CT检查骨性参数及手术方式对中低位直肠癌困难骨盆及围手术期疗效的影响

Influence of CT examination bony parameters and surgical methods on difficult pelvis and perioperative efficacy of mid-low rectal cancer

目的 探讨CT检查骨性参数及手术方式对中低位直肠癌困难骨盆及围手术期疗效的影响.方法 采用回顾性病例对照研究方法.收集2021年1月至2022年12月南昌大学第一附属医院收治的191例行机器人或腹腔镜全直肠系膜切除术中低位直肠癌患者的临床病理资料;男123例,女68例;年龄为(60±11)岁.191例患者根据手术难度评分,分为困难骨盆组41例,非困难骨盆组150例,在CT检查图像上获取13项骨性参数.观察指标:(1)困难骨盆组与非困难骨盆组患者术中及术后情况比较.(2)影响中低位直肠癌患者成为困难骨盆的因素分析.(3)困难骨盆患者不同手术方式分层分析.正态分布的计量资料以(-x)±s表示,组间比较采用t检验.偏态分布的计量资料以M(范围)表示,组间比较采用Mann-WhitneyU检验.计数资料以绝对数表示,组间比较采用x2检验或Fisher确切概率法.等级资料比较采用Mann-Whitney U检验.采用Logistic回归模型进行单因素和多因素分析.结果 (1)困难骨盆组与非困难骨盆组患者术中及术后情况比较.两组患者手术时间、术中出血量、病灶最大垂直径乘积、术后并发症、术后住院时间、住院费用比较,差异均有统计学意义(t=-4.853、-5.816,Z=2.838,x1=81.498,t=-5.897、-2.770,P<0.05).(2)影响中低位直肠癌患者成为困难骨盆的因素分析.多因素分析结果显示:性别、年龄、骨盆入口前后径、骶尾间径、骨盆深度、AB线、A角、B角是中低位直肠癌患者成为困难骨盆的独立影响因素(优势比=0.080,1.067,3.065,0.004,10 165.062,0.019,0.476,0.662,95%可信区间为 0.016~0.409,1.008~1.130,1.388~6.767,0.001~0.024,477.574~216 361.071,0.003~0.131,0.358~0.632,0.551~0.794,P<0.05).(3)困难骨盆患者不同手术方式分层分析.①困难骨盆患者不同手术方式术前一般资料比较.41例困难骨盆中低位直肠癌患者中,行机器人全直肠系膜切除术15例,行腹腔镜全直肠系膜切除术26例.两种手术方式患者体质量指数比较,差异有统计学意义(t=-2.055,P<0.05).②困难骨盆患者不同手术方式术中及术后情况比较.困难骨盆中低位直肠癌两种手术方式患者手术时间、术中出血量、病灶最大垂直径乘积、淋巴结清扫数目、淋巴结转移数目、肿瘤距肛缘距离、联合脏器切除、术后并发症、术后住院时间、住院费用、T分期、N分期、M分期、脉管癌栓、神经侵犯比较,差异均无统计学意义(P>0.05).结论 性别、年龄、骨盆入口前后径、骶尾间径、骨盆深度、AB线、A角、B角是中低位直肠癌患者成为困难骨盆的独立影响因素.中低位直肠癌困难骨盆患者行机器人手术或腹腔镜手术围手术期疗效无差异.

Objective To investigate the influence of computer tomography(CT)examination bony parameters and surgical methods on difficult pelvis and perioperative efficacy of mid-low rectal cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 191 patients who underwent robotic or laparoscopic total mesorectal excision(TME)for mid-low rectal cancer in the First Affiliated Hospital of Nanchang University from January 2021 to December 2022 were collected.There were 123 males and 68 females,aged(60±11)years.According to the surgical difficulty score,191 patients were divided into the difficult pelvis group of 41 patients and the non-difficult pelvic group of 150 patients.Thirteen pelvic parameters were obtained on CT images of the 191 patients.Observation indicators:(1)comparison of intraoperative and postoperative conditions of patients in the difficult pelvis group and the non-difficult pelvis group;(2)analysis of factors affecting difficult pelvis in patients with mid-low rectal cancer;(3)stratified analysis of different surgical methods for patients with difficult pelvis.Measurement data with normal distribu-tion were represented as Mean±SD,and comparison between groups was conducted using the t test.Measurement data with skewed distribution were represented as M(range),and comparison between groups was conducted using the Mann-Whitney U test.Count data were expressed as absolute numbers,and comparison between groups was conducted using the chi-square test or Fisher exact probability.Comparison of ordinal data was conducted using the Mann-Whitney U test.Univariate and multivariate analyses were conducted using the Logistic regression model.Results(1)Com-parison of intraoperative and postoperative conditions of patients in the difficult pelvis group and the non-difficult pelvis group.There were significant differences in operation time,volume of intra-operative blood loss,sum of the product of the longest diameters(SPD)of tumor lesions,postopera-tive complications,duration of postoperative hospital stay,and hospitalization expenses between the two groups(t=-4.853,-5.816,Z=2.838,χ²=81.498,t=-5.897,-2.770,P<0.05).(2)Analysis of factors affecting difficult pelvis in patients with mid-low rectal cancer.Results of multivariate analysis showed that gender,age,pelvic inlet,distance between the sacral promontory and the coccyx,depth of the pelvis,line AB,angle A,and angle B were independent factors affecting difficult pelvis in patients with mid-low rectal cancer(odds ratio=0.080,1.067,3.065,0.004,10165.062,0.019,0.476,0.662,95%confidence interval as 0.016-0.409,1.008-1.130,1.388-6.767,0.001-0.024,477.574-216361.071,0.003-0.131,0.358-0.632,0.551-0.794,P<0.05).(3)Stratified analysis of different surgical methods for patients with difficult pelvis.①Comparison of general preoperative data of patients with difficult pelvis receiving different surgical methods.Of the 41 mid-low rectal cancer patients with difficult pelvis,15 underwent robotic TME,and 26 underwent laparoscopic TME.There was a significant difference in the body mass index between patients receiving the two surgical methods(t=-2.055,P<0.05).②Comparison of intraoperative and postoperative conditions of patients with difficult pelvis receiving different surgical methods.There was no significant difference in operation time,volume of intraoperative blood loss,SPD of tumor lesions,number of lymph nodes dissected,number of lymph node metastases,distance between tumor and anal verge,combined organ resection,postoperative complications,duration of postoperative hospital stay,hospitalization costs,T staging,N staging,M staging,vascular tumor thrombus,and nerve invasion(P>0.05).Conclusions Gender,age,pelvic inlet,distance between the sacral promontory and the coccyx,pelvic depth,AB line,angle A,and angle B are independent factors affecting difficult pelvis in patients with mid-low rectal cancer.There is no difference in perioperative outcomes between mid-low rectal cancer patients of difficult pelvis who received robotic surgery and laparoscopic surgery.