[评论]腹会阴联合切除术与低位直肠前切除术治疗极低位直肠癌的疗效比较

[Comment]Comparison of outcomes for abdominoperineal resection versus low anterior resection for very-low rectal cancer

背景极低位直肠癌的治疗是普通外科和结直肠外科医师面临的最具挑战性的问题之一。为了获得更佳的肿瘤学结果,许多医师更倾向于实施腹会阴联合切除术而非低位直肠前切除术。本研究旨在比较腹会阴联合切除术或低位直肠前切除术治疗极低位直肠癌的长期肿瘤学预后。方法本研究回顾性分析了2010年至2016年间美国直肠癌联盟的数据,纳入了Ⅰ~Ⅲ期且接受了腹会阴联合切除术或低位直肠前切除术的极低位直肠癌(定义为肿瘤距离肛管直肠结合部<5 cm)患者。主要研究终点是无病生存率,次要研究终点包括总体生存率、住院时间、并发症发生率、复发位置以及围手术期的相关因素。结果研究共纳入了431例接受腹会阴联合切除术或低位直肠前切除术的极低位直肠癌患者。其中,154例(35.7%)患者接受了腹会阴联合切除术。患者的总体复发率为19.6%,中位随访期为42.5个月。对患者人口统计学特征和病理分期进行调整的分析显示,两种手术方法在无病生存率上并无显著差异(腹会阴联合切除术的HR=0.90,95%CI为0.53~1.52,P=0.70)。在包括总体生存率(HR=1.29,95%CI为0.71~2.32,P=0.39)、并发症发生率(OR=1.53,95%CI为0.94~2.50,P=0.12)和住院时间(估计值为0.04,标准误差为0.25,P=0.54)在内的次要终点方面,两种手术方法比较差异无统计学意义。结论本研究观察到,在治疗极低位直肠癌的患者中,无论是采用腹会阴联合切除术还是低位直肠前切除术,其无病生存率或总体生存率比较差异无统计学意义。这一发现支持在没有括约肌受累的情况下,可以根据具体情况选择腹会阴联合切除术或低位直肠前切除术来治疗极低位直肠癌。

Background The management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons.Many feel compelled to pursue abdominoperineal resection(APR)over low anterior resection(LAR)to optimize oncologic outcomes.This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer.Methods The United States Rectal Cancer Consortium(2010-2016)was queried for adults who underwent either APR or LAR for stageⅠ-Ⅲrectal cancers<5 cm from anorectal junction and met inclusion criteria.The primary outcome was disease-free survival.Secondary outcomes included overall survival,length of stay,complications,recurrence location,and perioperative factors.Results A total of 431 patients with very-low rectal cancer who underwent APR or LAR were identified;154(35.7%)underwent APR.The overall recurrence rate was 19.6%.The median follow-up was 42.5 months.An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types(APR-hazard ratio[HR],0.90;95%CI,0.53–1.52;P=0.70).Secondary outcomes demonstrated no significant difference between operation types,including overall survival(HR,1.29;95%CI,0.71-2.32;P=0.39),complications(OR,1.53;95%CI,0.94-2.50;P=0.12),or length of stay(estimate:0.04,SE=0.25,P=0.54).Conclusion We observed no significant difference in disease-free survival or overall survival between patients undergoing APR or LAR for very-low rectal cancer.This analysis supports the treatment of very-low rectal cancer,without sphincter involvement,by either APR or LAR.