patients. Methods Retrospectiveanalysis of 52 cases of patients with colorectal neoplasm local resection from July 2012 to September 2014in the department of colorectal surgery of the Second Affiliated Hospital of Harbin Medical University. 30cases were TAMIS group, 22 cases were TAE group. All the patients were followed up, and recorded detailclinical data. Results In TAMIS group, the average operation time was 41.5 minutes (25~90), the averagelength of hospital stay was 3 days (1~4), and setup time of SILS Port was 3 minutes on average (1~5). Theaverage operation time of TAE group was 55 minutes (25~110), and the average length of hospital stay was3 days (1~4). 52 cases were obtained complete resection, with no positive cut edge. Of all the patients, 1 casewas with anal sphincter dysfunction, 1 case was with urinary retention shortly after the postoperation, 1 casewas with postoperative anal bleeding. The difference of distance from neoplasm to anal edge was of statistical significance in two groups of patients, TAMIS technique can get wider operation range, and TAMIS group has shorter operation time(41.5 minutes, P < 0.05); In terms of anal function, the score of fecal incontinence in TAMIS group was significantly decreased(P=0.002), anal function recovered well; The intensity score of postoperative pain was lower than TAE group (P=0.001), TAMIScurve formula was Y=-13.15 ln (x) + 79.563 after mathematical analysis. According to operation time, the 12th case was inflectionpoint in the second derivative curve, indicating the previous 12 cases were the learning phase. Conclusions Transanal minimallyinvasive surgery can be finished by conventional laparoscopic instruments, the learning curve is smooth, and easy to master, withsmaller anus function damage, mild postoperative pain, wide scope of operation and clear operation field, which was of good curativeeffect in the treatment of benign neoplasm or local excision of early rectal cancer.