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不同结直肠癌根治术的临床疗效与术后并发症影响因素分析(附3 418例报告)

汤庆超, 熊寰, 王玉柳明, 胡汉卿, 袁子茗, 金英虎, 郁雷, 黄睿, 刘明, 王贵玉, 王锡山

汤庆超, 熊寰, 王玉柳明, 等. 不同结直肠癌根治术的临床疗效与术后并发症影响因素分析(附3 418例报告)[J]. 中华消化外科杂志, 2023, 22(1): 131-143. DOI: 10.3760/cma.j.cn115610-20221121-00701
引用本文: 汤庆超, 熊寰, 王玉柳明, 等. 不同结直肠癌根治术的临床疗效与术后并发症影响因素分析(附3 418例报告)[J]. 中华消化外科杂志, 2023, 22(1): 131-143. DOI: 10.3760/cma.j.cn115610-20221121-00701
Tang Qingchao, Xiong Huan, Wang Yuliuming, et al. Clinical efficacy of radical resection of rectal cancer with different surgical approaches and analysis of influencing factors of postoperative complications: a report of 3 418 cases[J]. Chinese Journal of Digestive Surgery, 2023, 22(1): 131-143. DOI: 10.3760/cma.j.cn115610-20221121-00701
Citation: Tang Qingchao, Xiong Huan, Wang Yuliuming, et al. Clinical efficacy of radical resection of rectal cancer with different surgical approaches and analysis of influencing factors of postoperative complications: a report of 3 418 cases[J]. Chinese Journal of Digestive Surgery, 2023, 22(1): 131-143. DOI: 10.3760/cma.j.cn115610-20221121-00701

不同结直肠癌根治术的临床疗效与术后并发症影响因素分析(附3 418例报告)

基金项目: 

国家自然科学基金 82072732

黑龙江省卫生计生委课题 2018749

吴阶平医学基金会 320.2710.1849

详细信息
    通讯作者:

    王贵玉,Email:guiywang@163.com

Clinical efficacy of radical resection of rectal cancer with different surgical approaches and analysis of influencing factors of postoperative complications: a report of 3 418 cases

Funds: 

National Natural Science Foundation of China 82072732

Project of Health and Family Planning Commission of Heilongjiang Province 2018749

Project of Wu Jieping Medical Foundation 320.2710.1849

More Information
  • 摘要:
    目的 

    探讨不同结直肠癌根治术的临床疗效与术后并发症影响因素。

    方法 

    采用回顾性研究方法。收集2011年7月至2020年9月哈尔滨医科大学附属第二医院收治的3 418例行结直肠癌根治术患者的临床病理资料;男2 060例,女1 358例;年龄为(61±11)岁。患者在符合根治性切除及手术适应证的条件下选择手术方式:开腹结直肠癌根治术、腹腔镜结直肠癌根治术和经自然腔道取标本手术(NOSES)。观察指标:(1)施行不同手术方式患者术中和术后情况。(2)施行不同手术方式患者术前临床特征比较。(3)施行不同手术方式患者术后组织病理学特征比较。(4)施行不同手术方式患者术后发生并发症情况。(5)影响患者术后发生并发症的因素分析。正态分布的计量资料以x±s表示;偏态分布的计量资料以M(范围)表示,组间比较采用Kruskal‑Wallis秩和检验比较;等级资料比较采用非参数秩和检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。多因素分析采用Logistic回归模型。

    结果 

    (1)施行不同手术方式患者术中和术后情况。3 418例患者中,施行开腹结直肠癌根治术1 978例,施行腹腔镜结直肠癌根治术1 028例,施行NOSES 412例。施行开腹结直肠癌根治术患者手术时间,术中出血量,造瘘情况(永久性造口、预防性造口、未造瘘),术后首次肛门排气时间,术后进食流质食物时间,术后转入重症监护室、术后住院时间分别为145(55~460)min,100(30~1 000)mL,435、88、1 455例,72(10~220)h,96(16~296)h,158例,10(6~60)d;施行腹腔镜结直肠癌根治术患者上述指标分别为175(80~450)min,50(10~800)mL,172、112、744例,48(14~120)h,72(38~140)h,17例,9(4~40)d;施行NOSES患者上述指标分别为180(80~400)min,30(5~500)mL,0、45、367例,48(14~144)h,72(15~148)h,1例,6(3~30)d;3者上述指标比较,差异均有统计学意义(H=291.38、518.56,χ²=153.82,H=408.86、282.97,χ²=78.66,H=332.30,P<0.05)。(2)施行不同手术方式患者术前临床特征比较。施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者性别、年龄、体质量指数、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、肠梗阻、肿瘤位置、术前癌胚抗原、术前CA19‑9比较,差异均有统计学意义(P<0.05)。(3)施行不同手术方式患者术后组织病理学特征比较。施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者肿瘤组织学类型、肿瘤分化程度、肿瘤最大径、淋巴结检出数目、神经侵犯、血管侵犯、淋巴结侵犯、T分期、N分期、M分期、TNM分期比较,差异均有统计学意义(P<0.05)。(4)施行不同手术方式患者术后发生并发症情况。施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者术后发生吻合口漏、腹腔感染、肠梗阻、吻合口出血、切口并发症、肺部感染、其他并发症分别为52、21、309、8、130、51、59例,33、17、75、3、45、58、9例,13、4、8、0、11、10、15例,3者肠梗阻、切口并发症、肺部感染、其他并发症比较,差异均有统计学意义(χ²=122.56,13.33,20.44,15.59,P<0.05);3者吻合口漏、腹腔感染、吻合口出血比较,差异均无统计学意义(χ²=0.96,2.21,3.08,P>0.05)。(5)影响患者术后发生并发症的因素分析。①结直肠癌根治术后患者发生肠梗阻的影响因素分析:年龄为20~39岁和40~59岁,手术方式为腹腔镜结直肠癌根治术、NOSES是结直肠癌根治术后患者发生肠梗阻的独立保护因素(优势比=0.46,0.59,0.43,0.13,95%可信区间为0.21~1.00,0.36~0.96,0.33~0.56,0.06~0.27,P<0.05)。②结直肠癌根治术后患者发生切口并发症的影响因素分析:体质量指数为24.0~26.9 kg/m2,手术方式为腹腔镜结直肠癌根治术和NOSES是结直肠癌根治术后患者发生切口并发症的独立保护因素(优势比=0.24,0.63,0.46,95%可信区间为0.11~0.51,0.44~0.89,0.24~0.87,P<0.05)。③结直肠癌根治术后患者发生肺感染的影响因素分析:手术方式为腹腔镜结直肠癌根治术是结直肠癌根治术后患者发生肺部感染的独立危险因素(优势比=2.15,95%可信区间为1.46~3.18,P<0.05);TNM分期为0~Ⅰ期是结直肠癌根治术后患者发生肺感染的独立保护因素(优势比=0.10,95%可信区间为0.01~0.88,P<0.05)。④结直肠癌根治术后患者发生其他并发症的影响因素分析:年龄(20~39岁、40~59岁、60~79岁),体质量指数(<18.5 kg/m2、18.5~23.9 kg/m2、24.0~26.9 kg/m2、27.0~29.9 kg/m2),手术方式为腹腔镜结直肠癌根治术是结直肠癌根治术后患者发生其他并发症的独立保护因素(优势比=0.10,0.29,0.37,0.08,0.22,0.35,0.32,0.29,95%可信区间为0.01~0.81,0.13~0.64,0.17~0.78,0.02~0.40,0.09~0.52,0.15~0.83,0.12~0.89,0.14~0.59,P<0.05)。

    结论 

    开腹结直肠癌根治术的手术适应证更广,手术时间更短,但围手术期治疗效果不及腹腔镜结直肠癌根治术和NOSES。具有手术适应证时,患者施行腹腔镜结直肠癌根治术和NOSES可获得较好的手术效果以及更低术后并发症发生率。

    Abstract:
    Objective 

    To investigate the clinical efficacy of radical resection of rectal cancer with different surgical approaches and influencing factors of postoperative complications.

    Methods 

    The retrospective study was conducted. The clinicopathological data of 3 418 patients who underwent radical resection of rectal cancer in the Second Affiliated Hospital of Harbin Medical University from July 2011 to September 2020 were collected. There were 2 060 males and 1 358 females, aged (61±11)years. Patients meeting the requirements of radical resection and surgical indications underwent surgeries choosing from open radical colorectal cancer surgery, laparoscopic radical colorectal cancer surgery, and natural orifice specimen extraction surgery (NOSES). Observation indicators: (1) intraoperative and postoperative conditions of patients undergoing different surgical approaches; (2) comparison of preoperative clinical characteristics in patients undergoing different surgical approaches; (3) comparison of postoperative histopathological characteristics in patients undergoing different surgical approaches; (4) postoperative complications of patients undergoing different surgical approaches; (5) analysis of influencing factors of postoperative complications. Measurement data with normal distribution were represented as Mean±SD. Measurement data with skewed distribution were represented as M(range), and comparisons between groups was analyzed using the Kruskal-Wallis rank test. Comparison of ordinal data was analyzed using the non‐parameter rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi‐square test. Multivariate analysis was conducted using the Logistic regression model.

    Results 

    (1) Intraoperative and postoperative conditions of patients undergoing different surgical approaches. Of the 3 418 patients, 1 978 cases underwent open radical colorectal cancer sur-gery, 1 028 cases underwent laparoscopic radical colorectal cancer surgery and 412 cases underwent NOSES, respectively. The operation time, volume of intraoperative blood loss, cases with permanent stoma, preventive stoma or without fistula, time to postoperative first flatus, time to postoperative liquid food intake, cases transferred to intensive care unit after surgery, duration of postoperative hospital stay were 145(range, 55‒460)minutes, 100(range, 30‒1 000)mL, 435, 88, 1 455, 72(range, 10‒220)hours, 96(range, 16‒296)hours, 158, 10(range, 6‒60)days, respectively, in patients undergoing open radical colorectal cancer surgery. The above indicators were 175(range, 80‒450)minutes, 50(range, 10‒800)mL, 172, 112, 744, 48(range, 14‒120)hours, 72(range, 38‒140)hours, 17, 9(range, 4‒40)days, respectively, in patients undergoing laparoscopic radical colorectal cancer surgery and 180(range, 80‒400)minutes, 30(range, 5‒500)mL, 0, 45, 367, 48 (range, 14‒144)hours, 72(range, 15‒148)hours, 1, 6(range, 3‒30)days, respectively, in patients undergoing NOSES. There were significant differences in the above indicators among the patients undergoing different surgical approaches (H=291.38, 518.56, χ²=153.82, H=408.86, 282.97, χ²=78.66, H=332.30, P<0.05). (2) Com-parison of preoperative clinical characteristics in patients undergoing different surgical approaches. The gender, age, body mass index, cases with diabetes, cases with hypertension, cases with coronary heart disease, cases with anemia, cases with hypoproteinemia, cases with intestinal obstruction, tumor location, preoperative carcinoembryonic antigen, preoperative CA19‑9 showed significant differences among patients undergoing open radical colorectal cancer surgery, laparoscopic radical colorectal cancer surgery and NOSES (P<0.05). (3) Comparison of postoperative histopathological characteris-tics in patients undergoing different surgical approaches. Tumor histological type, tumor differentiation degree, tumor diameter, number of lymph node detected, nerve invasion, vascular invasion, lymph node invasion, tumor T staging, tumor N staging, tumor M staging, tumor TNM staging showed significant differences among patients undergoing open radical colorectal cancer surgery, laparos-copic radical colorectal cancer surgery and NOSES (P<0.05). (4) Postoperative complications of patients undergoing different surgical approaches. Cases with postoperative complications as anastomotic leakage, abdominal infection, intestinal obstruction, anastomotic bleeding, incision complications, pulmonary infection, other complications were 52, 21, 309, 8, 130, 51, 59, respectively, in patients undergoing open radical colorectal cancer surgery. The above indicators were 33, 17, 75, 3, 45, 58, 9, respectively, in patients undergoing laparoscopic radical colorectal cancer surgery and 13, 4, 8, 0, 11, 10, 15, respectively, in patients undergoing NOSES. There were significant differences in the intes-tinal obstruction, incision complications, pulmonary infection, other complications among patients undergoing different surgical approaches (χ²=122.56, 13.33, 20.44, 15.59, P<0.05) and there was no significant difference in the anastomotic leakage, abdominal infection, anastomotic bleeding among patients undergoing different surgical approaches (χ²=0.96, 2.21, 3.08, P>0.05). (5) Analysis of influencing factors of postoperative complications. ① Analysis of influencing factors of intestinal obstruction in patients with radical resection of rectal cancer. Age as 20‒39 years and 40‒59 years, surgical approach as laparoscopic radical colorectal cancer surgery and NOSES were independent protective factors of intestinal obstruction in patients with radical resection of rectal cancer (odds ratio=0.46, 0.59, 0.43, 0.13, 95% confidence interval as 0.21‒1.00, 0.36‒0.96, 0.33‒0.56, 0.06‒0.27, P<0.05). ② Analysis of influencing factors of incision complications in patients with radical resection of rectal cancer. Body mass index as 24.0‒26.9 kg/m2, surgical approach as laparoscopic radical colorectal cancer surgery and NOSES were independent protective factors of incision complications in patients with radical resection of rectal cancer (odds ratio=0.24, 0.63, 0.46, 95% confidence interval as 0.11‒0.51, 0.44‒0.89, 0.24‒0.87, P<0.05). ③ Analysis of influencing factors of pulmonary infection in patients with radical resection of rectal cancer. The surgical approach as laparoscopic radical colorectal cancer surgery was an independent risk factor of pulmonary infection in patients with radical resection of rectal cancer (odds ratio=2.15, 95% confidence interval as 1.46‒3.18, P<0.05), and tumor TNM staging as 0‒Ⅰ stage was an independent protective factor (odds ratio=0.10, 95% confidence interval as 0.01‒0.88, P<0.05). ④ Analysis of influencing factors of other complica-tions in patients with radical resection of rectal cancer. Age as 20‒39 years, 40‒59 years, 60‒79 years, body mass index as <18.5 kg/m2, 18.5‒23.9 kg/m2, 24.0‒26.9 kg/m2, 27.0‒29.9 kg/m2, surgical approach as laparoscopic radical colorectal cancer surgery were independent protective factors of other complications in patients with radical resection of rectal cancer (odds ratio=0.10, 0.29, 0.37, 0.08, 0.22, 0.35, 0.32, 0.29, 95% confidence interval as 0.01‒0.81, 0.13‒0.64, 0.17‒0.78, 0.02‒0.40, 0.09‒0.52, 0.15‒0.83, 0.12‒0.89, 0.14‒0.59, P<0.05).

    Conclusions 

    Compared to laparoscopic radical colorectal cancer surgery and NOSES, open radical colorectal cancer surgery has wide indication and short operation time, but less perioperative treatment effect. Laparoscopic radical colorectal cancer surgery and NOSES can achieve better surgical result and less postoperative complication when patients meeting surgical indications.

  • 结直肠癌是常见的恶性肿瘤之一,新发病率和相关病死率在恶性肿瘤中排名均列第3位[1]。我国结直肠癌发病率和病死率均呈缓慢上升趋势,且逐渐呈年轻化趋势[2]。结直肠癌治疗采用以手术切除为主的综合治疗[3]。结直肠癌的手术方式由传统开腹肿瘤根治术逐渐发展为腹腔镜结直肠癌根治术[47]。传统腹腔镜手术需在腹壁行辅助切口取出标本,破坏腹壁完整性,易发生术后疼痛、出血、感染等切口相关并发症[78]。经自然腔道取标本手术(natural orifice specimen extraction surgery,NOSES)运用传统腹腔镜器械、经肛门内镜显微手术或软内窥镜行腹腔内手术,通过自然腔道(直肠、阴道或口腔)取出手术标本,无需腹部辅助切口[910]。本研究回顾性分析2011年7月至2020年9月哈尔滨医科大学附属第二医院收治的3 418例行结直肠癌根治术患者的临床病理资料,探讨不同结直肠癌根治术的临床疗效与术后并发症影响因素。

    采用回顾性研究方法。收集3 418例行结直肠癌根治术患者的临床病理资料;男2 060例,女1 358例;年龄为(61±11)岁。本研究通过哈尔滨医科大学附属第二医院伦理委员会审批,批号为KY2022‑007。患者及家属均签署知情同意书。

    纳入标准:(1)年龄≥18岁。(2)术前活组织病理学检查证实为结直肠恶性肿瘤。(3)行手术治疗。(4)临床病理资料完整。

    排除标准:(1)因急性肠梗阻、穿孔或出血行急诊手术。(2)术中发现腹腔广泛种植转移。(3)合并其他脏器原发恶性肿瘤。(4)术后组织病理学检查确诊为良性病变。(5)临床病理资料缺失。

    患者在符合根治性切除及手术适应证的条件下选择手术方式:开腹结直肠癌根治术、腹腔镜结直肠癌根治术和NOSES。手术均由哈尔滨医科大学附属第二医院结直肠肿瘤外科手术团队施行。

    开腹结直肠癌根治术:根据手术部位不同,采用腹部正中切口或腹直肌旁切口,经切口进入后探查腹腔脏器,打开肠系膜,使用分离钳等手术器械完成结直肠癌对应肠段切除并结扎,清扫该区域淋巴结,在距病灶上下5 cm处离断肠管以保证安全切缘,完成吻合。术后给予患者对症支持治疗。

    腹腔镜结直肠癌根治术:脐部放置1根10 mm套管针建立气腹,保持10~12 mmHg(1 mmHg=0.133 kPa)气腹压,于左髂区和右季肋区分别放置1枚5 mm戳卡,左季肋区放置1枚5 mm或12 mm戳卡,右髂区放置1枚5 mm或12 mm戳卡。套管针的具体位置和大小由不同手术部位决定。首先检查患者肝脏、胆囊、胃、脾、大网膜、结肠、小肠、直肠和骨盆。探查肿瘤位置后行系膜解剖和血管裸化。肠管裸化完成后,直视下行手术标本切除及消化道重建。

    NOSES:手术操作均在腹腔镜下完成。腹腔探查、淋巴结清扫、肠管及血管裸化过程与腹腔镜结直肠癌根治术相同。根据病变部位不同,手术标本取出方式可分为:(1)外翻切除式。将手术标本经肛门外翻,体外将标本切除,主要适用于低位直肠肿瘤。(2)拉出切除式。借助保护套,将病变肠段经自然腔道(直肠或阴道)拉出体外,在体外切除标本,主要适用于中位直肠肿瘤。(3)切除拖出式。在腹腔内完成手术标本切除后,借助保护套,将手术标本经自然腔道(直肠或阴道)拖出体外,主要适用于高位直肠肿瘤及结肠肿瘤。消化道重建方式与常规腹腔镜手术患者类似,结肠肿瘤患者的消化道重建主要借助腹腔镜下直线切割闭合器进行肠管吻合[10]

    观察指标:(1)施行不同手术方式患者术中和术后情况包括手术时间、术中出血量、造瘘情况、术后首次肛门排气时间、术后进食流质食物时间、术后转入ICU、围手术期二次手术、术后住院时间。(2)施行不同手术方式患者术前临床特征比较:性别、年龄、BMI、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、肠梗阻、肿瘤位置、术前CEA、术前CA19‑9。(3)施行不同手术方式患者术后组织病理学特征比较:肿瘤组织学类型、肿瘤分化程度、肿瘤最大径、淋巴结检出数目、神经侵犯、血管侵犯、淋巴结侵犯、肿瘤环周切缘、T分期、N分期、M分期、TNM分期。(4)施行不同手术方式患者术后发生并发症情况:吻合口漏、腹腔感染、肠梗阻、吻合口出血、切口并发症、肺部感染、其他并发症。(5)影响患者术后发生并发症的因素分析:性别、年龄、BMI、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、术前肠梗阻、手术方式、TNM分期。

    评价标准:CEA和CA19‑9的正常参考值分别为<5 μg/L和<37 U/mL。术后并发症评估参照《中国胃肠肿瘤外科术后并发症诊断登记规范专家共识(2018版)》。其他术后并发症包括术后肠应激性溃疡、肺不张、心脑血管并发症、造口相关并发症等。

    应用SPSS 25.0统计软件进行分析。正态分布的计量资料以x±s表示;偏态分布的计量资料以M(范围)表示,组间比较采用Kruskal‑Wallis秩和检验比较;等级资料比较采用非参数秩和检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。多因素分析采用Logistic回归模型。P<0.05为差异有统计学意义。

    3 418例患者中,施行开腹结直肠癌根治术1 978例,施行腹腔镜结直肠癌根治术1 028例,施行NOSES 412例。上述3种手术方式患者手术时间、术中出血量、造瘘情况、术后首次肛门排气时间、术后进食流质食物时间、术后转入ICU、术后住院时间比较,差异均有统计学意义(P<0.05)。开腹结直肠癌根治术与腹腔镜结直肠癌根治术上述指标比较,差异均有统计学意义(Z=14.41、14.96,χ²=51.46,Z=13.04、12.65,χ²=49.50,Z=7.27,P均<0.001)。开腹结直肠癌根治术与NOSES上述指标比较,差异均有统计学意义(Z=12.38、20.01,χ²=127.40,Z=13.28、15.35,χ²=32.94,Z=19.22,P均<0.001);腹腔镜结直肠癌根治术与NOSES术中出血量、造瘘情况、术后首次肛门排气时间、术后进食流质食物时间、术后转入ICU、术后住院时间比较,差异均有统计学意义(Z=10.03,χ²=79.57,Z=4.97、7.92,χ²=4.74,Z=15.66,P<0.001,<0.001,<0.001,<0.001,P=0.029,P<0.001)。3者围手术期二次手术比较,差异无统计学意义(P>0.05)。见表1

    表  1  3 418例结直肠癌患者施行不同手术方式术中和术后情况比较
    Table  1.  Comparison of intraoperative and postoperative situations in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches
    手术方式例数手术时间[M(范围),min]术中出血量[M(范围),mL]造瘘情况(例)
    永久性造口预防性造口未造瘘
    开腹结直肠癌根治术1 978145(55~460)100(30~1 000)435881 455
    腹腔镜结直肠癌根治术1 028175(80~450)50(10~800)172112744
    经自然腔道取标本手术412180(80~400)30(5~500)045367
    统计量值H=291.38H=518.56χ²=153.82
    P<0.001<0.001<0.001
    下载: 导出CSV 
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    施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者性别、年龄、BMI、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、肠梗阻、肿瘤位置、术前CEA、术前CA19‑9比较,差异均有统计学意义(P<0.05)。见表2

    表  2  施行不同手术方式的3 418例结直肠癌患者术前临床特征比较
    Table  2.  Comparison of preoperative clinical characteristics in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches
    临床资料手术方式(例)χ²值P
    开腹结直肠癌根治术腹腔镜结直肠癌根治术经自然腔道取标本手术
    性别
    1 20866418845.42<0.001
    770364224
    年龄(岁)a
    20~3984241821.07<0.001
    40~59731351190
    60~791 077611186
    ≥80864218
    体质量指数(kg/m2a
    <18.5141663746.79<0.001
    18.5~23.9944570263
    24.0~26.959826986
    27.0~29.92359324
    ≥30.060302
    基础疾病b
    糖尿病253128328.290.016
    原发性高血压5032636419.51<0.001
    冠心病2751033019.36<0.001
    贫血5331729141.89<0.001
    低蛋白血症2248274.75<0.001
    肠梗阻286572106.89<0.001
    肿瘤位置
    直肠941618302214.08<0.001
    左半结肠51224791
    右半结肠52516313
    多原发癌006
    术前癌胚抗原c
    正常1 050523327120.87<0.001
    异常64533177
    术前CA19‑9d
    正常1 345737373104.79<0.001
    异常33811731
    注:a应用非参数检验比较;b施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者合并基础疾病分别为1 424、677、136例,同1例患者合并多种疾病;c施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者术前未检测癌胚抗原分别为283、174、8例;d施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者术前未检测CA19‑9分别为295、174、8例
    下载: 导出CSV 
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    施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者肿瘤组织学类型、肿瘤分化程度、肿瘤最大径、淋巴结检出数目、神经侵犯、血管侵犯、淋巴结侵犯、T分期、N分期、M分期、TNM分期比较,差异均有统计学意义(P<0.05);肿瘤环周切缘比较,差异无统计学意义(P>0.05)。见表3

    表  3  施行不同手术方式的3 418例结直肠癌患者术后组织病理学特征比较
    Table  3.  Comparison of postoperative histopathological characteristics in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches
    术后病理学特征手术方式(例)统计量值P
    开腹结直肠癌根治术腹腔镜结直肠癌根治术经自然腔道取标本手术
    肿瘤组织学类型
    腺癌827302283χ²=535.99<0.001
    管状腺癌70356444
    黏液腺癌40314817
    其他类型451468
    肿瘤分化程度
    高分化癌10812048χ²=56.79<0.001
    中分化癌1 560797324
    低分化癌或未分化癌31011140
    肿瘤最大径(cm)
    <51 003608326χ²=115.81<0.001
    ≥597542086
    淋巴结检出数目aH=40.18<0.001
    神经侵犯
    837395233χ²=40.04<0.001
    1 141633179
    血管侵犯
    642262113χ²=16.94<0.001
    1 336766299
    淋巴结侵犯
    727301105χ²=29.47<0.001
    1 251727307
    肿瘤环周切缘
    阳性000χ²=0.001.000
    阴性1 9781 028412
    T分期b
    Tis~T1期282973H=263.92<0.001
    T2期1527691
    T3期812425175
    T4期98649873
    N分期b
    N0期1 214678305H=25.57<0.001
    N1~2期764350107
    M分期b
    M0期1 764981403H=57.30<0.001
    M1期214479
    TNM分期b
    0期0031H=134.90<0.001
    Ⅰ期14876113
    Ⅱ期995581157
    Ⅲ期621324102
    Ⅳ期214479
    注:a施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者淋巴结检出数目以[M(范围)]表示,分别为15(1~65)枚、14(2~46)枚、14(10~42)枚;TNM分期采用美国癌症联合委员会第7版分期;b应用非参数检验比较
    下载: 导出CSV 
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    施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、NOSES患者术后发生吻合口漏、腹腔感染、肠梗阻、吻合口出血、切口并发症、肺部感染、其他并发症分别为52、21、309、8、130、51、59例,33、17、75、3、45、58、9例,13、4、8、0、11、10、15例,3者肠梗阻、切口并发症、肺部感染、其他并发症比较,差异均有统计学意义(χ²=122.56,13.33,20.44,15.59,P<0.001,<0.001,P=0.001,P<0.001);3者吻合口漏、腹腔感染、吻合口出血比较,差异均无统计学意义(χ²=0.96,2.21,3.08,P=0.619,0.331,0.215)

    (1)结直肠癌根治术后患者发生肠梗阻的影响因素分析。单因素分析结果显示:年龄、原发性高血压、贫血、低蛋白血症、手术方式、TNM分期是结直肠癌根治术后患者发生肠梗阻的相关因素(P<0.05);性别、BMI、糖尿病、冠心病、术前肠梗阻不是结直肠癌根治术后患者发生肠梗阻的相关因素(P>0.05)。见表4。多因素分析结果显示:年龄为20~39岁和40~59岁,手术方式为腹腔镜结直肠癌根治术、NOSES是结直肠癌根治术后患者发生肠梗阻的独立保护因素(P<0.05)。见表5

    表  4  影响3 418例行结直肠癌根治术患者术后发生肠梗阻的单因素分析
    Table  4.  Univariate analysis of postoperative intestinal obstruction in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素赋值例数肠梗阻(例)χ²值P
    性别
    12 0602390.090.763
    01 358153
    年龄(岁)
    20~391126118.000.046
    40~5921 272128
    60~7931 874229
    ≥80414624
    体质量指数(kg/m2
    <18.51244272.750.601
    18.5~23.921 777193
    24.0~26.93953118
    27.0~29.9435240
    ≥30.059214
    糖尿病
    1413490.070.788
    03 005343
    原发性高血压
    18301134.970.026
    02 588279
    冠心病
    1408583.440.064
    03 010334
    贫血
    171411316.88<0.001
    02 704279
    低蛋白血症
    1271468.790.003
    03 147346
    术前肠梗阻
    1345503.460.063
    03 073342
    手术方式
    开腹结直肠癌根治术11 97830988.06<0.001
    腹腔镜结直肠癌根治术21 02875
    经自然腔道取标本手术34128
    TNM分期
    0~Ⅰ期13682014.940.002
    Ⅱ期21 733212
    Ⅲ期31 047129
    Ⅳ期427031
    下载: 导出CSV 
    | 显示表格
    表  5  影响3 418例行结直肠癌根治术患者术后发生肠梗阻的多因素分析
    Table  5.  Multivariate analysis of postoperative intestinal obstruction in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素b标准误Wald优势比95%可信区间P
    年龄(岁)
    20~39-0.770.393.860.460.21~1.000.049
    40~59-0.530.254.550.590.36~0.960.033
    60~79-0.350.242.130.710.44~1.130.145
    ≥80a------
    原发性高血压-0.200.122.790.820.64~1.040.095
    贫血-0.230.133.140.790.62~1.030.076
    低蛋白血症-0.120.180.420.890.62~1.270.518
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-0.860.1439.010.430.33~0.56<0.001
    经自然腔道取标本手术-2.030.3730.450.130.06~0.27<0.001
    TNM分期
    0~Ⅰ期-0.290.310.930.750.41~1.360.335
    Ⅱ期0.250.211.431.290.86~1.930.227
    Ⅲ期0.280.221.691.320.87~2.020.194
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV 
    | 显示表格

    (2)结直肠癌根治术后患者发生切口并发症的影响因素分析。单因素分析结果显示:BMI、手术方式、TNM分期是结直肠癌根治术后患者发生切口并发症的相关因素(P<0.05);性别、年龄、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、术前肠梗阻不是结直肠癌根治术后患者发生切口并发症的相关因素(P>0.05)。见表6。多因素分析结果显示:BMI为24.0~26.9 kg/m2,手术方式为腹腔镜结直肠癌根治术和NOSES是结直肠癌根治术后患者发生切口并发症的独立保护因素(P<0.05)。见表7

    表  6  影响3 418例行结直肠癌根治术患者术后发生切口并发症的单因素分析
    Table  6.  Univariate analysis of postoperative incision complications in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素赋值例数切口并发症(例)χ²值P
    性别
    12 0601110.030.865
    01 35875
    年龄(岁)
    20~39112662.370.500
    40~5921 27268
    60~7931 874100
    ≥80414612
    体质量指数(kg/m2
    <18.512441622.80<0.001
    18.5~23.921 777106
    24.0~26.9395327
    27.0~29.9435227
    ≥30.059210
    糖尿病
    1413240.130.724
    03 005162
    原发性高血压
    1830400.830.364
    02 588146
    冠心病
    1408190.560.456
    03 010167
    贫血
    1714331.180.278
    02 704153
    低蛋白血症
    1271120.590.443
    03 147174
    术前肠梗阻
    1345220.650.419
    03 073164
    手术方式
    开腹结直肠癌根治术11 97813013.330.001
    腹腔镜结直肠癌根治术21 02845
    经自然腔道取标本手术341211
    TNM分期
    0~Ⅰ期1368816.200.001
    Ⅱ期21 733117
    Ⅲ期31 04745
    Ⅳ期427016
    下载: 导出CSV 
    | 显示表格
    表  7  影响3 418例行结直肠癌根治术患者术后发生切口并发症的多因素分析
    Table  7.  Multivariate analysis of postoperative incision complications in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素b标准误Wald优势比95%可信区间P
    体质量指数(kg/m2
    <18.5-0.540.431.600.580.25~1.340.205
    18.5~23.9-0.590.352.790.560.28~1.110.095
    24.0~26.9-1.430.3913.440.240.11~0.51<0.001
    27.0~29.9-0.370.390.890.690.32~1.490.345
    ≥30.0a------
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-0.470.186.790.630.44~0.890.009
    经自然腔道取标本手术-0.780.335.750.460.24~0.870.017
    TNM分期
    0~Ⅰ期-0.860.453.640.420.18~1.020.056
    Ⅱ期0.200.280.501.220.71~2.100.478
    Ⅲ期-0.300.300.960.740.41~1.350.328
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV 
    | 显示表格

    (3)结直肠癌根治术后患者发生肺部感染的影响因素分析。单因素分析结果显示:手术方式、TNM分期是结直肠癌根治术后患者发生肺部感染的相关因素(P<0.05);性别、年龄、BMI、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、术前肠梗阻不是结直肠癌根治术后患者发生肺部感染的相关因素(P>0.05)。见表8。多因素分析结果显示:手术方式为腹腔镜结直肠癌根治术是结直肠癌根治术后患者发生肺部感染的独立危险因素(P<0.05);TNM分期为0~Ⅰ期是结直肠癌根治术后患者发生肺部感染的独立保护因素(P<0.05)。见表9

    表  8  影响3 418例行结直肠癌根治术患者术后发生肺部感染的单因素分析
    Table  8.  Univariate analysis of postoperative pulmonary infection in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素赋值例数肺部感染(例)χ²值P
    性别
    12 060730.060.807
    01 35846
    年龄(岁)
    20~39112621.540.674
    40~5921 27245
    60~7931 87466
    ≥8041466
    体质量指数(kg/m2
    <18.5124489.380.052
    18.5~23.921 77771
    24.0~26.9395320
    27~29.9435217
    ≥30.05923
    糖尿病
    1413110.940.333
    03 005108
    原发性高血压
    1830270.170.680
    02 58892
    冠心病
    1408120.400.526
    03 010107
    贫血
    1714191.810.179
    02 704100
    低蛋白血症
    1271110.290.589
    03 147108
    术前肠梗阻
    1345110.100.754
    03 073108
    手术方式
    开腹结直肠癌根治术11 9785120.44<0.001
    腹腔镜结直肠癌根治术21 02858
    经自然腔道取标本手术341210
    TNM分期
    0~Ⅰ期1368119.76<0.001
    Ⅱ期21 73380
    Ⅲ期31 04732
    Ⅳ期42706
    下载: 导出CSV 
    | 显示表格
    表  9  影响3 418例行结直肠癌根治术患者术后发生肺部感染的多因素分析
    Table  9.  Multivariate analysis of postoperative pulmonary infection in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素b标准误Wald优势比95%可信区间P
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术0.770.2014.972.151.46~3.18<0.001
    经自然腔道取标本手术0.210.360.361.240.62~2.490.547
    TNM分期
    0~Ⅰ期-2.271.094.340.100.01~0.880.037
    Ⅱ期0.580.431.791.780.76~4.160.181
    Ⅲ期0.170.450.131.180.48~2.870.717
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV 
    | 显示表格

    (4)结直肠癌根治术后患者发生其他并发症的影响因素分析。单因素分析结果显示:年龄、BMI、手术方式是结直肠癌根治术后患者发生其他并发症的相关因素(P<0.05);性别、糖尿病、原发性高血压、冠心病、贫血、低蛋白血症、术前肠梗阻、TNM分期不是结直肠癌根治术后患者发生其他并发症的相关因素(P>0.05)。见表10。多因素分析结果显示:年龄<80岁、BMI<30.0 kg/m2、手术方式为腹腔镜结直肠癌根治术是结直肠癌根治术后患者发生其他并发症的独立保护因素(P<0.05)。见表11

    表  10  影响3 418例行结直肠癌根治术患者术后发生其他并发症的单因素分析
    Table  10.  Univariate analysis of postoperative other complications in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素赋值例数其他并发症(例)χ²值P
    性别
    12 060360.470.492
    01 35847
    年龄(岁)
    20~391126110.530.015
    40~5921 27227
    60~7931 87446
    ≥8041469
    体质量指数(kg/m2
    <18.51244213.620.009
    18.5~23.921 77735
    24.0~26.9395329
    27.0~29.9435210
    ≥30.05927
    糖尿病
    1413152.870.090
    03 00568
    原发性高血压
    1830200.0020.968
    02 58863
    冠心病
    1408100.0010.975
    03 01073
    贫血
    1714150.410.523
    02 70468
    低蛋白血症
    127160.060.811
    03 14777
    术前肠梗阻
    1345121.790.181
    03 07371
    手术方式
    开腹结直肠癌根治术11 9785915.59<0.001
    腹腔镜结直肠癌根治术21 0289
    经自然腔道取标本手术341215
    TNM分期
    0~Ⅰ期136861.260.739
    Ⅱ期21 73345
    Ⅲ期31 04726
    Ⅳ期42706
    下载: 导出CSV 
    | 显示表格
    表  11  影响3 418例行结直肠癌根治术患者术后发生其他并发症的多因素分析
    Table  11.  Multivariate analysis of postoperative other complications in 3 418 patients undergoing radical resection of rectal cancer
    临床病理因素b标准误Wald优势比95%可信区间P
    年龄(岁)
    20~39-2.301.074.650.100.01~0.810.031
    40~59-1.240.409.510.290.13~0.640.002
    60~79-1.000.386.860.370.17~0.780.009
    ≥80a------
    体质量指数(kg/m2
    <18.5-2.530.829.520.080.02~0.400.002
    18.5~23.9-1.520.4412.040.220.09~0.520.001
    24.0~26.9-1.060.445.640.350.15~0.830.018
    27.0~29.9-1.130.524.820.320.12~0.890.028
    ≥30.0a------
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-1.240.3611.840.290.14~0.590.001
    经自然腔道取标本手术0.370.301.511.450.80~2.610.220
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV 
    | 显示表格

    结直肠癌早期症状不明显,当患者发生腹痛、便血、脓血便、贫血等症状时,可能已失去早期内镜切除时机,需行手术治疗和(或)放化疗[1112]。近年来,随着超声刀、腔内直线切割闭合器、血管夹和腹腔镜技术的发展,腹腔镜技术已广泛用于结直肠肿瘤的外科治疗[1315]。本研究结果显示:腹腔镜结直肠癌根治术、NOSES等微创手术方式已逐渐成为治疗结直肠癌的主流手术方式。腹腔镜通过光学聚焦,手术视野更加清晰,解剖结构易辨认,更容易找准组织间隙进行锐性分离,更精细清扫淋巴结,可有效避免手术副损伤。自2013年王锡山教授团队提出NOSES理念以来,现已广泛用于临床实践。NOSES可在全腹腔镜视野下进行组织精细解剖,通过自然腔道将手术标本取出,避免腹部辅助切口。目前多项研究结果已证实:在严格遵循无菌、无瘤原则前提下,NOSES安全、可行,其在减少术中出血量和术后并发症、提高术后生命质量等方面均优于腹腔镜手术[9,1618]

    开腹手术、腹腔镜手术、NOSES是不同时代发展的产物,具有严格的适应证[19]。本研究结果显示:女性、年龄为40~69岁患者施行NOSES的比例更高。这可能与行NOSES结直肠恶性肿瘤患者主要通过阴道取出标本,40~69岁患者对NOSES理念的接受程度更高有关。肥胖症患者肠系膜更厚,经自然腔道取出标本的难度非常大,行NOSES患者BMI≤27.0 kg/m2比例更高。合并冠心病或其他严重疾病患者对气腹建立和长时间深度麻醉耐受不佳,多选择开腹手术以尽量缩短手术时间[2021]。尽管结直肠肿瘤均可通过自然腔道取出,但本研究结果显示:与开腹、腹腔镜结直肠癌根治术比较,行NOSES直肠癌患者比例更高。这与直肠恶性肿瘤的高发病率以及经肛门取标本的便捷度和可行性有关。有术前检查结果显示:与开腹、腹腔镜结直肠癌根治术比较,行NOSES患者CEA和CA19‑9阳性比例更低。这可能与NOSES适应证对肿瘤最大径以及局部分期的要求相关[2223]

    与腹腔镜结直肠癌根治术和NOSES比较,开腹结直肠癌根治术手术时间更短,但术中出血量更多,术后首次肛门排气时间、术后进食流质食物时间、术后住院时间延长,造瘘情况、术后转入ICU比例更高;与开腹、腹腔镜结直肠癌根治术比较,施行NOSES患者手术时间、术中出血量、造瘘情况、术后首次肛门排气时间、术后进食流质食物时间、术后转入ICU、术后住院时间均有优势。NOSES全程在腹腔镜下操作,手术视野清晰,通过放大影像,在进行组织分离及标本切除时,更利于精细解剖操作,减少术中血管损伤[10]。术中可借助超声刀分离,增强止血效果,进一步减少术中出血量。全腹腔镜下精细操作对肠道血流动力学影响更小,不易造成黏膜屏障损伤,术后肠道功能恢复更快,缩短术后进食及住院时间。但这也与NOSES更严格适应证选择标准有关。

    3种不同手术方式治疗结直肠癌患者的肿瘤组织学类型腺癌比例均较高,肿瘤分化程度多为中分化。与开腹、腹腔镜结直肠癌根治术比较,施行NOSES患者的肿瘤最大径更小,术后TNM分期更早。这与术前血清学评估结果相吻合[22]。3种手术方式治疗结直肠癌患者淋巴结检出数目比较,差异有统计学意义,其中开腹结直肠癌根治术淋巴结检出数目高于腹腔镜结直肠癌根治术和NOSES。这说明开腹手术对淋巴结清扫更有优势。淋巴结检出数目不足常会导致对术后TNM分期的误判,是预后不良重要危险因素[2425]。3种手术方式治疗结直肠癌患者的手术切缘均为R0。这提示其手术安全性相当。

    与开腹、腹腔镜结直肠癌根治术比较,施行NOSES患者术后肠梗阻、切口并发症、肺部感染发生率低。患者术后疼痛减轻能减少术后并发症发生,改善手术体验[2627]。多因素分析结果显示:腹腔镜结直肠癌根治术和NOSES患者发生术后肠梗阻、切口并发症的风险更低;但施行腹腔镜结直肠癌根治术患者术后肺部感染风险更高。施行腹腔镜手术患者受CO2气腹影响,呼吸系统不良事件的发生率较高[28]。与NOSES比较,腹腔镜手术存在辅助切口,切口疼痛常阻止患者早期下床活动,增加肺部感染发生率。

    本研究结果显示:与年龄≥80岁的患者比较,年龄为20~39岁与40~59岁的患者术后发生肠梗阻的风险更低。这与既往研究结果基本一致[2930]。尽管既往研究结果显示:肥胖症患者发生切口感染的风险更高[3132]。本研究结果显示:与BMI≥30.0 kg/m2的患者比较,BMI为24.0~26.9 kg/m2患者发生术后切口相关并发症的风险更低。此外,与TNM分期为Ⅳ期结直肠癌患者比较,0~Ⅰ期患者发生肺感染的风险更低。这可能与早期结直肠癌患者术后恢复更快相关。与年龄≥80岁、BMI≥30.0 kg/m2的患者比较,年龄<80岁和BMI<30 kg/m2患者发生术后其他并发症的风险更低。这提示高龄及肥胖症患者更容易发生术后并发症[3335]

    综上,开腹结直肠癌根治术的手术适应证更广,手术时间更短,但围手术期治疗效果不及腹腔镜结直肠癌根治术和NOSES。具有手术适应证时,患者施行腹腔镜结直肠癌根治术和NOSES可获得较好的手术效果以及更低术后并发症发生率。

    本研究中所有手术方案的设计、实践由王锡山教授指导与示范。特别感谢王锡山教授对本研究中的手术病例做出的巨大贡献。
    汤庆超:研究设计,论文撰写;熊寰、王玉柳明、胡汉卿、金英虎:统计学分析,协助论文修改;汤庆超、袁子茗、郁雷、黄睿、刘明:协助构建数据库,指导统计学分析;王贵玉、王锡山:提出科学问题,指导研究设计和统计学分析,指导论文修改
    所有作者均声明不存在利益冲突
    汤庆超, 熊寰, 王玉柳明, 等. 不同结直肠癌根治术的临床疗效与术后并发症影响因素分析附3 418例报告)[J]. 中华消化外科杂志, 2023, 22(1: 131-143. DOI: 10.3760/cma.j.cn115610-20221121-00701.

    http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20221121-22701

  • 表  1   3 418例结直肠癌患者施行不同手术方式术中和术后情况比较

    Table  1   Comparison of intraoperative and postoperative situations in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches

    手术方式例数手术时间[M(范围),min]术中出血量[M(范围),mL]造瘘情况(例)
    永久性造口预防性造口未造瘘
    开腹结直肠癌根治术1 978145(55~460)100(30~1 000)435881 455
    腹腔镜结直肠癌根治术1 028175(80~450)50(10~800)172112744
    经自然腔道取标本手术412180(80~400)30(5~500)045367
    统计量值H=291.38H=518.56χ²=153.82
    P<0.001<0.001<0.001
    下载: 导出CSV

    表  2   施行不同手术方式的3 418例结直肠癌患者术前临床特征比较

    Table  2   Comparison of preoperative clinical characteristics in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches

    临床资料手术方式(例)χ²值P
    开腹结直肠癌根治术腹腔镜结直肠癌根治术经自然腔道取标本手术
    性别
    1 20866418845.42<0.001
    770364224
    年龄(岁)a
    20~3984241821.07<0.001
    40~59731351190
    60~791 077611186
    ≥80864218
    体质量指数(kg/m2a
    <18.5141663746.79<0.001
    18.5~23.9944570263
    24.0~26.959826986
    27.0~29.92359324
    ≥30.060302
    基础疾病b
    糖尿病253128328.290.016
    原发性高血压5032636419.51<0.001
    冠心病2751033019.36<0.001
    贫血5331729141.89<0.001
    低蛋白血症2248274.75<0.001
    肠梗阻286572106.89<0.001
    肿瘤位置
    直肠941618302214.08<0.001
    左半结肠51224791
    右半结肠52516313
    多原发癌006
    术前癌胚抗原c
    正常1 050523327120.87<0.001
    异常64533177
    术前CA19‑9d
    正常1 345737373104.79<0.001
    异常33811731
    注:a应用非参数检验比较;b施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者合并基础疾病分别为1 424、677、136例,同1例患者合并多种疾病;c施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者术前未检测癌胚抗原分别为283、174、8例;d施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者术前未检测CA19‑9分别为295、174、8例
    下载: 导出CSV

    表  3   施行不同手术方式的3 418例结直肠癌患者术后组织病理学特征比较

    Table  3   Comparison of postoperative histopathological characteristics in 3 418 patients undergoing radical resection of rectal cancer with different surgical approaches

    术后病理学特征手术方式(例)统计量值P
    开腹结直肠癌根治术腹腔镜结直肠癌根治术经自然腔道取标本手术
    肿瘤组织学类型
    腺癌827302283χ²=535.99<0.001
    管状腺癌70356444
    黏液腺癌40314817
    其他类型451468
    肿瘤分化程度
    高分化癌10812048χ²=56.79<0.001
    中分化癌1 560797324
    低分化癌或未分化癌31011140
    肿瘤最大径(cm)
    <51 003608326χ²=115.81<0.001
    ≥597542086
    淋巴结检出数目aH=40.18<0.001
    神经侵犯
    837395233χ²=40.04<0.001
    1 141633179
    血管侵犯
    642262113χ²=16.94<0.001
    1 336766299
    淋巴结侵犯
    727301105χ²=29.47<0.001
    1 251727307
    肿瘤环周切缘
    阳性000χ²=0.001.000
    阴性1 9781 028412
    T分期b
    Tis~T1期282973H=263.92<0.001
    T2期1527691
    T3期812425175
    T4期98649873
    N分期b
    N0期1 214678305H=25.57<0.001
    N1~2期764350107
    M分期b
    M0期1 764981403H=57.30<0.001
    M1期214479
    TNM分期b
    0期0031H=134.90<0.001
    Ⅰ期14876113
    Ⅱ期995581157
    Ⅲ期621324102
    Ⅳ期214479
    注:a施行开腹结直肠癌根治术、腹腔镜结直肠癌根治术、经自然腔道取标本手术患者淋巴结检出数目以[M(范围)]表示,分别为15(1~65)枚、14(2~46)枚、14(10~42)枚;TNM分期采用美国癌症联合委员会第7版分期;b应用非参数检验比较
    下载: 导出CSV

    表  4   影响3 418例行结直肠癌根治术患者术后发生肠梗阻的单因素分析

    Table  4   Univariate analysis of postoperative intestinal obstruction in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素赋值例数肠梗阻(例)χ²值P
    性别
    12 0602390.090.763
    01 358153
    年龄(岁)
    20~391126118.000.046
    40~5921 272128
    60~7931 874229
    ≥80414624
    体质量指数(kg/m2
    <18.51244272.750.601
    18.5~23.921 777193
    24.0~26.93953118
    27.0~29.9435240
    ≥30.059214
    糖尿病
    1413490.070.788
    03 005343
    原发性高血压
    18301134.970.026
    02 588279
    冠心病
    1408583.440.064
    03 010334
    贫血
    171411316.88<0.001
    02 704279
    低蛋白血症
    1271468.790.003
    03 147346
    术前肠梗阻
    1345503.460.063
    03 073342
    手术方式
    开腹结直肠癌根治术11 97830988.06<0.001
    腹腔镜结直肠癌根治术21 02875
    经自然腔道取标本手术34128
    TNM分期
    0~Ⅰ期13682014.940.002
    Ⅱ期21 733212
    Ⅲ期31 047129
    Ⅳ期427031
    下载: 导出CSV

    表  5   影响3 418例行结直肠癌根治术患者术后发生肠梗阻的多因素分析

    Table  5   Multivariate analysis of postoperative intestinal obstruction in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素b标准误Wald优势比95%可信区间P
    年龄(岁)
    20~39-0.770.393.860.460.21~1.000.049
    40~59-0.530.254.550.590.36~0.960.033
    60~79-0.350.242.130.710.44~1.130.145
    ≥80a------
    原发性高血压-0.200.122.790.820.64~1.040.095
    贫血-0.230.133.140.790.62~1.030.076
    低蛋白血症-0.120.180.420.890.62~1.270.518
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-0.860.1439.010.430.33~0.56<0.001
    经自然腔道取标本手术-2.030.3730.450.130.06~0.27<0.001
    TNM分期
    0~Ⅰ期-0.290.310.930.750.41~1.360.335
    Ⅱ期0.250.211.431.290.86~1.930.227
    Ⅲ期0.280.221.691.320.87~2.020.194
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV

    表  6   影响3 418例行结直肠癌根治术患者术后发生切口并发症的单因素分析

    Table  6   Univariate analysis of postoperative incision complications in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素赋值例数切口并发症(例)χ²值P
    性别
    12 0601110.030.865
    01 35875
    年龄(岁)
    20~39112662.370.500
    40~5921 27268
    60~7931 874100
    ≥80414612
    体质量指数(kg/m2
    <18.512441622.80<0.001
    18.5~23.921 777106
    24.0~26.9395327
    27.0~29.9435227
    ≥30.059210
    糖尿病
    1413240.130.724
    03 005162
    原发性高血压
    1830400.830.364
    02 588146
    冠心病
    1408190.560.456
    03 010167
    贫血
    1714331.180.278
    02 704153
    低蛋白血症
    1271120.590.443
    03 147174
    术前肠梗阻
    1345220.650.419
    03 073164
    手术方式
    开腹结直肠癌根治术11 97813013.330.001
    腹腔镜结直肠癌根治术21 02845
    经自然腔道取标本手术341211
    TNM分期
    0~Ⅰ期1368816.200.001
    Ⅱ期21 733117
    Ⅲ期31 04745
    Ⅳ期427016
    下载: 导出CSV

    表  7   影响3 418例行结直肠癌根治术患者术后发生切口并发症的多因素分析

    Table  7   Multivariate analysis of postoperative incision complications in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素b标准误Wald优势比95%可信区间P
    体质量指数(kg/m2
    <18.5-0.540.431.600.580.25~1.340.205
    18.5~23.9-0.590.352.790.560.28~1.110.095
    24.0~26.9-1.430.3913.440.240.11~0.51<0.001
    27.0~29.9-0.370.390.890.690.32~1.490.345
    ≥30.0a------
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-0.470.186.790.630.44~0.890.009
    经自然腔道取标本手术-0.780.335.750.460.24~0.870.017
    TNM分期
    0~Ⅰ期-0.860.453.640.420.18~1.020.056
    Ⅱ期0.200.280.501.220.71~2.100.478
    Ⅲ期-0.300.300.960.740.41~1.350.328
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV

    表  8   影响3 418例行结直肠癌根治术患者术后发生肺部感染的单因素分析

    Table  8   Univariate analysis of postoperative pulmonary infection in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素赋值例数肺部感染(例)χ²值P
    性别
    12 060730.060.807
    01 35846
    年龄(岁)
    20~39112621.540.674
    40~5921 27245
    60~7931 87466
    ≥8041466
    体质量指数(kg/m2
    <18.5124489.380.052
    18.5~23.921 77771
    24.0~26.9395320
    27~29.9435217
    ≥30.05923
    糖尿病
    1413110.940.333
    03 005108
    原发性高血压
    1830270.170.680
    02 58892
    冠心病
    1408120.400.526
    03 010107
    贫血
    1714191.810.179
    02 704100
    低蛋白血症
    1271110.290.589
    03 147108
    术前肠梗阻
    1345110.100.754
    03 073108
    手术方式
    开腹结直肠癌根治术11 9785120.44<0.001
    腹腔镜结直肠癌根治术21 02858
    经自然腔道取标本手术341210
    TNM分期
    0~Ⅰ期1368119.76<0.001
    Ⅱ期21 73380
    Ⅲ期31 04732
    Ⅳ期42706
    下载: 导出CSV

    表  9   影响3 418例行结直肠癌根治术患者术后发生肺部感染的多因素分析

    Table  9   Multivariate analysis of postoperative pulmonary infection in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素b标准误Wald优势比95%可信区间P
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术0.770.2014.972.151.46~3.18<0.001
    经自然腔道取标本手术0.210.360.361.240.62~2.490.547
    TNM分期
    0~Ⅰ期-2.271.094.340.100.01~0.880.037
    Ⅱ期0.580.431.791.780.76~4.160.181
    Ⅲ期0.170.450.131.180.48~2.870.717
    Ⅳ期a------
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV

    表  10   影响3 418例行结直肠癌根治术患者术后发生其他并发症的单因素分析

    Table  10   Univariate analysis of postoperative other complications in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素赋值例数其他并发症(例)χ²值P
    性别
    12 060360.470.492
    01 35847
    年龄(岁)
    20~391126110.530.015
    40~5921 27227
    60~7931 87446
    ≥8041469
    体质量指数(kg/m2
    <18.51244213.620.009
    18.5~23.921 77735
    24.0~26.9395329
    27.0~29.9435210
    ≥30.05927
    糖尿病
    1413152.870.090
    03 00568
    原发性高血压
    1830200.0020.968
    02 58863
    冠心病
    1408100.0010.975
    03 01073
    贫血
    1714150.410.523
    02 70468
    低蛋白血症
    127160.060.811
    03 14777
    术前肠梗阻
    1345121.790.181
    03 07371
    手术方式
    开腹结直肠癌根治术11 9785915.59<0.001
    腹腔镜结直肠癌根治术21 0289
    经自然腔道取标本手术341215
    TNM分期
    0~Ⅰ期136861.260.739
    Ⅱ期21 73345
    Ⅲ期31 04726
    Ⅳ期42706
    下载: 导出CSV

    表  11   影响3 418例行结直肠癌根治术患者术后发生其他并发症的多因素分析

    Table  11   Multivariate analysis of postoperative other complications in 3 418 patients undergoing radical resection of rectal cancer

    临床病理因素b标准误Wald优势比95%可信区间P
    年龄(岁)
    20~39-2.301.074.650.100.01~0.810.031
    40~59-1.240.409.510.290.13~0.640.002
    60~79-1.000.386.860.370.17~0.780.009
    ≥80a------
    体质量指数(kg/m2
    <18.5-2.530.829.520.080.02~0.400.002
    18.5~23.9-1.520.4412.040.220.09~0.520.001
    24.0~26.9-1.060.445.640.350.15~0.830.018
    27.0~29.9-1.130.524.820.320.12~0.890.028
    ≥30.0a------
    手术方式
    开腹结直肠癌根治术a------
    腹腔镜结直肠癌根治术-1.240.3611.840.290.14~0.590.001
    经自然腔道取标本手术0.370.301.511.450.80~2.610.220
    注:a为多分类变量,采用哑变量分析,该变量为哑变量;“-”为此项无
    下载: 导出CSV
  • [1]

    SiegelRL, MillerKD, FuchsHE, et al. Cancer statistics, 2021[J]. CA Cancer J Clin,2021,71(1):7‑33. DOI:10.3322/caac. 21654.

    [2] 王锡山.从中美结直肠癌流行病学特征看结直肠癌早诊早治的重要性[J/CD].中华结直肠疾病电子杂志,2021,10(1):26‑33. DOI: 10.3877/cma.j.issn.2095-3224.2021.01.004.
    [3] 练磊,兰平.国家卫健委中国结直肠癌诊疗规范解读(2020版)—外科部分[J].临床外科杂志,2021,29(1):10-12. DOI: 10.3969/j.issn.1005-6483.2021.01.004.
    [4]

    HemandasAK, AbdelrahmanT, FlashmanKG, et al. Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery[J]. Ann Surg,2010,252(1):84‑89. DOI: 10.1097/SLA.0b013e3181e45b66.

    [5]

    JacobBP, SalkyB. Laparoscopic colectomy for colon adeno-carcinoma: an 11‑year retrospective review with 5‑year survival rates[J]. Surg Endosc,2005,19(5):643‑649. DOI:10. 1007/s00464-004-8921-y.

    [6]

    JayneD, PigazziA, MarshallH, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial[J]. JAMA,2017,318(16):1569‑1580. DOI:10. 1001/jama.2017.7219.

    [7]

    GuillouPJ, QuirkeP, ThorpeH, et al. Short‑term endpoints of conventional versus laparoscopic‑assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial[J]. Lancet,2005,365(9472):1718‑1726. DOI: 10.1016/S0140-6736(05)66545-2.

    [8]

    ZhouZ, ChenL, LiuJ, et al. Laparoscopic natural orifice specimen extraction surgery versus conventional surgery in colorectal cancer: a meta‑analysis of randomized contro-lled trials[J]. Gastroenterol Res Pract,2022,2022:6661651. DOI: 10.1155/2022/6661651.

    [9]

    ZhuY, XiongH, ChenY, et al. Comparison of natural orifice specimen extraction surgery and conventional laparos-copic-assisted resection in the treatment effects of low rectal cancer[J]. Sci Rep,2021,11(1):9338. DOI: 10.1038/s41598-021-88790-8.

    [10]

    WangX. Natural Orifice Specimen Extraction Surgery: Colo-rectal Cancer[M]. Singapore: Springer;2018.

    [11]

    KuipersEJ, GradyWM, LiebermanD, et al. Colorectal cancer[J]. Nat Rev Dis Primers,2015,1:15065. DOI: 10.1038/nrdp.2015.65.

    [12]

    LadabaumU, DominitzJA, KahiC, et al. Strategies for colo-rectal cancer screening[J]. Gastroenterology,2020,158(2):418‑432. DOI: 10.1053/j.gastro.2019.06.043.

    [13] 姚宏伟,安勇博,王权,等.腹腔镜辅助经肛全直肠系膜切除术治疗低位直肠癌近期疗效的前瞻性和多中心病例登记研究[J].中华消化外科杂志,2021,20(12):1351-1357. DOI: 10.3760/cma.j.cn115610-20211027-00527.
    [14]

    LorenzonL, BiniF, BalducciG, et al. Laparoscopic versus robotic‑assisted colectomy and rectal resection: a systematic review and meta‑analysis[J]. Int J Colorectal Dis,2016, 31(2):161‑173. DOI: 10.1007/s00384-015-2394-4.

    [15]

    FleshmanJ, BrandaME, SargentDJ, et al. Disease‑free survival and local recurrence for laparoscopic resection compared with open resection of stage Ⅱ to Ⅲ rectal cancer: follow‑up results of the ACOSOG Z6051 randomized controlled trial[J]. Ann Surg,2019,269(4):589‑595. DOI:10. 1097/SLA.0000000000003002.

    [16]

    LiuZ, EfetovS, GuanX, et al. A Multicenter study evaluating natural orifice specimen extraction surgery for rectal cancer[J]. J Surg Res,2019,243:236‑241. DOI: 10.1016/j.jss.2019.05.034.

    [17]

    ZhouZQ, WangK, DuT, et al. Transrectal natural orifice specimen extraction (NOSE) with oncological safety: a pro-spective and randomized trial[J]. J Surg Res,2020,254:16-22. DOI: 10.1016/j.jss.2020.03.064.

    [18]

    GuanX, HuX, JiangZ, et al. Short‑term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5 055 patients[J]. Sci Bull (Beijing),2022,67(13):1331‑1334. DOI: 10.1016/j.scib.2022.05.014.

    [19] 王锡山.中国NOSES面临的挑战与展望[J/CD].中华结直肠疾病电子杂志,2018,7(1):2‑7. DOI: 10.3877/cma.j.issn.2095-3224.2018.01.001.
    [20]

    RistM, HemmerlingTM, RauhR, et al. Influence of pneumoperitoneum and patient positioning on preload and splanchnic blood volume in laparoscopic surgery of the lower abdomen[J]. J Clin Anesth,2001,13(4):244‑249. DOI: 10.1016/s0952-8180(01)00242-2.

    [21]

    KalmarAF, FoubertL, HendrickxJF, et al. Influence of steep trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy[J]. Br J Anaesth,2010,104(4):433‑439. DOI: 10.1093/bja/aeq018.

    [22]

    WuT, MoY, WuC. Prognostic values of CEA, CA19‑9, and CA72‑4 in patients with stages Ⅰ-Ⅲ colorectal cancer[J]. Int J Clin Exp Pathol,2020,13(7):1608‑1614.

    [23]

    GuanX, LiuZ, LongoA, et al. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer[J]. Gastroenterol Rep (Oxf),2019,7(1):24-31. DOI: 10.1093/gastro/goy055.

    [24]

    JiangK, ZhuY, LiuY, et al. Lymph node ratio as an independent prognostic indicator in stage Ⅲ colorectal cancer: especially for fewer than 12 lymph nodes examined[J]. Tumour Biol,2014,35(11):11685‑11690. DOI:10.1007/s1 3277-014-2484-x.

    [25]

    ZhangH, LiuY, WangC, et al. A modified tumor-node-metastasis staging system for colon cancer patients with fewer than twelve lymph nodes examined[J]. World J Surg,2021,45(8):2601‑2609. DOI: 10.1007/s00268-021-06141-0.

    [26]

    van BoekelR, WarléMC, NielenR, et al. Relationship between postoperative pain and overall 30‑day complications in a broad surgical population: an observational study[J]. Ann Surg,2019,269(5):856‑865. DOI: 10.1097/SLA.0000000000002583.

    [27]

    BoströmP, SvenssonJ, BrorssonC, et al. Early postoperative pain as a marker of anastomotic leakage in colorectal cancer surgery[J]. Int J Colorectal Dis,2021,36(9):1955-1963. DOI: 10.1007/s00384-021-03984-w.

    [28]

    ParkSJ, KimBG, OhAH, et al. Effects of intraoperative protective lung ventilation on postoperative pulmonary complications in patients with laparoscopic surgery: prospective, randomized and controlled trial[J]. Surg Endosc,2016,30(10):4598‑4606. DOI: 10.1007/s00464-016-4797-x.

    [29]

    Quiroga‑CentenoAC, Jerez‑TorraKA, Martin‑MojicaPA, et al. Risk factors for prolonged postoperative ileus in colorectal surgery: a systematic review and meta‑analysis[J]. World J Surg,2020,44(5):1612‑1626. DOI: 10.1007/s00268-019-05366-4.

    [30]

    HainE, MaggioriL, MonginC, et al. Risk factors for prolonged postoperative ileus after laparoscopic sphincter-saving total mesorectal excision for rectal cancer: an analysis of 428 consecutive patients[J]. Surg Endosc,2018,32(1):337‑344. DOI: 10.1007/s00464-017-5681-z.

    [31]

    KinugasaT, YoshidaT, MizobeT, et al. The impact of body mass index on perioperative outcomes after laparoscopic colorectal surgery[J]. Kurume Med J,2015,61(3/4):53‑58. DOI: 10.2739/kurumemedj.MS64005.

    [32]

    BalentineCJ, WilksJ, RobinsonC, et al. Obesity increases wound complications in rectal cancer surgery[J]. J Surg Res,2010,163(1):35‑39. DOI: 10.1016/j.jss.2010.03.012.

    [33]

    FrassonM, Flor‑LorenteB, RodríguezJL, et al. Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3 193 patients[J]. Ann Surg,2015,262(2):321‑330. DOI: 10.1097/SLA.000000000000973.

    [34]

    MakinoT, ShuklaPJ, RubinoF, et al. The impact of obesity on perioperative outcomes after laparoscopic colorectal resection[J]. Ann Surg,2012,255(2):228‑236. DOI: 10.1097/SLA.0b013e31823dcbf7.

    [35]

    OkabeH, OhsakiT, OgawaK, et al. Frailty predicts severe postoperative complications after elective colorectal surgery[J]. Am J Surg,2019,217(4):677‑681. DOI: 10.1016/j.amjsurg.2018.07.009.

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出版历程
  • 收稿日期:  2022-11-20
  • 网络出版日期:  2024-06-24
  • 刊出日期:  2023-01-19

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