摘要
目的：探讨腹腔镜辅助经肛门全直肠系膜切除术（LaTaTME）治疗中低位直肠癌的临床疗效。方法：采用回顾性横断面研究方法。收集2015年8月至2016年8月北京大学第三医院收治的16例行LaTaTME中低位直肠癌患者的临床资料。同一组医师序贯完成LaTaTME，先行腹腔镜手术，再行经肛门手术。观察指标：（1）手术及术后恢复情况：中转开腹情况、吻合方式、手术时间、术中出血量、术中并发症情况、术后首次下床活动时间、术后进流质食物时间、术后并发症情况、术后住院时间。 （2）术后病理学检查情况：手术切除标本长度、肿瘤直径、肿瘤远端肠管切除距离、直肠系膜完整程度、环周切缘、病理学T分期、病理学N分期、淋巴结检出数目、肿瘤细胞分化程度。（3）随访结果。TNM Ⅲ～Ⅳ期的直肠癌患者，术后接受辅助化疗。术后每3个月门诊随访1次，随访内容为患者生存情况和肿瘤复发情况，随访时间截至2016年12月。计量资料采用M（范围）表示。结果：（1）手术资料及术后恢复情况：16例患者顺利完成手术，无中转开腹患者，其中结肠直肠吻合10例，结肠肛管吻合3例，结肠单腔永久性造瘘3例。16例患者手术时间为290 min（215～420 min），术中出血量为50 mL（30～100 mL）。术中1例患者出现并发症，该患者在直肠切除标本并经肛门拖出后，发现乙状结肠断端缺血，经腹腔进一步游离脾曲结肠，切除缺血的乙状结肠约5 cm，再行降结肠直肠吻合术。术后首次下床活动时间为1 d（1～3 d），术后进食流质食物时间为2 d（1～9 d）。术后3例患者出现并发症（ClavienDindo分级均为2级），其中2例为不完全性小肠梗阻，经过胃肠减压及静脉营养支持治疗后缓解；1例为骶前感染，经过引流以及抗生素治疗后缓解。术后住院时间为7 d（5～21 d）。（2）术后病理学检查情况：16例患者手术切除标本长度为18.0 cm（12.0～ 24.0 cm），肿瘤直径为3.5 cm（0.5～6.8 cm），肿瘤远端肠管切除距离为2.5 cm（1.0～5.0 cm）；手术切除标本的直肠系膜质量评估：完整14例，近乎完整2例；环周切缘及远近断端无肿瘤残留。16例患者病理学 T分期：0期（新辅助治疗后病理学完全缓解）1例，1期1例，2期4例，3期10例。病理学N分期：0期 12例，1期2例，2期2例。淋巴结检出数目为16枚（6～32枚）。肿瘤细胞分化程度：未见肿瘤细胞（新辅助治疗后病理学完全缓解）1例，高分化2例，中分化7例，低分化6例。 （3）随访结果：16例患者均获得术后随访，中位随访时间为12个月（4～16个月），无局部复发及远处转移患者，无死亡患者。结论：LaTaTME为中低位直肠癌患者提供了一种新的、较为安全和有效的手术入路和切除方式，近期疗效较好。
Objective：To explore the clinical efficacy of laparoscopeassisted transanal total mesorectal excision （LaTaTME） for middlelow rectal cancer. Methods：The retrospective crosssectional study was conducted. The clinical data of 16 patients with middlelow rectal cancer who underwent LaTaTME in the Peking University Third Hospital from August 2015 to August 2016 were collected. Sequential surgery of LaTaTME was applied to patients in the same team, with laparoscopic surgery first and then transanal surgery. Observation indicators： （1） operation and postoperative recovery situations： conversion to open surgery, anastomosis method, operation time, volume of intraoperative blood loss, intraoperative complications, time for outofbed activity, time for liquid diet intake, postoperative complications and duration of postoperative hospital stay. （2） postoperative pathological situations： length of surgical specimen, tumor diameter, distance from tumor to resected distant intestinal canal, complete degree of mesorectum, circumferential resection margin, pathological T stage, pathological N stage, number of lymph node detected and tumor cell differentiation. （3） followup. Patients in stage Ⅲ-Ⅳ of TNM stage of RC underwent postoperative adjuvant chemotherapy. Followup using outpatient examination was performed once every 3 months postoperatively to detect the patients′ survival and tumor recurrence up to December 2016. Measurement data were represented as M （range）. Results： （1） Operation and postoperative recovery situations： all the 16 patients underwent successful LaTaTME without conversion to open surgery, including 10 with colorectal anastomosis, 3 with coloncanalis analis anastomosis and 3 with permanent colostomy. Operation time and volume of intraoperative blood loss were 290 minutes （range, 215-420 minutes） and 50 mL （range, 30-100 mL）, respectively. One patient had intraoperative complication, showing broken ends ischemia of sigmoid colon after dragging out resected rectum from the anus, following free splenic flexure of colon, about 5 cm ischemic sigmoid colon were resected, and descending colonrectum anastomosis was performed. Time for outofbed activity and time for liquid diet intake were 1 days （range, 1-3 days） and 2 days （range, 1-9 days）, respectively. Among 3 patients with postoperative complications （Ⅱ stage of ClavienDindo）, 2 with incomplete intestinal obstruction were improved by gastrointestinal decompression and total parenteral nutrition, and 1 with presacral infection was improved by drainage and antibiotic therapy. Duration of postoperative hospital stay was 7 days （range, 5-21 days）. （2） Postoperative pathological situations： length of surgecal specimen, tumor diameter and distance from tumor to resected distant intestinal canal were respectively 18.0 cm （range, 12.0-24.0 cm）, 3.5 cm （range, 0.5-6.8 cm） and 2.5 cm （range, 1.0-5.0 cm）. Evaluation of mesorectum of surgical specimen： 14 patients had complete mesorectum of surgical specimen and 2 had nearly complete mesorectum. There was no residual tumor at circumferential resection margin,proximal and distal ends. Pathological T stage of 16 patients： T0 （pathological complete response after neoadjuvant therapy）, T1, T2 and T3 stages were found in 1, 1, 4 and 10 patients, respectively. Pathological N stage： 12, 2 and 2 patients were detected in N0, N1 and N2 stages, respectively. Number of lymph node detected was 16 （range, 6-32）. Tumor cell differentiation： no tumor cell （pathological complete response after neoadjuvant therapy）, high, moderate and lowdifferentiated tumors were respectively detected in 1, 2, 7 and 6 patients. （3） Followup. All the patients were followed up for 12 months （range, 4-16 months）. There were no local tumor recurrence or distant metastasis and death. Conclusion：LaTaTME may be a new, safe and effective resection for middlelow rectal cancer.
作者
张志鹏
姚宏伟
陈宁
白洋
田茂霖
王德臣
袁炯
修典荣
Zhang Zhipeng Yao Hongwei Chen Ning Bai Yang Tian Maolin Wang Dechen Yuan Jiong Xiu Dianrong(Department of General Surgery, Peking University Third Hospital, Beijing 100191, China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2017年第7期695-700,共6页
Chinese Journal of Digestive Surgery
基金
北京大学第三医院临床重点项目基金（BYSY2016018）
首都医科大学附属北京友谊医院科研启动基金（YYQDKT2016-5）
