直肠癌骶前复发不同手术方式的临床疗效比较

Comparison of clinical efficacy among different surgical methods for presacral recurrent rectal cancer

目的:探讨不同手术方式治疗直肠癌骶前复发的有效性及预后。方法:采用回顾性队列研究方法。病例纳入标准为:(1)原发直肠癌不伴远处转移,且接受根治手术;(2)诊断为直肠癌骶前复发后接受外科根治性手术治疗;(3)病例资料及随访资料完整。根据以上标准,选取2008年1月至2017年12月期间,在北京大学人民医院胃肠外科收治的行外科手术治疗的47例直肠癌骶前复发患者临床资料,男性31例,女性16例,平均年龄为57岁,其中低分化或印戒细胞癌比例为9例(19.1%),中-高分化38例(80.9%);有40.4%(19/47)的患者进行术前新辅助治疗。根据行根治性手术方式的不同,分为经腹或腹会阴联合切除组(22例)、单纯骶骨切除组(15例)及腹骶联合切除组(10例)。总结并比较3组患者围手术期情况及预后。采用Kaplan-Meier法绘制生存曲线并计算总生存率,并用Log-rank检验进行组间比较。结果:3组患者基线资料的比较,差异均无统计学意义(均P>0.05)。47例患者均顺利完成外科根治手术,手术时间(4.7±2.1)h,术中中位出血量600 ml,术后中位住院时间17 d,共15例(31.9%)出现围手术期并发症,其中Ⅲ~Ⅳ级3例;无围手术期死亡病例出现。3组比较,腹骶联合切除组手术时间最长[(7.4±1.6)h],经腹或腹会阴联合切除组次之[(4.9±1.6)h],单纯骶骨切除组最短[(3.0±1.1)h],差异具有统计学意义(F=25.071,P<0.001);3组的术中出血量、术后住院天数以及围手术期并发症的比较,差异均无统计学意义(均P>0.05)。全组患者中位随访24个月,共12例(25.5%)出现术后功能障碍。腹骶联合切除组的术后功能障碍发生比例(5/10)高于单纯骶骨切除组(4/15)和经腹或腹会阴联合切除组(13.6%,3/22),差异具有统计学意义(χ^2=9.307,P=0.010)。全组患者1年总体生存率为86.1%,3年总体生存率为40.2%。经腹或腹会阴联合切除组、单纯骶骨切除组和腹骶联合切除组患者术后1年总体生存率分别为86.0%、86.7%和83.3%,3年总体生存率分别为33.2%、40.0%以及62.5%,差异无统计学意义(χ^2=0.222,P=0.895)。结论:经腹或腹会阴联合切除术、单纯骶骨切除术及腹骶联合切除手术均为治疗直肠癌骶前复发的有效手术方式,腹骶联合切除手术需关注术中功能保护。

Objective To investigate the efficacy and prognosis of three surgical methods for presacral recurrent rectal cancer(PRRC).Methods A retrospective cohort study was carried out.Case inclusion criteria:(1)primary rectal cancer without distant metastasis and undergoing radical surgery;(2)patients undergoing radical surgery after the diagnosis of PRRC;(3)complete inpatient,outpatient and follow-up data.Clinical data of 47 patients meeting the above criteria who underwent operation at the Department of Gastrointestinal Surgery,The Peking University People's Hospital from January 2008 to December 2017 were reviewed and analyzed retrospectively.Of the 47 patients,31 were male and 16 were female;the mean age was 57 years old;9(19.1%)were low differentiation or signet ring cell carcinoma,38(80.9%)were medium differentiation;19(40.4%)received neoadjuvant therapy.According to operative procedure,22 patients were in the abdominal/abdominoperineal resection group,15 in the sacrectomy group and 10 in the abdominosacral resection group.The operative data,postoperative data and prognosis were compared among the three groups.Survival curve was conducted using the Kaplan-Meier method,and log-rank test was used to compare survival difference among three groups.Results There were no significant differences in baseline data among three groups(all P>0.05).All the 47 patients completed the radical resection successfully.The mean operation time was(4.7±2.1)hours,the median intraoperative blood loss was 600 ml,and the median postoperative hospitalization time was 17 days.Fifteen cases(31.9%)had perioperative complications,of which 3 cases were grade III-IV.There was no perioperative death.The mean operative time was(7.4±1.6)hours in the abdominosacral resection group,(4.9±1.6)hours in the abdominal/abdominoperineal resection group,and(3.0±1.1)hours in the sacroectomy group,with a significant difference(F=25.071,P<0.001).There were no significant differences in intraoperative blood loss,postoperative hospitalization days and perioperative complications among the three groups(all P>0.05).The median follow-up period of all the patients was 24 months,12 cases(25.5%)developed postoperative dysfunction.The incidence of postoperative dysfunction in the abdominosacral resection group was 5/10,which was higher than 4/15 in the sacrectomy group and 3/22(13.6%)in the abdominoperineal resection group with statistically significant difference(χ^2=9.307,P=0.010).The 1-year and 3-year overall survival rates were 86.1%and 40.2%respectively.The 1-year overall survival rates were 86.0%,86.7%and 83.3%,and the 3-year overall survival rates were 33.2%,40.0%and 62.5%in the abdominal/abdominoperineal resection group,sacrectomy group and abdominosacral resection group,respectively,whose difference was not statistically significant(χ^2=0.222,P=0.895).Conclusions Abdominal/abdominoperineal resection,sacrectomy and abdominosacral resection are all effective for PRRC.Intraoperative function protection should be concerned for patients undergoing abdominosacral resection.