腹腔镜辅助经肛全直肠系膜切除术在低位直肠癌保肛根治术中的应用研究

Application of laparoscopically assisted transanal total mesorectal excision in the anal-preserving radical resection of low rectal cancer

目的探讨腹腔镜辅助经肛全直肠系膜切除术(Lap-TaTME)在低位直肠癌保肛根治手术中的安全性、近期临床疗效。方法回顾性队列研究。纳入2019年4月—2020年8月蚌埠医学院第一附属医院胃肠外科85例行低位直肠癌根治术患者的临床资料,其中男52例、女33例,年龄40~74岁。患者按照手术方式不同分为Lap-TaTME组31例和腹腔镜辅助全直肠系膜切除术组(Lap-TME组)54例。观察指标:比较2组患者的基线资料、围手术期指标、病理学指标、保肛率及手术中转率、术后30 d内并发症发生率、术后肛门功能Wexner评分以及术后复发、转移情况。结果(1)基线资料比较:2组患者的性别、年龄、体质量指数、糖尿病史、高血压病史、吸烟史、肿瘤分期等差异均无统计学意义(P值均>0.05)。(2)围手术期指标:Lap-TaTME组的手术时间长于Lap-TME组,术后住院时间和首次排气时间均短于Lap-TME组,差异均有统计学意义(t=2.19、3.26、4.43,P值均<0.05);2组患者术中出血量、预防性造口差异均无统计学意义(P值均>0.05)。(3)病理学指标:2组患者的肿瘤直径、下切缘距肛缘的距离、清扫淋巴结数目、肿瘤下切缘阳性、环周切缘阳性、分化程度比较差异均无统计学意义(P值均>0.05);(4)2组患者保肛率、手术中转率差异均无统计学意义(P值均>0.05)。(5)术后30 d内并发症发生率Lap-TaTME组为12.90%(4/31),Lap-TME组为11.11%(6/54),差异无统计学意义(χ2=7.92,P=0.244)。(6)肛门功能Wexner评分:术前1周和术后12个月的肛门功能Wexner评分,2组差异均无统计学意义(P值均>0.05);术后3个月、6个月时Lap-TaTME组均优于Lap-TME组,分别为(8.6±2.1)与(10.0±2.1)分、(6.4±1.4)与(7.8±1.9)分,差异均有统计学意义(t=2.77,P=0.007;t=3.55,P<0.001)。(7)复发、转移情况:患者均获随访12~16个月,期间Lap-TME组1例局部复发,无远处转移,Lap-TaTME组均未发生局部复发及转移。结论Lap-TaTME在低位直肠癌保肛根治术中安全可行,患者术后恢复快,短期临床疗效明确。

Objective To investigate the safety and short-term clinical efficacy of laparoscopically assisted transanal total mesorectal resection(Lap-TaTME)in the anal-preserving radical resection of low rectal cancer.Methods In this retrospective cohort study,the clinical data of 85 patients who underwent the radical resection of low rectal cancer at the Department of Gastrointestinal Surgery of the First Affiliated Hospital of Bengbu Medical College from April 2019 to August 2020 were included.Of the 85 patients,52 were males,and 33 were females,and their age range was 40-74 years.The patients were divided into two groups according to different surgical methods:the Lap-TaTME group(31 patients)and the laparoscopically assisted total mesorectal resection(Lap-TME)group(54 patients).The following observation indicators were obtained and compared:baseline data,perioperative indicators,pathological indicators,anus preservation rate and surgical transition rate,complications within 30 days after surgery,postoperative anal function Wexner score,postoperative recurrence,and metastasis.Results(1)The comparison of baseline data showed no statistically significant differences in gender,age,BMI,diabetes,hypertension,smoking history,tumor stage,and other indicators between the two groups(all P values>0.05).(2)As for the perioperative indicators,the operation time of the Lap-TaTME group was longer than that in the Lap-TME group,the postoperative hospital stay and the first exhaust time of the Lap-TaTME group were significantly shorter than those of the Lap-TME group(t=2.19,3.26,4.426;all P values<0.05).Their intraoperative blood loss,preventive stoma,and other indicators had no statistically significant differences(all P values>0.05).(3)In terms of the pathological indicators,the tumor diameter,the distance between the inferior resection margin and the anal margin,the number of lymph nodes,the positive inferior resection margin of the tumor,the positive circumferential resection margin,and the degree of differentiation did not significantly differ between the two groups(all P values>0.05).(4)The anus preservation rate and operation transition rate of the two groups were not significantly different(all P values>0.05).(5)The incidences of complications within 30 days after operation were 12.90%(4/31)in the Lap-TaTME group and 11.11%(6/54)in the Lap-TME group.These values had no significant differences(χ2=7.92,P=0.244).(6)The Wexner score of anal function 1 week before operation and 12 months after operation did not significantly differ(all P values>0.05);Wexner scores of anal function in the Lap-TATME group were(8.6±2.1)and(10.0±2.1)points at 3 and 6 months after surgery,which were significantly higher than those in the Lap-TME group(6.4±1.4)and(7.8±1.9)points(t=2.77,P=0.007;t=3.55,P<0.001).(7)All patients were followed up to monitor recurrence and metastasis(12-16 months).During this period,one case in the Lap-TME group had local recurrence and no distant metastasis.Conversely,the cases in the Lap-TaTME group did not have local recurrence or metastasis.Conclusion Lap-TaTME is safe during the anal-preserving radical resection of low rectal cancer and has a quick postoperative recovery.Its short-term clinical effect is clear.