经肛门与腹腔镜全直肠系膜切除术治疗直肠癌的疗效分析

罗双灵; 蔡永华; 张兴伟; 侯煜杰; 胡焕新; 康亮

doi:10.3760/cma.j.issn.1673-9752.2017.07.013

经肛门与腹腔镜全直肠系膜切除术治疗直肠癌的疗效分析

Efficacies of transanal total mesorectal excision and laparoscopic total mesorectal excision for rectal cancer

摘要

摘要: 目的:比较经肛门全直肠系膜切除术(TaTME)与腹腔镜全直肠系膜切除术(LapTME)治疗直肠癌的临床疗效。
方法:采用个案控制匹配方法和回顾性队列研究方法。收集2014年7月至2016年1月中山大学附属第六医院收治的100例直肠癌患者的临床病理资料。100例患者中，50例行TaTME设为TaTME组，50例同期行LapTME经个案控制方法匹配作为对照，设为LapTME组。观察指标：(1)手术情况：手术时间、术中出血量、术中并发症发生情况、预防性造口例数。(2)术后恢复情况：术后恢复进食时间、术后首次下床活动时间、术后30 d内并发症发生情况、术后住院时间。(3)术后病理学检查情况：术后病理学标本长度、淋巴结获取数目、肿瘤下缘距远切缘距离、环周切缘阳性例数等。(4)随访情况。采用门诊及网络调查方式进行随访。了解患者肿瘤局部复发和远处转移情况。随访时间截至2016年12月。正态分布的计量资料以±s表示，组间比较采用配对样本t检验。偏态分布的计量资料以M(范围)表示。计数资料比较采用x²检验。偏态分布的计量资料及等级资料比较采用非参数检验。
结果:(1)手术情况：TaTME组患者手术时间、术中出血量、术中并发症发生例数、预防性造口例数分别为(259±111)min、100 mL(20～2 000 mL)、2例、28例，LapTME组患者分别为(220±80)min、50 mL(20～1 000 mL)、1例、33例，两组患者上述指标比较，差异均无统计学意义(t=1.90，Z=-0.30， x²=0.34，0.01，P>0.05)。(2)术后恢复情况：TaTME组患者术后恢复进食时间及术后首次下床活动时间分别为(1.6±0.5)d和(2.6±0.6)d，LapTME组患者分别为(2.4±0.5)d和(3.5±0.6)d，两组患者上述指标比较，差异均有统计学意义(t=8.90，11.30，P<0.05)。TaTME组和LapTME组患者术后30 d内吻合口瘘、吻合口出血、吻合口狭窄、肠梗阻、腹腔脓肿、伤口感染并发症发生例数分别为6例和5例、1例和1例、1例和2例、0和2例、1例和1例、0和2例，两组患者上述指标比较，差异均无统计学意义(x²=0.10，0.00，0.30，2.00，0.00，2.00，P>0.05)。两组患者术后30 d内尿潴留发生例数分别为3例和0，两组比较，差异有统计学意义(x²=3.00，P<0.05)。TaTME组和LapTME组分别有2例吻合口瘘患者术后行二次手术，其余患者均经对症治疗后好转。两组患者术后住院时间分别为7 d(5～36 d)和8 d(6～29 d)，两组比较，差异无统计学意义(Z=-0.90，P>0.05)。(3)术后病理学检查情况：TaTME组和LapTME组患者术后病理学标本长度、淋巴结获取数目、肿瘤下缘距远切缘距离、环周切缘阳性例数分别为(11±3)cm和(12±3)cm、(13±5)枚和(13±5)枚、(1.3±0.7)cm和(1.3±0.7)cm、0和1例，两组患者上述指标比较，差异均无统计学意义(t=0.50，0.20，0.10， x²=1.00，P>0.05)。(4)随访情况：100例患者均获得术后随访，随访时间为9～27个月，平均随访时间为18个月。随访期间，TaTME组 2例患者出现远处转移，3例出现局部复发； LapTME组2例出现远处转移，2例出现局部复发，两组远处转移和局部复发例数比较，差异均无统计学意义(x²=0.00，0.20，P>0.05)。
结论:TaTME治疗直肠癌安全可行，与LapTME比较，具有相当的病理学切除质量，未增加术中及术后并发症发生率，在术后恢复中具有明显优势。

Abstract: Objective:To compare the clinical efficacies of transanal total mesorectal excision(TaTME) and laparoscopic total mesorectal excision (LapTME)for rectal cancer (RC).
Methods:The casecontrol matching method and retrospective cohort study were conducted. The clinicopathological data of 100 RC patients who were admitted to the Sixth Affiliated Hospital of Sun Yatsen University between July 2014 and January 2016 were collected. Of 100 patients, 50 undergoing TaTME and 50 undergoing LapTME were respectively allocated into the TaTME and LapTME groups by casecontrol matching method. Observation indicators: (1) operation situations: operation time, volume of intraoperative blood loss, cases with intraoperative complications and preventive stoma; (2) postoperative recovery: time for diet intake, time for outofbed activity, occurrence of complications within 30 days postoperatively and duration of hospital stay; (3) postoperative pathological examinations: postoperative pathological specimen length, number of lymph node harvest, distance from lower boundary of tumor to distant margin and cases with positive circumferential margin; (4) followup. Followup using outpatient examination and network tracing was performed to detect local tumor recurrence and distant metastasis up to December 2016. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the pairedsamples t test. Measurement data with skewed distribution were represented as M (range). Comparisons of count data were analyzed using the chisquare test. Comparisons of measurement data with skewed distribution and ranked data were done by the nonparametric test.
Results:(1) Operation situations: operation time, volume of intraoperative blood loss, cases with intraoperative complications and preventive stoma were (259±111)minutes, 100 mL (range, 20-2 000 mL), 2, 28 in the TaTME group and (220±80)minutes, 50 mL (range, 20-1 000 mL), 1, 33 in the LapTME group, respectively, with no statistically significant difference (t=1.90, Z=-0.30, x²=0.34, 0.01, P>0.05). (2) Postoperative recovery: time for diet intake and time for outofbed activity were (1.6±0.5)days, (2.6±0.6)days in the TaTME group and (2.4±0.5)days, (3.5±0.6)days in the LapTME group, respectively, with statistically significant differences (t=8.90, 11.30, P<0.05). Cases with anastomotic fistula, bleeding and stenosis, intestinal obstruction, abdominal abscess and wound infection within 30 days postoperatively were 6, 1, 1, 0, 1, 0 in the TaTME group and 5, 1, 2, 2, 1, 2 in the LapTME group, respectively, with no statistically significant difference (x²=0.10, 0.00, 0.30, 2.00, 0.00, 2.00, P>0.05). Cases with urinary retention within 30 days postoperatively were 3 and 0 in the TaTME and LapTME groups, respectively, with a statistically significant difference (x²=3.00, P<0.05). Two and 2 patients with anastomic fistula underwent reoperation in the TaTME and LapTME groups respectively, and other patients were improved by symptomatic treatment. Duration of hospital stay was 7 days (range, 5-36 days) and 8 days (range, 6-29 days) in the TaTME and LapTME groups, respectively, with no statistically significant difference (Z=-0.90, P>0.05). (3) Postoperative pathological examinations: postoperative pathological specimen length, number of lymph node harvest, distance from lower boundary of tumor to distant margin and cases with positive circumferential margin were (11±3)cm, 13±5, (1.3±0.7)cm, 0 in the TaTME group and (12±3)cm, 13±5, (1.3±0.7)cm, 1 in the LapTME group, respectively, with no statistically significant difference (t=0.50, 0.20, 0.10, x²=1.00, P>0.05). (4) Followup: 100 patients were followed up for 9-27 months, with an average time of 18 months. During the followup, distant metastasis and local tumor recurrence were detected in 2, 3 patients of TaTME group and in 2, 2 patients of LapTME group, respectively, with no statistically significant difference (x²=0.00, 0.20, P>0.05).
Conclusions:TaTME for RC is safe and feasible. Compared with LapTME, TaTME not only achieves identical pathological quality without increasing intra and postoperative complications, but also benefits postoperative recovery of patients.

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