进展期低位直肠癌腹腔镜与开放侧方淋巴结清扫近期疗效及生存质量比较研究

Comparison of short-term efficacy and midterm survival of laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer

目的探讨腹腔镜直肠癌根治术中行侧方淋巴结清扫(LLND)治疗局部进展期低位直肠癌的可行性、安全性及疗效。方法回顾性分析2000年1月至2019年12月北京大学第一医院普通外科收治的行直肠癌根治术的200例进展期低位直肠癌病人的临床资料,术中均行LLND。根据手术方式分为腹腔镜组(77例)和开放组(123例),比较两组病人的近期疗效及中期肿瘤学结果。结果与开放组比较,腹腔镜组病人手术时间缩短[240(110~550)min vs. 310(140~780)min,Z=-8.714,P<0.001],出血量减少[100(10~1200)mL vs. 400(60~2500)mL,Z=-5.233,P<0.001],术后尿潴留发生率降低(8.8%vs. 21.1%,χ^(2)=4.607,P=0.032),术后尿管拔除时间[4(1~12)d vs. 5(2~24)d,Z=-2.722,P=0.006]和术后住院时间[11(6~59)d vs. 16(7~64)d,Z=-2.274,P=0.023]均缩短。腹腔镜组单侧侧方淋巴结检出总数[5.5(1~17)枚vs. 5.0(1~17)枚,Z=-2.134,P=0.033]和单侧髂内及闭孔动脉淋巴结检出数目[4(1~17)枚vs. 3(1~11)枚,Z=-2.234,P=0.025]均增高。两组病人总生存率及无病生存率差异均无统计学意义(78.6%vs. 79.0%,69.8%vs. 71.3%,P>0.05)。结论腹腔镜技术用于LLND有助于减少术中出血,更好地保护植物神经功能,病人术后恢复更快,可清扫更多的区域淋巴结,但中期肿瘤学结果与开放手术相当。

Objective To compare the technical feasibility,safety,and efficacy of laparoscopic radical excision combined with lateral lymph node dissection(LLND) with open LLND for locally advanced low rectal cancer.Methods A total of 200 patients’ clinical data with rectal cancer who received radical resection with LLND at the Department of General Surgery of Peking University First Hospital from January 2000 to December 2019 were retrospectively analyzed.Patients were divided into laparoscopic LLND group(n=77) and open LLND group(n=123).Variables of short-term efficacy and midterm oncological outcomes were compared between the two groups.Results Compared with open LLND,laparoscopic LLND group had a shorter operative time(240 min vs.310 min,Z=-8.714,P<0.001),less intraoperative blood loss(100 mL vs.400 mL,Z=-5.233,P<0.001),a decreased incidence of postoperative urinary retention(8.8% vs.21.1%,χ^(2)=4.607,P=0.032),shorter postoperative urinary catheter indwelling duration(4 d vs.5 d,Z=-2.722,P=0.006) and shorter postoperative hospital stay(11 d vs.16 d,Z=-2.274,P=0.023).Pathological results showed that the laparoscopic LLND group retrieved more dissected unilateral lateral lymph nodes(5.5 vs.5,Z=-2.134,P=0.033).As to the subgroup in the internal iliac and obturator artery regions,laparoscopic LLND group yielded more lymph nodes than open LLND group(4 vs.3,Z=-2.234,P=0.025).There were no significant differences in overall survival and disease-free survival between two groups(P>0.05).Conclusion Laparoscopic LLND can reduce intraoperative bleeding,better preserve autonomic nerve function,and recover faster postoperatively.Laparoscopic LLND can yield more regional lymph nodes,but the midterm oncological results are comparable to those of open LLND.