3D腹腔镜在经肛全直肠系膜切除术中的应用价值

Application value of 3D laparoscope in transanal total mesorectal excision

目的:探讨3D腹腔镜在经肛全直肠系膜切除术(TaTME)中的应用价值。方法:采用回顾性队列研究方法。收集2018年6月至2019年10月上海交通大学医学院附属瑞金医院收治的20例行TaTME中低位直肠癌患者的临床病理资料;男15例,女5例;中位年龄为64岁,年龄范围为28~81岁。20例患者中,10例行TaTME经肛手术入路采用3D腹腔镜手术系统设为3D组,10例行TaTME经肛手术入路采用2D腹腔镜手术系统设为2D组。观察指标:(1)术中及术后恢复情况。(2)术后病理学检查情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后生存情况及肿瘤复发转移情况。随访时间截至2020年4月。偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验。计数资料以绝对数表示,组间比较采用Fisher确切概率法。等级资料组间比较采用Mann-Whitney U检验。结果:(1)术中及术后恢复情况:两组患者均顺利完成手术,无腹腔镜中转开腹或经肛手术中转经腹手术,无术中死亡。3D组患者末端回肠造口,吻合方式(手工吻合、器械吻合),手术时间,术中出血量,术后住院时间,术后短期并发症(吻合口漏、吻合口出血),术后吻合口狭窄分别为7例,4、6例,150 min(100~220 min),50 mL(30~100 mL),8.5 d(7.0~16.0 d),2、0例,1例;2D组上述指标分别为8例,5、5例,180 min(120~250 min),100 mL(30~200 mL),9.5 d(6.0~17.0 d),1、1例,1例。两组患者末端回肠造口、吻合方式、术后短期并发症、术后吻合口狭窄比较,差异均无统计学意义(P>0.05)。两组患者手术时间、术中出血量、术后住院时间比较,差异均无统计学意义(Z=1.909,1.827,0.687,P>0.05)。两组发生短期并发症患者均经保守治疗后好转。两组各有1例吻合口狭窄患者,内镜无法通过,经内镜下球囊扩张术后好转。(2)术后病理学检查情况:3D组患者术后病理学检查肿瘤最大径,肿瘤下切缘距离,淋巴结清扫数目,系膜内癌结节,直肠系膜完整性(完整、一般),术后病理学分期(Ⅰ期、Ⅱ期、Ⅲ期)分别为3.8 cm(1.8~5.0 cm),1.0 cm(0.5~2.5 cm),14.5枚(6.0~19.0枚),1例,9、1例,4、2、4例;2D组患者上述指标分别为4.8 cm(1.0~8.5 cm),0.8 cm(0.3~1.5 cm),15.5枚(8.0~18.0枚),1例,8、2例,2、4、4例。两组患者肿瘤最大径、肿瘤下切缘距离、淋巴结清扫数目、直肠系膜完整性、术后病理学分期比较,差异均无统计学意义(Z=1.673,1.772,0.038,0.610,0.482,P>0.05)。两组患者系膜内癌结节比较,差异无统计学意义(P>0.05)。两组患者肿瘤下切缘及环周切缘均为阴性。(3)随访情况:3D组和2D组患者均获得随访,随访时间分别为11个月(6~16个月)和13个月(6~21个月)。随访期间,患者均未发现肿瘤局部复发与远处转移,无肿瘤相关死亡。结论:3D腹腔镜应用于TaTME可取得与2D腹腔镜相当的临床疗效,且对手术时间和术中出血量有积极影响。

Objective:To investigate the application value of three-dimensional(3D)laparoscope in the transanal total mesorectal excision(TaTME).Methods:The retrospective cohort study was conducted.The clinicopathological data of 20 patients with middle and low rectal cancer who underwent TaTME in the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2018 to October 2019 were collected.There were 15 males and 5 females,aged from 28 to 81 years,with a median age of 64 years.Of the 20 patients,10 patients using 3D laparoscopic system for transanal approach of TaTME were divided into 3D group,and 10 patients using two-dimensional(2D)laparoscopic system for transanal approach of TaTME were divided into 2D group.Observation indicators:(1)intraoperative situations and postoperative recovery;(2)postoperative pathological examination;(3)follow-up.Follow-up was conducted by outpatient examination and telephone interview to detect survival of patients and recurrence and metastasis of tumors in patients up to April 2020.Measurement data with skewed distribution were represented as M(range),and comparison between groups was analyzed using the Mann-Whitney U test.Count data were described as absolute numbers,and comparison between groups was analyzed using the Fisher exact propability.Comparison of ordinal data was analyzed using the Mann-Whitney U test.Results:(1)Intraoperative situations and postoperative recovery:patients in the two groups completed surgeries successfully,without tranversion to laparostomy from laparoscopic surgery,transversion to transabdominal surgery from transanal surgery,or intraoperative death.The cases with terminal ileostomy,cases with manual anstomosis or mechanical anastomosis(anastomotic methods),operation time,volume of intra-operative blood loss,duration of postoperative hospital stay,cases with anastomotic leakage or anastomotic hemorrahge(postoperative short-term complications),cases with anastomotic stenosis of the 3D group were 7,4,6,150 minutes(range,100-220 minutes),50 mL(range,30-100 mL),8.5 days(range,7.0-16.0 days),2,0,1,respectively,versus 8,5,5,180 minutes(range,120-250 minutes),100 mL(range,30-200 mL),9.5 days(range,6.0-17.0 days),1,1,1 of the 2D group.There was no significant difference in the terminal ileostomy,anastomotic methods,postoperative short-term complications,or anastomotic stenosis between the two groups(P>0.05).There was no significant difference in the operation time,volume of intraoperative blood loss,or duration of postoperative hospital stay between the two groups(Z=1.909,1.827,0.687,P>0.05).Patients with short-term complications in the two groups were improved after conservative treatments.There was 1 patient with anastomotic stenosis in either group,and they were improved after endoscopic balloon dilatation.(2)Postoperative pathological examination:the maximum tumor diameter,distal margin of the tumor,the number of lymph nodes harvested,cases with cancer nodes in the mesentery,cases with complete mesentery or median complete mesentery(the integrity of mesentery),cases in stageⅠ,Ⅱ,Ⅲ(postoperative pathological stage)of the 3D group were 3.8 cm(range,1.8-5.0 cm),1.0 cm(range,0.5-2.5 cm),14.5(range,6.0-19.0),1,9,1,4,2,4,respectively,versus 4.8 cm(range,1.0-8.5 cm),0.8 cm(range,0.3-1.5 cm),15.5(range,8.0-18.0),1,8,2,2,4,4 of the 2D group.There was no significant difference in the maximum tumor diameter,distal margin of the tumor,the number of lymph nodes harvested,the integrity of mesentery,or postoperative pathological stage between the two groups(Z=1.673,1.772,0.038,0.610,0.482,P>0.05).There was no significant difference in the cases with cancer nodes in the mesentery between the two groups(P>0.05).Patients in the two groups had negative distal margin and circumferential margin.(3)Follow-up:patients in the 3D group and 2D group were followed up for 11 months(range,6-16 months)and 13 months(range,6-21 months),respectively.During the follow-up,there was no local recurrence,distal metastasis,or tumor-related death.Conclusions:3D laparoscope applied in the TaTME can achieve similar clinical efficacy with 2D laparoscope,which may have a positive impact on the operation time and volume of intraoperative blood loss.