手套法经肛微创手术与经肛内镜微创手术治疗直肠肿瘤的临床疗效

Clinical efficacy of transanal minimally invasive surgery with glove method and transanal endoscopic microsurgery in the treatment of rectal neoplasms

目的探讨手套法经肛微创手术(TAMIS)与经肛内镜微创手术(TEM)治疗直肠肿瘤的临床疗效。方法采用回顾性队列研究方法。收集2015年3月至2017年5月福建医科大学附属第一医院收治的60例直肠肿瘤患者的临床病理资料;男34例,女26例;平均年龄为62岁,年龄范围为49~74岁。60例患者均行经肛手术,其中30例采用手套法TAMIS,设为TAMIS组;30例采用TEM,设为TEM组。观察指标:(1)手术及术后恢复情况。(2)术后短期并发症情况。(3)随访情况。采用门诊或电话方式进行随访,了解患者术后肿瘤复发转移情况。随访时间截至2018年8月。正态分布的计量资料以±s表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ^2检验或Fisher确切概率法。等级资料组间比较采用Mann-WhitneyU检验。结果(1)手术及术后恢复情况:两组患者均顺利完成手术。TAMIS组患者手术操作时间,术中出血量,术后首次肛门排气时间,术后首次进食半流质食物时间,术后肛门疼痛评分,术后住院时间,术后3个月肛门功能Kirwan分级(Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级、Ⅴ级)例数分别为(35±7)min,(9±5)mL,(2.7±0.9)d,(2.9±0.6)d,(2.1±0.9)分,(3.6±1.9)d,29、1、0、0、0例;TEM组患者上述指标分别为(38±7)min,(9±6)mL,(2.5±0.8)d,(2.7±0.7)d,(1.8±0.9)分,(4.0±2.3)d,28、1、1、0、0例,两组患者上述指标比较,差异均无统计学意义(t=-1.377,-0.099,0.931,0.770,1.418,-0.789,Z=-0.607,P>0.05)。TAMIS组和TEM组患者总手术时间分别为(38±7)min和(46±7)min,治疗费用分别为(8507±1471)元和(9551±1747)元,两组患者上述指标比较,差异均有统计学意义(t=-4.628,-2.506,P<0.05)。两组患者术后病理学检查结果示切缘均为阴性。(2)术后短期并发症情况:TAMIS组2例患者发生术后短期并发症,其中1例术前因合并前列腺增生症,术后发生尿潴留,经导尿膀胱训练3 d后改善,1例术后2 d畏冷、发热诊断为脓毒血症,血培养检查出大肠埃希菌,予抗感染治疗后好转。TEM组3例患者发生术后短期并发症,其中1例术后2 d肛门失禁,经肛门功能锻炼4 d后好转;1例术后发生便血,予肠镜下止血治疗后好转;1例发生会阴部感染,经抗炎治疗后好转。两组患者短期并发症比较,差异无统计学意义(P>0.05)。(3)随访情况:TAMIS组和TEM组患者术后均获得随访,随访时间分别为(17±4)个月和(16±3)个月,两组比较,差异无统计学意义(t=0.200,P>0.05)。随访期间,TAMIS组1例直肠管状腺瘤患者于术后1年肿瘤局部复发,直径约为0.5 cm,距离肛缘约为12 cm,于内镜下再次治疗后未再复发,术后病理学检查结果示管状腺瘤。TEM组1例直肠低分化腺癌患者于术后6个月MRI检查示直肠系膜淋巴结转移,行腹腔镜直肠癌根治术,术后病理学检查示直肠标本未见癌细胞残留,送检15枚淋巴结(1枚阳性),截至随访时间肿瘤未再复发转移。两组患者术后肿瘤复发转移比较,差异无统计学意义(P>0.05)。结论手套法TAMIS治疗中上段直肠肿瘤可取得与TEM相当的临床疗效,手术方式安全、可行;且手套法TAMIS更省时,治疗费用更低。

Objective To investigate the clinical efficacy of transanal minimally invasive surgery(TAMIS)with glove method and transanal endoscopic microsurgery(TEM)in the treatment of rectal neoplasms.Methods The retrospective cohort study was conducted.The clinicopathological data of 60 patients with rectal neoplasms who were admitted to the First Affiliated Hospital of Fujian Medical University from March 2015 to May 2017 were collected.There were 34 males and 26 females,aged from 49 to 74 years,with an average age of 62 years.Of the 60 patients,30 undergoing TAMIS with glove method and 30 undergoing TEM were allocated into TAMIS group and TEM group,respectively.Observation indicators:(1)surgical situations and postoperative recovery;(2)postoperative short-term complications;(3)follow-up.Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis up to August 2018.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test or Fisher exact propability.Comparison of ordinal data between groups was analyzed by the Mann-Whitney U test.Results (1)Surgical situations and postoperative recovery:patients in the two groups underwent surgery successfully.The operation time,volume of intraoperative blood loss,time to postoperative first flatus,time to postoperative semi-fluid diet intake,postoperative anal pain score,duration of postoperative hospital stay and cases with Kirwan classificationⅠ,Ⅱ,Ⅲ,Ⅳ,Ⅴof anus function at 3 months after surgery were respectively(35±7)minutes,(9±5)mL,(2.7±0.9)days,(2.9±0.6)days,2.1±0.9,(3.6±1.9)days,29,1,0,0,0 in the TAMIS groups and(38±7)minutes,(9±6)mL,(2.5±0.8)days,(2.7±0.7)days,1.8±0.9,(4.0±2.3)days,28,1,1,0,0 in the TEM group,showing no significant difference in the above indicators between the two groups(t=-1.377,-0.099,0.931,0.770,1.418,-0.789,Z=-0.607,P>0.05).Total operation time and treatment expenses were(38±7)minutes and(8507±1471)yuan in the TAMIS group,versus(46±7)minutes and(9551±1747)yuan in the TEM group,showing significant differences between the two groups(t=-4.628,-2.506,P<0.05).Results of postoperative pathological examination showed negative margin in the two groups.(2)Postoperative short-term complications:of 2 patients with postoperative short-term complications in the TAMIS group,1 had postoperative urine retention due to preoperative prostatic hyperplasia and was improved after 3 days of bladder training,1 was diagnosed as sepsis due to postoperative cold and fever at 2 days after operation with escherichia coli detected in blood culture,and the patient was cured after anti-infection treatment.Of 3 patients with postoperative short-term complications in the TEM group,1 had anal incontinence at 2 days after operation and was improved after 4 days of anus function exercise,1 had hematochezia and was improved after hemostatic therapy under colonoscopy,1 had perineal infection and was improved after anti-inflammation.There was no significant difference in the short-term complications between the two groups(P>0.05).(3)Follow-up:patients in the TAMIS group and TEM group were respectively followed up for(17±4)months and(16±3)months,with no significant difference between the two groups(t=0.200,P>0.05).During the follow-up,1 case of rectal tubular adenoma in the TAMIS group had local tumor recurrence at 1 year after surgery,with a diameter of about 0.5 cm and a distance of about 12 cm from the anal margin.The patient had no recurrence after endoscopic retreatment and was confirmed tubular adenoma by postoperative pathological examination.One patient with poorly differentiated adenocarcinoma in the TEM group was detected mesorectal lymph node metastasis at 6 months after surgery by magnetic resonance imaging examination and underwent laparoscopic radical resection of rectal cancer.The postoperative pathological examination showed no residual cancer cells in the rectum specimen and there was 1 positive in 15 lymph nodes for pathological examination.No tumor recurrence or metastasis occurred by the end of follow-up.There was no significant difference in postoperative tumor recurrence and metastasis between the two groups(P>0.05).Conclusions The clinical efficacy of TAMIS with glove method in the treatment of upper-middle rectal neoplasms is comparable to TEM,which is safe and feasible.In addition,the TAMIS with glove method has shorter time and lower treatment expenses.