改良腹腔镜肛提肌外腹会阴联合切除术治疗超低位直肠癌的近期疗效

Short⁃term efficacy of modified laparoscopic extralevator abdominoperineal excision for ultralow rectal cancer

目的探讨改良腹腔镜肛提肌外腹会阴联合切除术(L⁃ELAPE)治疗超低位直肠癌的近期疗效。方法采用回顾性队列研究方法。收集2014年1月至2018年7月空军军医大学附属唐都医院收治的60例行L⁃ELAPE治疗超低位直肠癌患者的临床病理资料;男32例,女28例;年龄为(58±12)岁,年龄范围为38~75岁。60例患者中,30例行改良L⁃ELAPE,设为改良组,30例行传统L⁃ELAPE,设为对照组。改良组患者腹部手术步骤同传统L⁃ELAPE。改进部分如下:(1)当肿瘤位于直肠前壁时,采用折刀位直视下完成会阴部手术;(2)为避免小肠术后坠入盆腔,均在腹腔镜下关闭盆底腹膜,必要时放置生物补片。对照组患者腹部及会阴部手术均在截石位下施行,将生物补片缝合于肛提肌边缘。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊方式进行随访,患者术后3个月行盆腔CT检查,了解患者小肠坠入骶前间隙情况。随访时间截至2019年1月。正态分布的计量资料以x􀭰±s表示,组间比较采用t检验。计数资料以绝对数表示,组间比较采用χ2检验或Fisher确切概率法。结果(1)手术情况:改良组和对照组患者均顺利完成手术,无中转开腹及术后1个月内死亡患者。改良组患者手术时间、术中出血量、淋巴结清扫数目、全组标本质量评分、前壁肿瘤标本质量评分分别为(359±105)min、(192±99)mL、(17±6)枚、(4.1±0.8)分、(4.7±0.5)分;对照组患者上述指标分别为(268±37)min、(136±61)mL、(15±5)枚、(3.5±0.7)分、(3.9±0.7)分。两组患者手术时间、全组标本质量评分、前壁肿瘤标本质量评分比较,差异均有统计学意义(t=2.613,2.130,2.871,P<0.05)。两组患者术中出血量和淋巴结清扫数目比较,差异均无统计学意义(t=1.521,0.864,P>0.05)。(2)术后情况:改良组患者术后首次进食流质饮食时间、术后尿管拔除时间、术后第1天C反应蛋白量、术后住院时间、会阴部并发症发生例数分别为(3.3±1.1)d、(8.7±4.8)d、(85±27)mg/L、(8.5±4.5)d、4例。对照组患者上述指标分别为(2.7±1.4)d、(7.7±2.8)d、(79±25)mg/L、(7.7±2.2)d、5例。两组患者术后首次进食流质饮食时间、术后尿管拔除时间、术后第1天C反应蛋白量、术后住院时间比较,差异均无统计学意义(t=1.311,1.520,0.521,0.509,P>0.05)。两组患者会阴部并发症比较,差异无统计学意义(P>0.05)。所有出现会阴部并发症的患者经引流、换药、营养支持、延长住院时间后治愈。(3)随访情况:改良组和对照组患者均获得术后随访,术后3个月随访CT检查结果示术后小肠坠入骶前间隙例数分别为2例和19例,两组比较,差异有统计学意义(χ2=21.172,P<0.05)。结论改良L⁃ELAPE治疗超低位直肠癌安全、可行,对于超低位直肠前壁肿瘤显露更好、标本质量更高,可减少小肠坠入骶前间隙发生率,但手术时间较长。

Objective To evaluate the short⁃term efficacy of modified laparoscopic extralevator abdomino⁃perineal excision(L⁃ELAPE)for ultralow rectal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 60 patients with ultralow rectal cancer who underwent L⁃ELAPE in the Tangdu Hospital Affiliated to the Air Force Medical University from January 2014 to July 2018 were collected.There were 32 males and 28 females,aged(58±12)years,with a range from 38 to 75 years.Of the 60 patients,30 patients undergoing modified L⁃ELAPE were allocated into modified group and 30 patients undergoing traditional L⁃ELAPE were allocated into control group.For patients in the modified group,the abdominal procedure is the same as the traditional L⁃ELAPE.The improvements were as follows:(1)when tumor was located in the anterior rectal wall,the patient was plased into the jackknife position before starting the perineal procedure.(2)In order to prevent the small intestine from falling into the presacral space after surgery,the pelvic floor peritoneum was closed under laparoscopy and the biological patch was placed if necessary.For patients in the control group,the whole procedure was performed in the lithotomy position and the biological patch was sutured at the levator ani muscle.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow⁃up.Follow⁃up was conducted by outpatient examinations and pelvic computed tomography(CT)examination at 3 months after surgery to assess the small intestine falling into the presacral space up to January 2019.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were described as absolute numbers,and comparison between groups was analyzed using the chi⁃square test or Fisher′s exact probability.Results(1)Surgical situations:patients in the two groups completed surgeries successfully,without tranversion to laparostomy or death within 1 month after operation.The operation time,volume of intraoperative blood loss,the number of lymph node harvested,quality score of the whole group specimens,quality score of anterior wall tumor specimens were(359±105)minutes,(192±99)mL,17±6,4.1±0.8,4.7±0.5 for the modified group,respectively,versus(268±37)minutes,(136±61)mL,15±5,3.5±0.7,3.9±0.7 for the control group,respectively.There were significant differences in the operation time,the quality score of the whole group specimens and the quality score of anterior wall tumor specimens between the two groups(t=2.613,2.130,2.871,P<0.05).There was no significant difference in the volume of intraoperative blood loss or the number of lymph node harvested between the two groups(t=1.521,0.864,P>0.05).(2)Postoperative situations:the time to first liquid food intake,time to urinary catheter removal,the level of C⁃reactive protein at the first postoperative day,duration of postoperative hospital stay and cases with perineal complications were(3.3±1.1)days,(8.7±4.8)days,(85±27)mg/L,(8.5±4.5)days and 4 for the modified group,respectively,versus(2.7±1.4)days,(7.7±2.8)days,(79±25)mg/L,(7.7±2.2)days and 5 for the control group.There was no significant difference in the time to first liquid food intake,time to urinary catheter removal,the level of C⁃reactive protein at the first postoperative day,duration of postoperative hospital stay between the two groups(t=1.311,1.520,0.521,0.509,P>0.05).There was no significant difference in the perineal complications between the two groups(P>0.05).All patients with perineal complications were cured after drainage,wound management,nutritional support and extention of hospital stay.(3)Follow⁃up:all patients were followed up after surgery.The modified group and the control group had 2 cases and 19 cases of small intestine falling into the presacral space showed by the pelvic CT examination at the postoperative 3 months,respectively,showing a significant difference between the two groups(χ2=21.172,P<0.05).Conclusions Modified L⁃ELAPE is safe and feasible for the ultralow rectal cancer,which can provide a better exposure and specimen quality for the tumor located at anterior rectal wall and reduce the incidence of small intestine falling into the presacral space.However,it has longer operation time.