经腹单孔腔镜联合经肛门腔镜技术治疗低位直肠癌临床疗效研究

郑九建; 王建平

doi:10.16766/j.cnki.issn.1674-4152.003548

经腹单孔腔镜联合经肛门腔镜技术治疗低位直肠癌临床疗效研究

doi: 10.16766/j.cnki.issn.1674-4152.003548

郑九建^,,
王建平

丽水市中心医院肛肠外科，浙江丽水 323000

基金项目:

浙江省卫生健康科技计划项目 2021ZH074

详细信息

通讯作者:
郑九建，E-mail：zhengjiujian86@163.com

中图分类号: R735.37 R730.56
计量
- 文章访问数: 34
- HTML全文浏览量: 13
- PDF下载量: 4
- 被引次数: 0
出版历程
- 收稿日期: 2023-12-11
- 网络出版日期: 2024-07-22

Investigation of the clinical efficacy of transabdominal single-port endoscopic combined with transanal endoscopic techniques in managing low rectal cancer

ZHENG Jiujian^,,
WANG Jianping

Department of Anorectal Surgery, Lishui Central Hospital, Lishui, Zhejiang 323000, China

摘要

摘要: 目的探究单孔入路腹腔镜联合经肛门腔镜全肠系膜切除术治疗低位直肠癌的短期与中期临床效果。方法选择2018年1月—2022年6月丽水市中心医院收治的低位直肠癌患者，均接受直肠前切除术和结肠肛管吻合术。对早期和中期的临床疗效进行分析，并依据标本提取方式进行比较。结果总计62例患者，手术时间为(182.6±30.5)min。22例患者需进行内括约肌切除术。所有患者均进行结肠肛管端端吻合器或手工吻合。术后(1.5±0.3)d回肠造口处首次排便。61例患者为R0切除，1例R1切除，远端切除边缘为(6.2±0.3)mm，3例患者的环形切缘呈阳性。所有病例标本病理检查显示45例完整，17例为接近完整。获得的淋巴结平均为13.5个，其中25例患者标本上的淋巴结数低于12个。35例自回肠造口处、27例经肛管进行标本提取，2种方式患者的BMI(χ²=39.388，P＜0.001)、肿瘤大小(t=4.415, P=0.020)比较，差异均有统计学意义。术后随访时间为(40.6±5.5)个月，中期结局评价研究对象的总生存率为98.4%，无病生存率为80.6%，局部控制率为95.2%。结论腹腔镜联合经肛门腔镜技术治疗低位直肠癌可取得较为理想的短中期临床疗效，能够通过较小的创口实现充分的肿瘤切除和较低的并发症发生率。
- 低位直肠癌 /
- 微创 /
- 腹腔镜 /
- 经肛门腔镜全肠系膜切除术
Abstract: Objective To explore the short-term and mid-term clinical effects of single-port laparoscopy combined with transanal total mesenteric excision for treating low rectal cancer. Methods From January 2018 to June 2022, patients diagnosed with low rectal cancer and treated with anterior rectal resection and coloanal anastomosis at Lishui Central Hospital were included in this study. The early and mid-term clinical efficacies were analyzed and compared based on specimen extraction methods. Results Among the 62 patients, the average operation time was (182.6±30.5) minutes, with 22 requiring internal sphincter resection. All patients underwent either colostomy end-to-end stapler or manual anastomosis. The first bowel movement at the ileostomy site occurred on average (1.5±0.3) days post-surgery. R0 resection was achieved in 61 patients, with only 1 patient of R1 resection. The average distal resection margin was (6.2±0.3) mm, and 3 patients had positive circumferential resection margins. Pathological analysis showed that 45 complete and 17 nearly complete cases. The average number of lymph nodes obtained was 13.5, with 25 patients yielding fewer than 12 lymph nodes on their specimens. Specimens were extracted from the ileostomy site in 35 cases and through the anal canal in 27 cases. There were significant differences in BMI-related variables (χ²=39.388, P < 0.001) and tumor size (t=4.415, P=0.020) between the two methods. The average postoperative follow-up time was (40.6±5.5) months. The mid-term outcome evaluation indicated an overall survival rate of 98.4%, disease-free survival rate of 80.6%, and local control rate of 95.2% among the study subjects. Conclusion Laparoscopy combined with transanal endoscopic techniques can achieve ideal short-and medium-term clinical effects in the treatment of low rectal cancer, facilitate sufficient tumor resection, and minimize complications through smaller wounds.
- Low rectal cancer /
- Minimally invasive /
- Laparoscopy /
- Transanal total mesentery resection

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表 1 不同手术标本取出方式直肠癌患者相关指标比较

Table 1. Comparison of relevant indexes in rectal cancer patients with different surgical specimen extraction methods

组别	例数	性别[例(%)]		BMI[例(%)]		肿瘤大小(x±s，mm)	肛内解剖[例(%)]
组别	例数	男性	女性	25	≥25	肿瘤大小(x±s，mm)	直肠壁切开术	括约肌间切除术
经回肠造口处	35	26(74.3)	9(25.7)	7(20.0)	28(80.0)	21.8±12.4	25(71.4)	10(28.6)
经肛管	27	14(51.9)	13(48.1)	27(100.0)	0	12.0±7.6	15(55.6)	12(44.4)
统计量		3.351^a		39.388^a		4.415^b	1.677^a
P值		0.067		＜0.001		0.020	0.195
注：^a为χ²值，^b为t值。

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表 2 不同手术标本取出方式直肠癌患者相关结局指标比较

Table 2. Comparison of relevant outcome indexes in rectal cancer patients with different surgical specimen extraction methods

组别	例数	直肠系膜完整性[例(%)]			直肠切除手术时间(x±s, min)	造口关闭时间(x±s, min)	直肠切除后并发症[例(%)]			住院时间(x±s, d)	造口延迟关闭(x±s, 周)
组别	例数	3级	2级	1级	直肠切除手术时间(x±s, min)	造口关闭时间(x±s, min)	无	Dindo 1~2	Dindo 3~4	住院时间(x±s, d)	造口延迟关闭(x±s, 周)
经回肠造口处	35	27(77.1)	8(22.9)	0	162.6±40.5	100.6±20.2	32(91.4)	2(5.7)	1(2.9)	4.5±3.3	12.2±4.6
经肛管	27	15(55.6)	12(44.4)	0	196.0±15.8	98.8±14.0	25(92.6)	2(7.4)	0	5.2±2.0	10.4±3.0
统计量		3.250^a			22.015^b	16.225^b	0.028^c			3.303^b	3.169^b
P值		0.071			0.002	0.005	0.867			0.448	0.604
注：^a为χ²值，^b为t值，^c为Z值。

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参考文献(16)

[1]	WILKINSON N. Management of rectal cancer[J]. Surg Clin North Am, 2020, 100(3): 615-628. doi: 10.1016/j.suc.2020.02.014
[2]	白雪杉, 林国乐, 薛晓强, 等. 以经肛门内镜微创手术为平台经肛全直肠系膜切除术治疗中低位直肠癌的临床疗效[J]. 中华消化外科杂志, 2021, 20(3): 339-345. doi: 10.3760/cma.j.cn115610-20210209-00075 BAI X S, LIN G L, XUE X Q, et al. Clinical efficacy of transanal total mesorectal excision in the treatment of middle and low rectal cancer using transanal endoscopic minimally invasive surgery as a platform[J]. Chinese Journal of Digestive Surgery, 2021, 20(3): 339-345. doi: 10.3760/cma.j.cn115610-20210209-00075
[3]	SCHIETROMA M, ROMANO L, APOSTOL A I, et al. Mid-and low-rectal cancer: laparoscopic vs open treatment-short-and long-term results. Meta-analysis of randomized controlled trials[J]. Int J Colorectal Dis, 2022, 37(1): 71-99. doi: 10.1007/s00384-021-04048-9
[4]	孙戈, 臧怡雯, 丁海波, 等. 适形切除保肛术与经括约肌间切除术治疗低位直肠癌的临床疗效[J]. 中华消化外科杂志, 2021, 20(3): 292-300. doi: 10.3760/cma.j.cn115610-20201231-00819 SUN G, ZANG Y W, DING H B, et al. Clinical efficacy of conformal resection, anus-preserving surgery and transsphincteric resection in the treatment of low rectal cancer[J]. Chinese Journal of Digestive Surgery, 2021, 20(3): 292-300. doi: 10.3760/cma.j.cn115610-20201231-00819
[5]	PYO D H, HUH J W, LEE W Y, et al. The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: a propensity score-matched study[J]. Surgery, 2023, 173(2): 335-341. doi: 10.1016/j.surg.2022.10.033
[6]	姚宏伟, 安勇博, 李俊, 等. 如何做好经肛全直肠系膜切除规范化手术、数据录入及数据库管理[J]. 中华胃肠外科杂志, 2019, 22(3): 296-299. YAO H W, AN Y B, LI J, et al. How to perform standardized surgery, data entry and database management of transanal total mesorectal excision[J]. Chinese Journal of Gastrointestinal Surgery, 2019, 22(3): 296-299.
[7]	LI Z, WANG Q, FENG Q, et al. Laparoscopic intersphincteric resection vs. transanal total mesorectal excision in overweight patients with low rectal cancer[J]. Front Surg, 2022, 9: 984680. DOI: 10.3389/fsurg.2022.984680.
[8]	揭海清, 李泽, 罗双灵, 等. 经肛手工加固低位吻合口在直肠癌经肛全直肠系膜切除术后预防吻合口漏中的作用[J]. 中华胃肠外科杂志, 2021, 24(6): 530-535. doi: 10.3760/cma.j.cn.441530-20210408-00151 JIE H Q, LI Z, LUO S L, et al. The role of transanal manual reinforcement of low anastomosis in preventing anastomotic leakage after transanal total mesorectal resection for rectal cancer[J]. Chinese Journal of Gastrointestinal Surgery, 2021, 24(6): 530-535. doi: 10.3760/cma.j.cn.441530-20210408-00151
[9]	ENOMOTO H, ITO M, SASAKI T, et al. Anastomosis-related complications after stapled anastomosis with reinforced sutures in transanal total mesorectal excision for low rectal cancer: a retrospective single-center study[J]. Dis Colon Rectum, 2022, 65(2): 246-253. doi: 10.1097/DCR.0000000000002016
[10]	ZHAO S, ZHANG L, GAO F, et al. Transanal drainage tube use for preventing anastomotic leakage after laparoscopic low anterior resection in patients with rectal cancer: a randomized clinical trial[J]. JAMA Surg, 2021, 156(12): 1151-1158. doi: 10.1001/jamasurg.2021.4568
[11]	王永森, 谢贻祥, 王传思, 等. 腹腔镜下保留左结肠动脉直肠癌根治术的临床研究[J]. 中华全科医学, 2022, 20(3): 366-370. doi: 10.16766/j.cnki.issn.1674-4152.002354 WANG Y S, XIE Y X, WANG C S, et al. Clinical study on laparoscopic left colic artery-preserving radical resection of rectal cancer[J]. Chinese Journal of General Practice, 2022, 20(3): 366-370. doi: 10.16766/j.cnki.issn.1674-4152.002354
[12]	BHATTACHARYA P, PATEL I, FAZILI N, et al. Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer: importance of appropriate patient selection[J]. World J Gastrointest Surg, 2022, 14(12): 1397-1410. doi: 10.4240/wjgs.v14.i12.1397
[13]	王政宇, 刘牧林. 腹腔镜结直肠癌根治术治疗不同分期结直肠癌的短期疗效及安全性分析[J]. 中华全科医学, 2018, 16(10): 1659-1661. doi: 10.16766/j.cnki.issn.1674-4152.000452 WANG Z Y, LIU M L. Analysis of the short-term efficacy and safety of laparoscopic radical colorectal resection in the treatment of different stages of colorectal cancer[J]. Chinese Journal of General Practice, 2018, 16(10): 1659-1661. doi: 10.16766/j.cnki.issn.1674-4152.000452
[14]	PARK J W, KANG S B, HAO J, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): 10-year follow-up of an open-label, non-inferiority, randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2021, 6(7): 569-577. doi: 10.1016/S2468-1253(21)00094-7
[15]	SHIMIZU H, YAMAGUCHI S, ISHII T, et al. Who needs diverting ileostomy following laparoscopic low anterior resection in rectal cancer patients? Analysis of 417 patients in a single institute[J]. Surg Endosc, 2020, 34(2): 839-846. doi: 10.1007/s00464-019-06837-4
[16]	YANG B, ZHANG S, YANG X, et al. Analysis of bowel function, urogenital function, and long-term follow-up outcomes associated with robotic and laparoscopic sphincter-preserving surgical approaches to total mesorectal excision in low rectal cancer: a retrospective cohort study[J]. World J Surg Oncol, 2022, 20(1): 167. doi: 10.1186/s12957-022-02631-0