江蘇省無錫市錫山區(qū)中醫(yī)醫(yī)院普外科,無錫 214194

開腹與腹腔鏡ISR術(shù)式治療Ⅱ～Ⅲ期低位直腸癌保肛的對(duì)比分析

梁炳英

江蘇省無錫市錫山區(qū)中醫(yī)醫(yī)院普外科,無錫214194

目的對(duì)比分析開腹與腹腔鏡內(nèi)外括約肌間切除術(shù)(intersphincteric resection,ISR)Ⅱ～Ⅲ期低位直腸癌保肛中的臨床療效。方法選取普外科治療的70例Ⅱ～Ⅲ期低位直腸癌保肛患者,隨機(jī)分為觀察組(腹腔鏡ISR術(shù))和對(duì)照組(開腹ISR術(shù)),對(duì)比兩組術(shù)后的臨床指標(biāo)、并發(fā)癥和轉(zhuǎn)移復(fù)發(fā)率。結(jié)果觀察組術(shù)中出血量[(94.68±18.76) mL]、肛門首次排氣時(shí)間[(1.21±0.36) d]、住院時(shí)間[(9.54±1.39) d]均顯著優(yōu)于對(duì)照組[(203.22±35.18) mL、(2.18±0.67)d、(12.73±1.52)d,P<0.05],而手術(shù)時(shí)間、術(shù)中淋巴結(jié)清掃數(shù)等差異無統(tǒng)計(jì)學(xué)意義。術(shù)后并發(fā)癥(11.4%)、轉(zhuǎn)移復(fù)發(fā)(5.7%)也明顯低于對(duì)照組(37.1%、22.9%,P<0.05)。結(jié)論相較于開腹ISR手術(shù),腹腔鏡ISR手術(shù)具有較高的臨床療效,較低的術(shù)后并發(fā)癥和轉(zhuǎn)移復(fù)發(fā)率,值得臨床推廣。

開腹手術(shù); 腹腔鏡ISR手術(shù); 低位直腸癌

隨著醫(yī)療水平的不斷提升,內(nèi)外括約肌間切除術(shù)(intersphincteric resection,ISR)日益成為治療低位直腸癌的經(jīng)典術(shù)式,并發(fā)揮出較好的臨床療效[1];尤其是近年腹腔鏡技術(shù)的進(jìn)步,有效提高了低位直腸癌保肛概率,對(duì)患者恢復(fù)產(chǎn)生了積極影響[2-3]。相較于傳統(tǒng)的會(huì)陰聯(lián)合切除術(shù),ISR創(chuàng)傷小,提高了保肛率,利于患者恢復(fù)[4-5]。本研究對(duì)比分析開腹ISR與腹腔鏡ISR的臨床療效?，F(xiàn)報(bào)道如下。

1 資料與方法

1.1 一般資料

選取2011年11月—2016年11月錫山區(qū)中醫(yī)醫(yī)院接受治療的70例Ⅱ～Ⅲ期低位直腸癌保肛患者,在知情同意情況下進(jìn)行臨床研究。將70例患者隨機(jī)分為觀察組和對(duì)照組。觀察組35例,男19例,女16例,年齡50～68歲,平均(56.39±4.27)歲,采取腹腔鏡ISR手術(shù),下切緣距離2.5～3.7 cm,平均(3.31±0.46) cm。對(duì)照組35例,男20例,女15例,年齡51～66歲,平均(55.82±4.35)歲,采取常規(guī)開腹ISR手術(shù),下切緣距離2.7～3.7 cm,平均(3.26±0.41) cm。兩組基本資料無統(tǒng)計(jì)學(xué)差異,具有可比性。

1.2 方法

在采取腹腔鏡ISR手術(shù)治療的觀察組,于右下腹和臍部分別穿刺置入12 mm、10 mm Trocar作為主操作孔和觀察孔,行腸系膜下動(dòng)脈結(jié)扎,同時(shí)清掃周圍淋巴脂肪組織,并避免損傷輸尿管及下腹血管,盡可能向恥骨直腸肌及內(nèi)括約肌間平面分離至尾側(cè);將距離腫瘤下緣處>1 cm的環(huán)周黏膜組織及肌層切除,使切口保持自直腸至肛門括約肌,向上直對(duì)直腸至肛提肌處游離。對(duì)照組采取常規(guī)開腹ISR手術(shù),在下腹正中切開后經(jīng)肛門口處拉出直腸,標(biāo)記處離斷直腸,行結(jié)腸肛管吻合;對(duì)合并吻合口瘺等高危患者,采取預(yù)防性造口,術(shù)后數(shù)月行回納手術(shù)。

比較分析兩組臨床指標(biāo),包括手術(shù)時(shí)間、術(shù)中出血量、術(shù)中淋巴結(jié)清掃數(shù)、肛門首次排氣時(shí)間及住院時(shí)間;并隨訪術(shù)后6個(gè)月的并發(fā)癥及轉(zhuǎn)移復(fù)發(fā)情況。

1.3 統(tǒng)計(jì)學(xué)處理

2 結(jié)果

2.1 臨床指標(biāo)比較

兩組手術(shù)時(shí)間、術(shù)中淋巴結(jié)清掃數(shù)無差異;但術(shù)中出血量、肛門首次排氣時(shí)間及住院時(shí)間,觀察組明顯優(yōu)于對(duì)照組(P<0.05),見表1。

2.2 術(shù)后并發(fā)癥比較

通過術(shù)后6個(gè)月隨訪發(fā)現(xiàn),觀察組4例(11.4%)發(fā)生并發(fā)癥,對(duì)照組13例(37.1%)出現(xiàn)并發(fā)癥,前者并發(fā)癥顯著低于對(duì)照組(P<0.05),見表2。

2.3 轉(zhuǎn)移復(fù)發(fā)比較

術(shù)后6個(gè)月隨訪發(fā)現(xiàn),觀察組有3例(8.6%)出現(xiàn)轉(zhuǎn)移,2例(5.7%)局部復(fù)發(fā);對(duì)照組有10例(28.6%)轉(zhuǎn)移,8例(22.9%)局部復(fù)發(fā);觀察組轉(zhuǎn)移、復(fù)發(fā)率顯著低于對(duì)照組(P<0.05),見表3。

3 討論

表1 兩組臨床指標(biāo)比較

注：與對(duì)照組相比,(1)P<0.05。

表2 兩組術(shù)后并發(fā)癥比較[n (%)]

注：與對(duì)照組比較,(1)P<0.05。

表3 兩組轉(zhuǎn)移復(fù)發(fā)比較[n(%)]

注：與對(duì)照組比較,(1)P<0.05。

直腸癌發(fā)病位居惡性腫瘤第二位,嚴(yán)重威脅了患者生命健康[6]。低位直腸癌主要指腹膜反折以下直腸癌[7-8],有較高發(fā)病率,且中晚期居多,多見于40歲以上男性,目前臨床治療主要采取手術(shù)治療方式[9-10]。臨床研究認(rèn)為,針對(duì)直腸癌的治療應(yīng)以腫瘤病灶切除為主要目的,同時(shí)也應(yīng)將患者肛門、泌尿生殖功能保留作為治療首要目標(biāo)[11]。傳統(tǒng)會(huì)陰聯(lián)合切除術(shù)治療直腸癌,不僅會(huì)留下永久性造口,同時(shí)也降低患者治療依從性,對(duì)生活質(zhì)量造成巨大影響[12]。

1992年,ISR治療低位直腸癌被首次報(bào)道。近年來,隨著ISR手術(shù)的廣泛應(yīng)用,直腸癌保肛率提高,為改善患者術(shù)后生活質(zhì)量做出了貢獻(xiàn)[13]。有研究表明,在直腸癌的臨床治療過程中,所施手術(shù)主要取決于肛門外括約肌是否受累,而與腫瘤距肛緣距離無關(guān)。相較于傳統(tǒng)開腹ISR手術(shù),腹腔鏡ISR手術(shù)具有創(chuàng)傷小、恢復(fù)快、住院時(shí)間短等優(yōu)點(diǎn),還因有較好臨床療效而提高了患者術(shù)后生活信心。腹腔鏡ISR手術(shù)的本質(zhì)是腹腔鏡全系膜切除術(shù)(TME)與ISR的聯(lián)合,在腹腔鏡技術(shù)下,ISR優(yōu)勢(shì)得到更好體現(xiàn),術(shù)者可清晰辨認(rèn)患處組織,同時(shí)因有更開闊視野游離脾結(jié)腸韌帶無需延長切口,尤其對(duì)開腹ISR下屬操作“盲區(qū)”的直腸末端游離。但目前臨床針對(duì)此研究相對(duì)較少,導(dǎo)致了臨床腹腔鏡ISR手術(shù)開展率相對(duì)較低,不利低位直腸癌患者的康復(fù)[14-15]。

相較于開腹ISR手術(shù),腹腔鏡ISR手術(shù)具有較高的臨床療效,較少的術(shù)后并發(fā)癥及轉(zhuǎn)移復(fù)發(fā),值得臨床推廣。

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ComparativeanalysisoflaparotomyandlaparoscopicintersphinctericresectionintreatmentofstageⅡ-Ⅲlowrectalcancer

LIANGBingying

DepartmentofGeneralSurgery,WuxiTraditionalChineseMedicineHospital,Wuxi214194,China

ObjectiveTo analyze and compare the clinical effects of laparotomy and laparoscopic intersphincteric resection (ISR) in the preservation of rectal cancer at stage Ⅱ-Ⅲ.MethodsA total of 70 patients with stage Ⅱ-Ⅲ low rectal cancer were selected from Department of General Surgery and randomly divided into an observational group (laparotomy ISR) and a control group (laparoscopic ISR).The clinical indicators,incidence rate of postoperative complications,and recurrence rate between the two groups were compared.ResultsThe observation group showed significantly less intraoperative blood loss volume[(94.68±18.76) mLvs.(203.22±35.18) mL],shorter first anal exsufflation time[(1.21±0.36) dvs.(2.18±0.67) d],and shorter hospital stay[(9.54±1.39) dvs.(12.73±1.52) d] than the control group (P<0.05),but no differences in operation time and the number of lymph node dissection were observed.The incidence rate of postoperative complications (11.43%vs.37.14%) and recurrence rate (5.71%vs.22.86%) in the observation group were also significantly lower than those of the control group (P<0.05).ConclusionCompared with laparotomy ISR,laparoscopic ISR has a better clinical therapeutic effect and lower postoperative complication rate and recurrence rate;therefore,it is worthy of clinical application.

Laparotomy; Laparoscopic intersphincteric resection; Low rectal cancer

R61

A

2095-378X(2017)03-0162-03

2017-05-15)

梁炳英(1975—),男,主治醫(yī)師,本科,從事外科手術(shù)治療;電子信箱:f093221@126.com

10.3969/j.issn.2095-378X.2017.03.005