摘要
目的探讨肛提肌外腹会阴联合切除术（ELAPE）治疗低位进展期直肠癌的安全性和可行性。方法由7家综合性医院协作，自2008年8月至2011年10月进行ELAPE治疗低位进展期直肠癌的前瞻性多中心研究。共完成ELAPE手术102例，其中男性60例，女性42例，中位年龄61岁（27～78岁）。记录患者手术情况、并发症及预后。结果102例患者均顺利完成手术，平均手术时间180min（110—495min），平均术中失血量200ml（50～1000m1）。术后常见的并发症分别为性功能障碍（40．5％）、会阴伤口相关并发症（23．5％）、尿潴留（18．6％）和骶尾部慢性疼痛（术后12个月，13．7％）。其中骶尾部慢性疼痛随时间延长而逐渐改善，且与切除尾骨密切相关（术后12个月时，t=8．06，P〈0．01）；与直接缝合相比，补片重建盆底能够显著降低会阴部伤口裂开（x2=13．502，P=0．006）和会阴部伤口相关并发症的发生（x2=5．836，P=0．016）。环周切缘（CRM）阳性6例（5．9％），术中穿孔4例（3．9％），CRM阳性部位和穿孔部位均位于直肠前壁和前侧壁。平均随访35个月（18～58个月），局部复发率4．9％。结论ELAPE手术可以降低低位进展期直肠癌的CRM阳性率和肠穿孔率，降低术后局部复发率，从而可能提高患者的生存率，但可能增加会阴区域的相关并发症，而生物补片重建盆底可以降低会阴伤口并发症的发生。
Objective To demonstrate the feasibility of extralevator abdominoperineal excision （ELAPE） for locally advanced low cancer in China. Methods A prospective muhieenter clinical trial was carried out by 7 general hospitals across China from August 2008 to October 2011. A total of 102 patients underwent ELAPE for primary locally advanced low rectal cancer. There were 60 male and 42 female patients. The patients＇ characteristics, complications and prognosis were recorded. Results All patients underwent the ELAPE procedure successfully. The median operating time was 180 minutes （range 110- 495 minutes） and median intraoperative blood loss was 200 ml （range 50-1000 ml）. The rates of sexual dysfunction, perineal eomplieations, urinary retention, and ehronic perineal pain were 40. 5%, 23.5%, 18.6% and 13.7%, respectively. Chronic perineal pain was assoeiated with coceygectomy （12 monthspostoperatively, t =8.06, P 〈0. 01 ） , and the pain might gradually ease over time. Reconstruction of pelvic floor with biologic mesh was associated with lower rate of perineal dehiscence （ X2 = 13. 502, P = 0. 006） and overall perineal wound complications （ x2 = 5. 836, P = 0. 016 ） compared with primary closure. A positive circumferential margin （CRM） was demonstrated in 6 （5.9%） patients, and intraoperative perforations occulted in 4 （3.9%） patients. All CRM involvement and intraoperative perforation located at anteriorly and anterolaterally. The local recmxence was 4. 9% at a median follow-up of 35 months （ range, 18-58 months）. Conclusions ELAPE performed in the prone position for low rectal cancer leads to a reduction in CRM involvement, intraoperative perforations, and local recurrence, but it might result in a little high rate of perineal wound related complications. Reconstruction of pelvic floor with biologic mesh might lower the rate of perineal wound complications.
出处
《中华外科杂志》
CAS
CSCD
北大核心
2014年第1期11-15,共5页
Chinese Journal of Surgery
基金
基金项目：首都临床特色应用研究资助项目（Z12110700101213I）
北京市卫生系统高层次卫生技术人才培养计划资助项目（2009-1-03）
新世纪百千万人才工程资助项目（09-911-002、08-009）
首都医学发展科研基金资助项目（2009-3109）
关键词
直肠肿瘤
结直肠外科手术
手术后并发症
预后
Rectal neoplasms
Colorectal surgery
Postoperative complications
Prognosis
