摘要
目的探讨经阴道右半结肠切除术的安全性和可行性。方法采用回顾性队列研究方法。将北京协和医院基本外科结直肠专业组于2019年1月至2022年3月期间连续收治的30例经阴道进行右半结肠切除术的女性患者作为经阴道手术组,纳入标准为绝经后妇女,肿物直径<6 cm,术前影像判断不需清扫中央组淋巴结的右半结肠癌、阑尾黏液性肿瘤或难以镜下切除的右半结肠腺瘤患者。同时选取2022年1—6月期间23例接受经腹的腹腔镜右半结肠切除术女性患者作为腹腔镜手术组,纳入标准为术前病理活检为腺癌或高级别上皮内瘤变,肿瘤位于盲肠至横结肠右1/3,临床分期为T1~4NanyM0;排除术中发现有远处转移、肿瘤累及周围脏器需要行联合脏器切除或无法达到R0切除以及中转开腹者。两组基线资料的比较显示,除经阴道手术组患者体质指数低于腹腔镜手术组[(22.0±3.1)kg/m^(2)比(24.1±2.6)kg/m^(2),t=2.617,P=0.012]和两组的肿瘤病理类型比较差异有统计学意义(P<0.05)外,其余资料差异无统计学意义(均P>0.05)。对两组患者手术情况、术后恢复情况及标本质量进行比较。结果经阴道手术组30例患者中,26例为完全经阴道路径,3例需要腹部Trocar辅助(2例因为吻合困难,1例因为腹腔粘连严重),1例因出血中转为经腹腹腔镜手术。相比腹腔镜手术组,经阴道手术组患者手术时间更长[175.0(147.5,216.3)min比120.0(100.0,120.0)min,U=63.000,P<0.001],术中出血量更多[30.0(10.0,50.0)ml比23.0(10.0,20.0)ml,U=208.000,P=0.011],差异均有统计学意义。经阴道手术组术中并发症发生率较高[16.7%(5/30)比0],但两组比较,差异无统计学意义(P=0.061)。经阴道手术组有5例术中损伤,其中3例为膀胱损伤,1例为回结肠动脉损伤,1例为右侧子宫动脉损伤。经阴道手术组与腹腔镜手术组患者术后并发症发生率的比较,差异无统计学意义[20.0%(6/30)比17.4%(4/23),χ^(2)<0.001,P>0.999],但经阴道手术组有2例为Clavien-DindoⅢ级并发症,分别为1例盆腔血肿(需介入治疗),1例术中膀胱损伤后出现膀胱阴道瘘(需手术修补)。术后第1天、第3天及第5天的可视化疼痛评分,经阴道手术组中位数分别为4分、1分和0分,明显优于腹腔镜手术组的6分、3分和1分,差异有统计学意义(均P<0.001)。两组患者术后首次下床、首次排气、首次饮水时间及术后住院时间的比较,差异均无统计学意义(均P>0.05)。所有手术切除标本评分都能达到中等以上,经阴道手术组标本良好率达83.3%(25/30),腹腔镜手术组标本良好率为100%(23/23),两组比较差异无统计学意义(P=0.061)。经阴道手术组23例患者采用D_(2)淋巴结清扫术,获取淋巴结数目为18(15,27)枚,腹腔镜手术组7例接受D_(2)淋巴结清扫术,获取淋巴结数目为20(16,29)枚,两组差异亦无统计学意义(U=69.500,P=0.589)。结论经阴道右半结肠手术的优势是能够减轻术后疼痛,但手术并发症较多,目前尚无法替代现有的经腹腹腔镜手术。
Objective To investigate the safety and feasibility of performing right colectomy via a transvaginal approach.Methods This was a retrospeltive cohort study.Data of 30 patients who had undergone transvaginal laparoscopic right colectomy(transvaginal group)and 23 women who had undergone laparoscopic right colectomy(laparoscopic group)from January 2019 to March 2022 in the Division of Colorectal Surgery,Department of General Surgery,Peking Union Medical College Hospital were collected retrospectively.The inclusion criteria for the transvaginal group were as follows:(1)post-menopausal woman;(2)transverse diameter of the tumor<6 cm;and(3)diagnosis of benign polyps that were unresectable by endoscopy,mucinous tumors of the appendix,or confirmed right colon cancer not requiring D3 lymphadenectomy.The inclusion criteria for the laparoscopic group were as follows:(1)pathologically confirmed adenocarcinoma or high-grade intraepithelial neoplasia;(2)lesion located from the cecum to the right third of the transverse colon;and(3)clinically stage T1-4NanyM0.The exclusion criteria for the laparoscopic group were as follows:(1)distant metastasis discovered during surgical exploration;(2)multiple organ resection required or R0 resection not possible;or(3)conversion to open surgery required.Safety was evaluated on the basis of intra-and post-operative complications.Feasibility was assessed by postoperative recovery and quality of operative specimen.The body mass index was lower in the transvaginal than the laparoscopic group(22.0±3.1 kg/m^(2)vs.24.1±2.6 kg/m^(2),t=2.617,P=0.012).Results Among the 30 transvaginal laparoscopic right colectomies,26 were pure transvaginal surgeries,three required laparoscopic assistance because of difficulties with anastomosis(n=2)or abdominal adhesions(n=1),and one required conversion to laparoscopic surgery because of vascular injury.Compared with the laparoscopic group,the transvaginal group had a longer surgery time(175.0[147.5,216.3]minutes vs.120.0[100.0,120.0]minutes,U=63.000,P<0.001)and more blood loss(30.0[10.0,50.0]ml vs.23.0[10.0,20.0]ml,U=208.000,P=0.011).The incidence of intraoperative complications(16.7%(5/30)vs.0,P=0.061)was comparable between the two groups.In the transvaginal group,the sites of intraoperative injuries were bladder(n=3),ileocecal artery(n=1),and right uterine artery(n=1).The incidence of postoperative complications(20.0%[6/30]vs.17.4%[4/23],χ^(2)<0.001,P>0.999)was also comparable between the two groups.Clavien-Dindo grade III postoperative complications occurred in two patients in the transvaginal group(one patient had a pelvic hematoma that required embolization;the other had a vesico-vaginal fistula that required surgery).Postoperative visual analogue scale scores were significantly lower(P<0.001)in the transvaginal group.Times to first flatus,ambulation,and first intake and duration of postoperative hospital stay were comparable between the two groups(P>0.05).The proportion of specimens of moderate quality was 83.3%(25/30)in the transvaginal group and 100%(23/23)in the laparoscopic group;this difference is not significant(P=0.061).Among patients who underwent D2 lymph node dissection,the number of lymph nodes examined was comparable between the transvaginal(n=23)and laparoscopic groups(n=7)(18[15,27]vs.20[16,29],U=69.500,P=0.589).Conclusion Transvaginal right colon surgery is associated with less postoperative pain than laparoscopic surgery,but is not yet the preferred alternative because of the incidence of surgical complications.
作者
肖毅
孙振
孙蕊
侯文运
徐徕
陆君阳
Xiao Yi;Sun Zhen;Sun Rui;Hou Wenyun;Xu Lai;Lu Junyang(Division of Colorectal Surgery,Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100730,China;the Department of Colorectal Surgery in the Sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou,Guangdong 510655,China;the Department of Colorectal Surgery,National Cancer Center,National Clinical Research Center for Cancer,Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China)
出处
《中华胃肠外科杂志》
CSCD
北大核心
2023年第6期588-594,共7页
Chinese Journal of Gastrointestinal Surgery
基金
国家自然科学基金(62172437)
中国医学科学院北京协和医院-医疗新技术新项目(2021年)。
关键词
结直肠肿瘤
经阴道自然腔道内镜手术
右半结肠切除术
Colorectal neoplasms
Transvaginal natural orifice transluminal endoscopic surgery
Right colectomy
