腹腔镜下完全经腹入路部分内括约肌切除术在低位直肠癌保肛手术中的应用研究

Application of laparoscopic completely abdominal approach partial intersphincteric resection for low rectal cancer

目的探讨腹腔镜下完全经腹入路部分内括约肌切除术(completely abdominal approach partial intersphincteric resection,CAPISR)治疗低位直肠癌的可行性、肿瘤安全性及术后肛门功能。方法回顾性分析武汉大学中南医院实施CAPISR及完全经括约肌间切除术(total intersphincteric resection,TISR)病人的临床资料及随访信息,包含手术学指标、肿瘤学指标及肛门功能评分等。结果53例病人纳入研究,CAPISR组31例,TISR组22例,两组病人均顺利完成手术,无围手术期死亡病例。与TISR组相比,CAPISR组手术更快(P=0.003)、术中失血量更少(P=0.000)、住院时间更短(P=0.038),并发症发生率更低(22.6%比72.7%,P=0.000)。所有病例术后标本远、近切缘、环周切缘的病理学检查均为阴性。两组术后标本在肿瘤远切缘长度、淋巴结数量、淋巴结阳性率及TNM分期方面差异均无统计学意义(P>0.05)。术后中位随访时间为16个月,CAPISR组在随访期内无局部复发及转移;TISR组有2例出现转移,总生存率为90.9%。术后肛门功能与术前相比,两组病人术后3、6、12个月时的每日平均排便次数及肛门失禁Wexner评分均显著升高(P<0.05)。与TISR组相比,CAPISR组术后3、6、12个月时的每日排便次数更少,肛门失禁Wexner评分更低(P<0.05)。术后12个月的Kirwan分级表明,两组病人术后1年肛门功能逐渐恢复,控便功能良好,无1例因严重肛门失禁(KirwanⅤ级)行永久性造瘘。CAPISR组病人术后肛门控便能力较TISR组更好(P=0.015)。结论腹腔镜CAPISR手术治疗低位直肠癌安全可行,手术时间短、术中失血量少、恢复快、住院时间短、并发症少,可使低位直肠癌病人在肿瘤根治性切除的同时最大化保留肛门功能。

Objective To evaluate the feasibility, tumor safety and postoperative anal function of completely abdominal approach partial intersphincteric resection (completely abdominal approach partial intersphincteric resection,CAPISR) with laparoscopy for low rectal cancer. Methods The clinical data and follow-up information of patients who underwent CAPISR and total intersphincteric resection (TISR) in our hospital were analyzed retrospectively, including surgical indicators, oncology indicators and the score of anus function. Results 53 patients were included in the study, 31 patients in the CAPISR group and 22 patients in the TISR group. All patients in the two groups were performed the surgery successfully, and there were no perioperative deaths. Compared with the TISR group, the CAPISR group had a faster procedure ( P =0.003), less intraoperative blood loss ( P = 0.000 ), shorter postoperative hospital stay ( P =0.038), and fewer postoperative complications ( 22.6% vs. 72.7%, P =0.000). Pathological examination of the distal and proximal resection margins and circumferential resection margin of the all groups of postoperative specimens was confirmed to be negative. There was no significant difference between the two groups in the length of the distal margin of the tumor, the number of lymph nodes, the positive rate of lymph nodes and TNM stage ( P > 0.05). After a median follow-up of 16 months, there was no local recurrence or metastasis in the CAPISR group during the follow-up period;2 patients in the TISR group showed metastasis, and the overall survival rate was 90.9%. Compared with the preoperative period, the average daily defecation times and the Wexner score of anal incontinence were significantly increased in the two groups at 3, 6 and 12 months after surgery ( P <0.05). Intergroup comparisons at 3, 6, and 12 months after surgery showed that patients in CAPISR group had fewer daily defecation frequency and lower anal incontinence Wexner score ( P <0.05). Kirwan grading in both groups showed that the anal function recovered gradually one year after the surgery with good fecal control function, and no permanent colostomy was performed due to postoperative severe anal incontinence (KirwanⅤ grade). Compared with TISR group, patients in CAPISR group had better anal defecation control ability ( P =0.015). Conclusion Laparoscopic CAPISR is a safe and feasible for the treatment of low rectal cancer with short operation time, less intraoperative blood loss, rapid recovery, short hospital stay and less complications, which will make the patients with ultra-low rectal cancer not only preserve the shape of anus, but also retain maximally anal function after radical resection.