内括约肌切除术治疗低位直肠癌手术难度的影响因素分析

Factors influencing the surgical difficulty of intershphincteric resection for low rectal cancer

目的探讨内括约肌切除术(ISR)治疗低位直肠癌手术难度的影响因素,并初步建立预测模型。方法回顾性分析2016年1月至2020年11月武汉大学中南医院收治的100例行ISR手术的低位直肠癌患者的临床信息及影像学资料,根据患者的临床信息建立ISR手术难度的评分标准,将患者分为容易组和困难组,进行单因素分析和多因素Logistic回归分析ISR手术难度的影响因素,并建立预测模型,用受试者工作特征曲线验证其效能。结果根据手术难度评分标准,78例患者归为手术容易组,22例患者归为困难组。单因素分析表明,肥胖(χ^(2)=4.549,P<0.05)、肿瘤距肛缘距离[(4.49±0.55)cm比(4.40±0.62)cm,t=3.525,P<0.01]、新辅助放化疗(χ^(2)=4.948,P<0.05)、直肠系膜脂肪面积[(18.10±5.30)cm^(2)比(22.38±6.18)cm^(2),t=-3.220,P<0.01]、坐骨结节间距[(11.48±1.39)cm比(10.17±0.84)cm,t=5.497,P<0.01]、骨盆β角[(43.25±6.48)°比(46.50±5.90)°,t=-2.116,P<0.05]是ISR手术困难的影响因素,多因素Logistic回归分析提示肥胖[比值比(OR)=11.935,P<0.05]、新辅助放化疗(OR=11.464,P<0.05)、直肠系膜脂肪面积(OR=1.189,P<0.05)、坐骨结节间距(OR=0.358,P<0.05)是ISR手术难度的独立预测因素。结论肥胖(体质指数≥28 kg/m^(2))、新辅助放化疗、直肠系膜脂肪面积≥21.90 cm^(2)、坐骨结节间距≤10.29 cm的患者行ISR手术难度较大。

Objective To investigate the factors influencing the operative difficulty of intershphincteric resection(ISR)in the treatment of low rectal cancer,and to establish a prediction model.Methods The clinical information and imaging data of 100 patients with low rectal cancer undergoing ISR surgery admitted to Zhongnan Hospital of Wuhan University from January 2016 to November 2020 were retrospectively analyzed.According to the clinical information of the patients,the scoring standard of ISR operation difficulty was established,dividing the patients into easy group and difficult group.Single factor analysis and multivariable logistic regression analysis were used to pick out the influence factors of ISR operation difficulty,and a prediction model was established.Receiver operating characteristic curve was used to verify the effectiveness of the prediction model.Results According to the scoring standard of operation difficulty,78 patients were classified as easy group and 22 patients as difficult group.Single factor analysis showed that obesity(χ^(2)=4.549,P<0.05),distance of tumor from anal margin[(4.49±0.55)cm vs.(4.40±0.62)cm,t=3.525,P<0.01],neoadjuvant chemoradiotherapy(χ^(2)=4.948,P<0.05),mesorectal fat area[(18.10±5.30)cm^(2) vs.(22.38±6.18)cm^(2),t=-3.220,P<0.01],the intertuberous distance[(11.48±1.39)cm vs.(10.17±0.84)cm,t=5.497,P<0.01]and the pelvic angle β[(43.25±6.48)°vs.(46.50±5.90)°,t=-2.116,P<0.05]were the influential factors for the surgical difficulty of ISR,multivariate logistic regression analysis suggested that obesity[odds ratio(OR=11.935,95% confidence interval(CI):2.411-63.577,P<0.05)],neoadjuvant chemoradiotherapy(OR=11.646,95%CI:1.648-79.760,P<0.05),mesorectal fat area(OR=1.189,95%CI:1.015-1.393,P<0.05)and intertuberous distance(OR=0.358,95%CI:0.135-0.949,P<0.05)were the independent risk factors for surgical difficulty of ISR.Conclusion Preoperative comprehensive evaluation of clinical data and pelvic factors in patients with low rectal cancer can predict the surgical difficulty of ISR,which is helpful to determine an appropriate surgical approach before surgery and reduce complications.