经闭孔神经前入路二次离断用于低位直肠癌初次离断远端切缘不足的可行性及近期疗效分析

Feasibility and short-term efficacy of secondary transction by trans-anterior obturator nerve gateway for the insufficiency of primary transection in low rectal cancer

目的评估经闭孔神经前入路二次离断应用于低位直肠癌初次离断远端切缘不足的可行性及近期疗效。方法回顾性分析2021年9月至2023年8月中国医学科学院肿瘤医院结直肠外科收治的10例应用经闭孔神经前入路完成低位直肠癌初次离断失败的挽救治疗病例的临床资料。所有病人均经闭孔神经前入路完成二次离断,采用管状吻合器行结肠肛管吻合或经腹经括约肌间切除术,并常规行末端回肠预防性造口。结果10例病人均顺利完成二次离断和双吻合手术。初次切缘情况:3例术中冰冻切片病理检查示远端切缘阳性,7例远端切缘紧邻肿瘤。围手术期情况:建立经闭孔神经前入路通道的时间为7(5~10)min,二次离断距离为8.5(7.0~11.0)mm,最终远端切缘距离为11.0(8.0~14.0)mm,吻合口距肛缘距离为2.0(2.0~2.5)cm。术后二次离断切缘病理检查结果均为阴性。术后发生Clavien-Dindo分级>Ⅱ级并发症3例,其中吻合口漏2例,小肠梗阻1例,均经保守治疗好转。中位随访14(8~24)个月,9例病人造口还纳,1例术后吻合口漏病人继发吻合口狭窄,致永久性造口。术后无排尿功能障碍、局部复发和远处转移。结论经闭孔神经前入路二次离断可作为低位保肛初次远端切缘不足的补救措施,并可获得再次保留肛门括约肌的可能,其长期疗效及较传统经肛离断的优势有待进一步研究证实。

To evaluate the feasibility and short-term efficacy of secondary transection by trans-anterior obturator nerve gateway in the treatment of the failure of primary transection and the insufficiency of distal margin in low rectal cancer.Methods The clinical data of 10 patients were retrospectively analyzed in the same surgical team of the Department of Colorectal Surgery,Cancer Hospital,Chinese Academy of Medical Sciences,who used the anterior obturator nerve gateway to complete salvage treatment for the failure of primary resection of ultralow rectal cancer between September 2021 and August 2023.All patients underwent secondary transection by trans-anterior obturator nerve gateway,coloanal anastomosis or transabdominal intersphincteric resection,and routine ileostomy.Results All 10 patients successfully received the secondary transection.Results of primary transection margin:frozen biopsy indicated positive margin in 3 cases and tumor adjacent to margin in 7 cases.Perioperative results:the median time for gateway establishment was 7(5-10)minutes,the secondary transection height was 8.5(7.0-11.0)mm,the final distal margin was 11.0(8.0-14.0)mm,and the anastomosis was 2.0(2.0-2.5)cm from the anal margin.The postoperative pathology of the secondary transection margin was negative.Postoperative complications(CD gradeⅡor above)were reported in 3 cases,including·2 cases of anastomotic leakage and 1 case of small-bowel obstruction,all of which were improved by conservative treatment.During a median follow-up time of 14(8-24)months,9 patients underwent stoma reversal,and 1 patient underwent permanent stoma because of anastomotic stenosis due to anastomotic leakage.No voiding dysfunction,local recurrence,or distant metastasis was observed in all patients.Conclusion Secondary transection by trans-anterior obturator nerve gateway can be the salvage for the insufficiency of primary transection in low rectal cancer and provide the possibility of anal preservation again,but its long-term efficacy and advantages over traditional transanal transection need further research.