术前骨盆出口横径测量用于评估腹腔镜低位直肠癌NOSES的临床价值

Preoperative pelvic transverse outlet measurement in patient selection for laparoscopic anterior resection with trans-anal eversible extraction of specimen in treatment of low rectal cancer

目的探讨骨盆出口横径等临床病理因素对腹腔镜低位直肠癌经直肠取标本手术的影响,探索低位直肠(natural orifice specimen extraction surgery, NOSES)NOSES选择的独立预测因子。方法本研究回顾性纳入于2017年3~8月在同济大学附属东方医院胃肠肛肠外科接受全腹腔镜低位直肠癌经直肠取标本病例(NOSES组)及同期取出困难而改行腹腔镜辅助低位直肠手术病例(小切口组)的临床病理资料,通过单因素及多因素Logistic回归分析NOSES术式选择的相关影响因素及其独立预测因子。结果 NOSES组骨盆口横径显著小于小切口组(P=0.0188),单因素分析结果显示NOSES手术与女性患者(P=0.035)、BMI(P=0.006)、肿瘤位置(P=0.005)、肿瘤横断面最大直径(P=0.004)、隆起型肿瘤(P=0.017)、LNC(P=0.041)、T分期(P=0.011)及骨盆出口横径(P=0.020)特征显著相关,而与患者年龄(P=0.935)、术前CEA水平(P=0.304)、分化程度(P=0.853)、N分期(P=0.326)和TNM分期(P=0.169)相关性不显著。多因素分析结果显示骨盆出口横径、BMI、肿瘤距肛缘距离及肿瘤横断面最大直径是NOSES的独立相关和预测因子,其中以骨盆出口横径(OR:0.13,95%CI:0.03~0.52,P=0.004)的相关程度最密切。结论本研究结果均提示低位直肠癌经直肠取标本NOSES术式是多因素相关的,而骨盆出口横径等局部因素对NOSES术式的选择的临床参考价值可能更大。

Objective To assess the clinical values of preoperative pelvic transverse outlet measurement in patient selection for laparoscopic anterior resection with trans-anal eversible extraction of specimen(NOSES) in treatment of low rectal cancer. Methods Clinical data of 71 patients who underwent laparoscopic low anterior resection(LAR) between March and August of 2017 at Department of Colorectal Surgery, East Hospital, Tongji University School of Medicine were retrospectively analyzed. There were 32 patient received trans-anal eversible extraction of specimen(NOSES group) and 39 patients received laparoscopy-assisted LAR(Mini-Lap group). Univariate and multivariate Logistic regression analyses were performed to analyze the independent predictors for NOSES. Results Patients in NOSES group tended to have an increased pelvic transverse outlet(P=0.0188). Univariate analysis showed that the application of NOSES were significantly associated with female gender(P=0.035), decreased BMI(P=0.006), tumor location(P=0.005), maximum cross-sectional tumor diameter(P=0.004), T stage(P=0.011), lymph node count(P=0.041), polypoid tumor(P=0.017) and increased transverse outlet(P=0.020);while no correlations were observed with patient age(P=0.935), preoperative CEA level(P=0.304), tumor differentiation(P=0.853), N stage(P=0.326) and TNM stages(P=0.169). Multivariate analyses showed that transverse outlet, BMI, tumor location and maximum cross-sectional tumor diameter were independent predictors for NOSES;and the increased transverse outlet was the strongest predictor for NOTES(OR=0.13,95%CI: 0.03-0.52,P=0.004). Conclusion Multiple factors are associated with laparoscopic anterior resection with trans-anal eversible extraction of specimen for treatment of low rectal cancer;and pelvic transverse outlet may play a major role in the patient selection for NOSES.