摘要目的: 观察腹腔镜下全经腹入路低位直肠癌部分内括约肌切除保肛术的临床疗效及生存质量情况。方法: 回顾性分析2015年1月至2019年12月,选取181例,依据不同术式将患者分为观察组,对照组1和对照组2,收集术中及术后恢复情况、肿瘤根治、肛门功能、生存质量评分等情况。结果: 观察组比对照组1中肿瘤距肛缘的距离更低(3.72±0.74cm vs 5.67±0.54cm,P<0.05);三组手术指标比较中,观察组与对照组1比对照组2的出血量更少(52.3±28.2mL vs 48.2±20.9mL vs 96.2±27.3mL),手术时间更短(197±6.8min vs 195±5.4min vs 208±10.7min),术后住院时间更短(13.5±4.9d vs 13.1±3.7d vs 17.3±4.7d),具有统计学意义(P<0.05);术后三组并发症方面无统计学意义。三组间肿瘤根治中,患者远端切缘距离、环周切缘、淋巴结清扫等情况差异无统计学意义;三组生存预后中总的生存率分别为93.3%、90.2%、91.7%(P>0.05),无统计学意义。2组保肛患者术后肛门功能比较显示,对照组1中肛管静息压力、肛管最大收缩压、最大耐受容积、排便次数,术后3个月内相较于观察组恢复较快,排便功能良好率较高(85.2% vs 58.3%,P<0.05);但手术3~6个月后,肛门功能差异并无统计差异(P>0.05)。肿瘤患者生活质量评分中,观察组保肛患者明显高于对照组2中腹壁造口患者(P<0.05);肛门功能逐步恢复,有助于生活质量也逐步提高。结论: 腹腔镜下全经腹入路部分内括约肌切除保肛术治疗低位直肠癌患者,术后临床疗效及肛门功能恢复良好,有助于提高患者生存质量,具有一定的安全性及可行性。
Abstract：Objective: To observe the clinical efficacy and quality of life of laparoscopic partial internal sphincter resection for low rectal cancer. Methods: From January 2015 to December 2019, 181 patients were selected and divided into observation group, control group 1 and control group 2 according to different surgical methods. The intraoperative and postoperative recovery, radical tumor resection, anal function and quality of life score were collected. Results: The distance between tumor and anal margin in the observation group was lower than that in control group 1 ( 3.72±0.74cm vs 5.67±0.54cm, P<0.05 ), which was statistically significant. Among the three groups of surgical indicators, the amount of bleeding in the observation group and control group 1 was less than that in control group 2 ( 52.3±28.2ml vs 48.2±20.9 ml vs 96.2±27.3 ml ), the operation time was shorter (197±6.8min vs 195±5.4 min vs 208±10.7 min ), and the postoperative hospitalization time was shorter (13.5±4.9 d vs 13.1±3.7d vs 17.3±4.7d ), with statistical significance ( P<0.05 ). There was no significant difference in postoperative complications among the three groups. There was no significant difference in distal margin distance, circumferential margin and lymph node dissection among the three groups in tumor radical resection. The overall survival rates in the three groups were 93.3 %, 90.2 % and 91.7 %, respectively ( P>0.05 ), with no statistical significance. The comparison of anal function between the two groups showed that the resting pressure of anal canal, maximum systolic pressure of anal canal, maximum tolerated volume and defecation frequency in control group 1 were faster than those in the observation group within 3 months after operation, and the good rate of defecation function was higher ( 85.2 %vs 58.3%, P<0.05 ). However, there was no statistical difference in anal function between 3 and 6 months after surgery ( P>0.05 ).In the quality of life score of tumor patients, the anus-preserving patients in the observation group were significantly higher than those in control group 2 ( P<0.05 ). The gradual recovery of anal function helps to improve the quality of life. Conclusion: Laparoscopic total transabdominal partial internal sphincter resection and anal sphincter preservation for patients with low rectal cancer has good postoperative clinical efficacy and anal function recovery, which is helpful to improve the quality of life of patients and has certain safety and feasibility.
[1] Lyttle J A,Parks A G.Proceedings: Intersphincteric excision of the rectum in benign inflammatory conditions[J].Gut,1976,17(5): 392. [2] Masahiko Watanabe,Tatsuo Teramoto,Hirotoshi Hasegawa.Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer[J].Dis Colon Rectum,2000,43(10 Suppl): S94~S97. [3] Chi Pan,Huang Sheng-Hui,Lin Hui-Ming et al.Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome[J].Ann Surg Oncol,2015,22(3): 944~951. [4] 任聪,白文武,罗志民,等.腹腔镜直肠癌根治术中保留左结肠动脉可行性的研究[J].河北医学,2018,24(2): 286~290. [5] Shahjehan Faisal,Kasi Pashtoon M,Habermann Elizabeth et al.Trends and outcomes of sphincter-preserving surgery for rectal cancer:a national cancer database study.[J].Int Colorectal Dis,2019,34(2): 239~245. [6] 张斌,刘泉龙,赵玉涓,等.腹腔镜低位直肠癌部分、次全和完全经括约肌间切除术式的肿瘤学结果及肛门功能比较[J].中华胃肠外科杂志,2017,20(8): 904~909. [7] Yamada Kazutaka,Saiki Yasumitsu,Takano Shota et al.Long-term results of intersphincteric resection for low rectal cancer in Japan[J].Surg Today,2019,49(4): 275~285. [8] Hayden Dana M,Mora Pinzon Maria C,Francescatti Amanda B et al.Patient factors may predict anastomotic complications after rectal cancer surgery: Anastomotic complications in rectal cancer[J].Ann Med Surg (Lond),2015,4(1): 11~16. [9] Kim Jin Cheon,Lee Jong Lyul,Bong Joon Woo et al.Oncological and anorectal functional outcomes of robot-assisted intersphincteric resection in lower rectal cancer,particularly the extent of sphincter resection and sphincter saving[J].Surg Endosc,2020,34(5): 2082~2094. [10] Manegold Philipp,Taukert Johannes,Neeff Hannes et al.The minimum distal resection margin in rectal cancer surgery and its impact on local recurrence - A retrospective cohort analysis[J].Int Surg,2019,69: 77~83. [11] 郭志刚.不同内括约肌切除方案对低位直肠癌患者术后肛门功能影响的研究[J].临床医学,2017,37(6): 26~28. [12] 金黑鹰.低位直肠癌术后肛门生理的改变及其对策[J].世界华人消化杂志,2018,26(16): 1005~1009. [13] 郭志刚,周仕海,陈宏,等.腹腔镜超低位直肠癌经括约肌间切除术后肛门控便机制变化的研究[J].中华普通外科学文献(电子版),2018,12(3):200~203.
2021, Vol. 27 
冀公网安备13080202000677号