经肛腔镜部分内括约肌切除术治疗超低位直肠癌的应用价值

Application value of transanal endoscopic partial intersphincteric resection for ultra-low rectal cancer

目的探讨经肛腔镜部分内括约肌切除术(ISR)治疗超低位直肠癌的应用价值。方法采用回顾性描述性研究方法。收集2017年12月至2020年8月厦门大学附属第一医院收治的9例超低位直肠癌行经肛腔镜部分ISR病人的临床病理资料;男8例,女1例;中位年龄为58岁,年龄范围为39~62岁。观察指标:(1)手术及术后情况。(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,了解病人术后肿瘤局部复发与远处转移,生存,造瘘口还纳,还纳后3个月肛门功能,直肠癌术后6个月男性病人性功能、排尿功能,女性病人性功能情况。随访时间截至2021年2月。正态分布的计量资料以x±s表示。偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术及术后情况:9例病人均顺利完成手术,无中转开腹。9例病人中,7例行经肛腔镜部分ISR,2例由于肿瘤下缘位于齿状线水平,行经肛腔镜改良部分ISR。9例病人手术时间为(267±48)min,术中出血量为50 mL(30~60 mL)。9例病人中,5例经肛移除标本,4例经腹移除标本。9例病人均采用经肛手工吻合完成消化道重建,均行保护性回肠造口术,术后均留置2根盆腔引流管。9例病人中,3例留置肛管,6例未留置肛管;3例发生术中不良事件,6例未发生术中不良事件。9例病人术后首次肠造口排气时间为3 d(2~4 d),术后首次进食半流质食物时间为5 d(4~7 d),术后30 d发生Clavien-Dindo分级Ⅰ级并发症1例、Ⅱ级并发症2例,余6例病人均未见术后相关并发症;9例病人均无吻合口出血、狭窄及尿潴留。9例病人术后住院时间为11 d(9~23 d),住院总费用为(6.8±1.3)万元。(2)术后病理学检查情况:9例病人肿瘤长径为(3.2±1.4)cm,远端切缘距离为0.6 cm(0.5~1.5 cm),淋巴结清扫数目为(17±7)枚,阳性淋巴结数目为0枚(0~7枚),肿瘤病理学类型均为腺癌,肿瘤结节与神经浸润均为阴性,仅1例病人发现脉管癌栓。9例病人标本远端切缘和环周切缘均为阴性,直肠系膜均完整。9例病人中,6例术前临床T分期T1~T2期病人术后病理学TNM分期分别为pT2N0M0期3例,pT2N1M0期、pT2N2M0期、pT3N1M0期各1例;3例术前临床T分期T3期病人术后病理学TNM分期分别为ypT0N0M0期、ypT2N0M0期、ypT3N0M0期各1例。(3)随访情况:9例病人均获得随访,随访时间为6~13个月,中位随访时间为9个月,未发现肿瘤局部复发与远处转移,无肿瘤相关死亡。9例病人中,1例病人未行造瘘口还纳术,未评估术后肛门功能;余8例均行造瘘口还纳术,术后肛门功能排便控制能力为无障碍5例、轻度障碍2例、重度障碍1例;8例男性病人术后排尿功能为轻度障碍6例,中度障碍、重度障碍各1例,术后性功能为无障碍3例、轻度障碍2例、中度障碍3例;1例女性病人术后性功能无障碍,女性性功能指数6项评分表总评分为25分。结论经肛腔镜部分ISR可用于治疗超低位直肠癌。

Objective To investigate the application value of transanal endoscopic partial intersphincteric resection for ultra-low rectal cancer.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 9 ultra-low rectal cancer patients undergoing transanal endoscopic partial intersphincteric resection at the First Affiliated Hospital of Xiamen University from December 2017 to August 2020 were collected.There were 8 males and 1 female,aged from 39 to 62 years,with a median age of 58 years.Observation indicators:(1)surgical and postoperative situations;(2)postoperative pathological examination;(3)follow-up.Follow-up was conducted using outpatient examination and telephone interview to detect postoperative tumor local recurrence and distant metastasis,survival of patients,ileostomy closure,anus function at 3 months after ileostomy closure,male urinary and sexual function and female sexual function at 6 months after rectal surgery.The follow-up was up to February 2021.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers.Results(1)Surgical and postoperative situations:all 9 patients underwent surgery successfully,without conversion to open surgery.Seven of the 9 patients underwent transanal endoscopic partial intersphincteric resection and the rest of 2 patients with tumor close to the dentate line underwent transanal endoscopic modified partial intersphincteric resection.The operation time and volume of intraoperative blood loss of 9 patients were(267±48)minutes and 50 mL(range,30‒60 mL),respectively.Five of the 9 patients underwent transanal specimen extraction,and 4 patients underwent specimen extraction by an abdominal incision.All 9 patients underwent transanal hand-sewn coloanal anastomosis and protective ileostomy,and two pelvic drainage tubes were indwelled.Transanal drainage tube was placed after anastomosis in 3 of 9 patients.Three cases had intraoperative adverse events and there were no intraoperative adverse event reported in the remaining 6 cases.The time to postoperative initial stoma exhausting and time to postoperative first semi-liquid food intake of 9 patients were 3 days(range,2‒4 days)and 5 days(range,4‒7 days),respectively.One case had Clavien-Dindo gradeⅠcomplication and 2 cases had Clavien-Dindo gradeⅡcomplication during postoperative 30 days and the rest of 6 cases had no postoperative complication.No anastomotic stricture,hemorrhage or urinary retention occurred in 9 patients.The duration of postoperative hospital stay and cost of hospitalization of 9 patients were 11 days(range,9‒23 days)and(6.8±1.3)×10^(4) yuan,respectively.(2)Postoperative pathological examination:the diameter of tumor,the distance of distal resection margin,the number of lymph node dissected and the number of positive lymph node of 9 patients were(3.2±1.4)cm,0.6 cm(range,0.5‒1.5 cm),17±7 and 0(range,0‒7),respectively.The tumor histopathological type was adenocarcinoma with negative tumor nodule and nerve infiltration in all 9 patients.Only 1 case of 9 patients was found vascular tumor thrombus.The surgical specimens of all 9 patients showed negative for distal and circumferential margins and complete mesorectum.Results of postoperative pathological TNM staging showed that of 6 cases with preoperative T1-T2 staging tumors,3 cases were classified as pT2N0M0 stage,and 3 cases were classified as pT2N1M0 stage,pT2N2M0 stage or pT3N1M0 stage,respectively.Three cases with preoperative T3 staging tumors were classified as ypT0N0M0 stage,ypT2N0M0 stage or ypT3N0M0 stage,respectively.(3)Follow-up:all 9 patients were followed up for 6 to 13 months,with a median follow-up time of 9 months.No local recurrence,distant metastasis or tumor-related death was found during follow-up.Of the 9 patients,only 1 case did not receive stoma closure and undergo anus function assessment,and the rest of 8 cases underwent stoma closure.Results of postoperative anus function assessment showed 5 cases of accessibility,2 cases of mild impairment and 1 case of severe impairment.Results of urogenital function assessment showed 6 cases of the 8 male patients of mild impairment,1 case of moderate impairment and 1 case of severe impairment in micturition function,respectively,and 3 cases of accessibility,2 cases of mild impairment and 3 cases of moderate impairment in sexual function,respectively.The female patient underwent accessibility of sexual function and the six-item version of the female sexual function index was 25.Conclusion Transanal endoscopic partial intersphincteric resection can be used for the treatment of ultra-low rectal cancer.