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中华结直肠疾病电子杂志 ›› 2021, Vol. 10 ›› Issue (06) : 613 -620. doi: 10.3877/cma.j.issn.2095-3224.2021.06.008

论著

NOSES在低位直肠癌保肛手术中的临床观察
郭新宇1, 刘茂希2, 江波2,()   
  1. 1. 030001 山西医科大学第二临床学院
    2. 030013 太原,山西省肿瘤医院结直肠肛门外科
  • 收稿日期:2021-07-25 出版日期:2021-12-25
  • 通信作者: 江波
  • 基金资助:
    山西省自然科学基金(201901D111398)

Clinical effects of NOSES in anus reserved for low rectal cancer

Xinyu Guo1, Maoxi Liu2, Bo Jiang2,()   

  1. 1. Department of Second Clinical College, Shanxi Medical University, Taiyuan 030001, China
    2. Department of Colorectal Surgery, Shanxi Cancer Hospital, Taiyuan 030013, China
  • Received:2021-07-25 Published:2021-12-25
  • Corresponding author: Bo Jiang
引用本文:

郭新宇, 刘茂希, 江波. NOSES在低位直肠癌保肛手术中的临床观察[J/OL]. 中华结直肠疾病电子杂志, 2021, 10(06): 613-620.

Xinyu Guo, Maoxi Liu, Bo Jiang. Clinical effects of NOSES in anus reserved for low rectal cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2021, 10(06): 613-620.

目的

研究经自然腔道取标本手术(NOSES)在低位直肠癌根治中的近中期临床疗效。

方法

回顾性分析2017年1月至2019年4月收治的低位直肠癌(Tis-T3,N0,M0)未行预防性造瘘手术的患者的临床资料共109例;按术式分组,A组57例行腹腔镜下腹部辅助切口移除标本手术(Dixon);B组25例行经自然腔道取标本手术(NOSES-Ⅰ式A法),C组27例行经自然腔道取本手术(NOSES Ⅰ式E法,改良Bacon)。比较三组一般资料、围手术期指标、术后回访评估肛门功能、并发症情况及无病生存期等数据。

结果

BMI在B组最小(F=9.62,P<0.05),其余两组差异无统计学意义;肿瘤位置C组最低(F=18.77,P<0.05),A组与B组比较差异无统计学意义。B组与C组在开始进食时间方面与A组差异无统计学意义(F=8.07,χ2=5.34;P>0.05),但C组优于B组;导尿时间与拔除引流管时间C组明显优于其他两组(χ2=7.59,F=7.48;P<0.05),A组与B组差异无统计学意义(P>0.05)。住院费用方面C组为3组中最少(F=9.51,P<0.05),余围手术期指标3组间差异均无统计学意义(P>0.05)。12个月Vaizey量表评分A组及B组优于C组(χ2=12.04,P<0.05);24个月Vaizey量表评分组间差异无统计学意义(χ2=5.04,P>0.05)。全部患者并发症率为26.6%,B组为29.65%,高于A组(26.33%)和C组(20.21%),但3组间差异无统计学意义(χ2=0.48,P>0.05)。2年0例患者局部复发;2年无病生存期分别为94.7%,96.0%和88.9%(χ2=1.36,P>0.05);3组患者远处转移率为4.6%,4.0%和11.1%,差异无统计学意义(χ2=2.19,P>0.05)。

结论

NOSES在低位直肠癌根治中是安全可靠的,同时具有良好的肿瘤学预后以及较好地保留了肛门功能。

Objective

To observe the short mid-term clinical effects of natural orifice specimen extraction surgery (NOSES) in the radical treatment of low rectal cancer.

Methods

A retrospective analysis of the clinical datum of 109 patients with low rectal cancer (Tis-T3, N0, M0) who had not undergone preventive sotma from January 2017 to April 2019 was grouped by different surgical procedure. Group A including 57 cases underwent laparoscopic with abdominal incision surgery (Dixon), 25 patients in group B underwent natural orifice specimen extraction surgery (NOSES Ⅰ-A type), and 27 patients in group C underwent natural orifice specimen extraction surgery (NOSES Ⅰ-E type, modified Bacon). The general datum, perioperative indexes, postoperative follow-up assessment of anal function, compications and disease-free survival were compared between the three groups.

Results

BMI was minimal in group B (F=9.62, P<0.05), and there was no statistical difference in the remaining groups; the tumor position in group C was the lowest (F=18.77, P<0.05), and there was no statistical difference between the group A and the group B. The groups B and C in hospitalization expenses and the postoperative feed time were no statistical difference with group A (F=8.07, χ2=5.34; P>0.05), but the group C was better than the group B. The group C was significantly better than other two groups in the time of indwelling catheter and extracted drainage tube (χ2=7.59, F=7.48; P<0.05), and there was no statistical difference between the group A and the group B. Remainal indicators of perioperative period were no significant difference. The Vaizey scale scores of group A and group B were better than group C at 12 months after surgery (χ2=12.04, P<0.05), but the scores were not statistically significant at 24 months after surgery (χ2=5.04, P>0.05). All patients had a complication rate of 26.6%. The group B was 29.65%, which was higher than the group A (26.33%) and group C (20.21%), but there was no statistical difference (χ2=0.48, P>0.05). There was no patient occurred by local recurrence after 2 years surgery. 2-year disease-free survivals were 94.7%, 96.0% and 88.9% (χ2=1.36, P>0.05). There was no statistical difference in distant metastasis rate among the three groups (χ2=2.19, P>0.05).

Conclusion

NOSES is safe and reliable in the radical treatment of low rectal cancer and have a good oncologic prognosis and good preservation of anal function.

图1 直肠癌根治腹部主要手术步骤。1A:游离乙状结肠粘连;1B:内侧入路骶前第一刀;1C:结扎肠系膜血管;1D:游离直肠
图2 Dixon经腹移除标本及吻合主要操作步骤。2A:经腹移除标本;2B:肠管吻合
图3 NOSES Ⅰ式-A法移除标本及吻合主要操作步骤。3A:将远端肠管外翻于体外移除;3B:肠管吻合
图4 NOSES Ⅰ式-E法移除标本及二次肛门成形主要操作步骤。4A:充分暴露肛门;4B:移除标本后拖出肠管固定;4C:二次成型后外观
表1 一般资料
表2 围手术期及病理情况
项目 A组 B组 C组 统计值 P
手术时间(min) 187.87±56.17 221.42±55.59 203.61±65.18 F=2.13 0.12
术中出血量(mL) 65.09±48.03 77.20±65.86 75.93±63.98 F=0.56 0.57
住院费用a(万) 7.85±2.61 9.21±2.70 6.38±2.21 F=8.07 0.01

A-B

0.87

A-C

0.51

B-C

0.01
住院费用b(万) 7.85±2.61 9.21±2.70 6.01±2.17 F=9.51 0.00

A-B

0.87

A-C

0.02

B-C

0.00
排气时间(天) 2.96±0.98 2.92±0.95 2.70±0.75 F=0.74 0.47
进食时间(天) 6.0(4.0,8.5) 9.0(6.0,14.0) 4.0(4.0,6.0) χ2=10.24 0.01

A-B

0.051

A-C

0.14

B-C

0.00
导尿时间(天) 5.0(3.0,8.0) 5.0(4.0,7.5) 4.0(3.0,5.0) χ2=7.59 0.02

A-B

0.86

A-C

0.02

B-C

0.01
住院时间a(天) 15.46±10.13 17.88±8.69 13.33±8.17 F=1.53 0.22
住院时间b(天) 15.46±10.13 17.88±8.69 11.74±7.58 F=2.65 0.07
镇痛天数(天) 4.96±1.50 4.88±1.20 4.52±1.69 F=0.83 0.43
拔管时间(天) 11.54±8.87 14.88±8.0 6.70±4.12 F=7.48 0.00

A-B

1.00

A-C

0.00

B-C

0.03
标本长度(cm) 10.49±3.23 11.26±3.70 9.80±2.21 F=4.13 0.19
淋巴结个数 13.21±4.76 12.56±4.40 12.70±4.56 F=0.21 0.81
切缘阳性(例) 0 0 0
肿瘤距下切缘距离(cm) 1.60±0.86 1.78±1.30 1.23±0.67 F=2.23 0.11
肿物长径(cm) 4.00(2.85,5.00) 3.00(2.00,4.25) 3.00(3.50,4.00) χ2=3.51 0.17
肿物宽径(cm) 3.00(2.50,3.50) 2.50(2.00,3.00) 3.00(2.00,4.00) χ2=5.09 0.08
肿物厚度(cm) 1.50(0.80,2.00) 1.00(1.00,1.50) 1.50(1.00,2.00) χ2=3.06 0.22
表3 回访情况
图5 不同术式无病生存期比较
图6 不同肿瘤分期无病生存期比较
图7 不同术式远处转移率比较
图8 不同肿瘤分期远处转移率比较
表4 术后并发症情况(例)
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