腹腔镜与开腹全直肠系膜切除保肛术治疗低位直肠癌的对照研究及短期疗效分析

Laparoscopic versus open total mesorectal exision with anal sphincter preservation for low rectal cancer: a randomized trial on short-term outcomes

目的 探索应用腹腔镜技术实施全直肠系膜切除保肛术治疗低位直肠癌的可行性。方法将171例低位直肠癌患者(肿瘤下缘均位于齿状线以上1.5～7.0 cm内)随机选取82例行腹腔镜下全直肠系膜切除(TME)保肛术(腹腔镜组);另89例作为对照组在开腹条件下完成相同手术(开腹组)。结果 手术均获成功,保肛率100％。腹腔镜组和开腹组的平均手术时间分别为120 min和106 min(P>0.05),术中平均失血量分别为20ml和92ml(P<0.05)。两组术后镇痛和术后进食时间差异无显著性意义。腹腔镜组较开腹组术后并发症发生率低、胃肠功能恢复快、住院时间短(P<0.05)。腹腔镜组52例(63.4％)和开腹组59例(66.3％)患者在术后1个月内恢复控便能力;其余出现不同程度控便能力障碍(大便次数10～20次/d)的患者,经过药物治疗和括约肌功能训练,6个月后也逐渐实现了良好的控便。术后随访1～18个月,两组均无腹壁切口种植、局部复发以及死亡病例。结论 应用腹腔镜技术实施低位直肠癌TME保肛术安全可行,其创伤小、出血少、保肛率高、术后恢复快,是极具应用前景的微创新技术。

Objective To assess the feasibility of laparoscopic total mesorectal excision(TME) with anal sphincter preservation (ASP) for low rectal cancer. Methods From June 2001 to Sep. 2002, 171 patients with low rectal cancer which the distance from the lowest margin of tumor to the dentate line ranged from 1. 5 to 7cm underwent total mesorectal excision with anal sphincter preservation. Among them, 82 patients were selected randomly to receive laparoscopic operation (laparoscopic group) and the other 89 patients to receive open operation(laparotomic group) . Results The rate of sphincter preservation were 100%. TME and ASP were accomplished in all the patients except one in laparoscopic group who was converted to open procedure because of blood coagulation disorder. The mean operating time was 120 min in laparoscopic group and 106 min in open laparotomic group ( P > 0. 05), while the mean intra-operative blood loss was 20 ml and 92 ml respectively (P < 0. 05) . There was no significant difference in the use of parenteral analgesics and the start of food intake between the two groups. However, the morbidity rate was lower (6. 1% vs 12. 4%, P < 0. 05), and the return of bowel function was earlier and hospitalization stay was shorter in laparoscopic group than those in laparotomic group. After a follow-up time from 1 to 18 months, there were no port-site recurrence, local recurrence and mortality in the both groups. Conclusions Laparoscopic TME with ASP is feasible, and it is a minimally invasive and perspective technique with the benefits of much lower blood loss during operation, higher rate of sphincter preservation, earlier return of bowel function and shorter hospitalization.