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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2022, Vol. 11 ›› Issue (01) : 24 -29. doi: 10.3877/cma.j.issn.2095-3224.2022.01.004

论著

低位直肠癌腹腔镜TME手术经直肠取出标本影响因素的分析
张振宇1, 朱哲1, 张园园1, 倪荔1, 纪昉1, 鲁兵1,†()   
  1. 1. 200120　同济大学医学院，同济大学附属东方医院（上海市东方医院）普外科，肛肠外科
  • 收稿日期:2021-05-05 出版日期:2022-02-25
  • 通信作者: 鲁兵
  • 基金资助:
    国家自然科学基金(82060103); 上海市科委课题(19411966500)

Influencing factors for trans-rectal specimen extraction following laparoscopic total mesorectal excision in patients with low rectal cancer

Zhenyu Zhang1, Zhe Zhu1, Yuanyuan Zhang1, Li Ni1, Fang Ji1, Bing Lu1,†()   

  1. 1. Department of General Surgery, Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200120, China
  • Received:2021-05-05 Published:2022-02-25
  • Corresponding author: Bing Lu
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引用本文：

张振宇, 朱哲, 张园园, 倪荔, 纪昉, 鲁兵. 低位直肠癌腹腔镜TME手术经直肠取出标本影响因素的分析[J]. 中华结直肠疾病电子杂志, 2022, 11(01): 24-29.

Zhenyu Zhang, Zhe Zhu, Yuanyuan Zhang, Li Ni, Fang Ji, Bing Lu. Influencing factors for trans-rectal specimen extraction following laparoscopic total mesorectal excision in patients with low rectal cancer[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2022, 11(01): 24-29.

目的

探讨低位直肠癌腹腔镜TME手术经直肠取出标本的限制因素。

方法

回顾性分析经纳排标准筛选的于2018年6~12月在同济大学附属东方医院接受低位直肠癌腹腔镜保肛手术的有效病例，利用单因素和多因素logistic分析比较经直肠取标本组（LAR-NOSES）和腹部小切口取标本组（Mini-Lapar）在术前基线资料、经CT/MRI测得肿瘤及盆腔局部骨性及软组织参数和术后临床病理分期等特征的差异。

结果

本研究最终共纳入有效患者89例，其中Mini-Lapar组48例，LAR-NOSES组41例，经直肠取标本成功率为46.1%。单因素分析结果显示LAR-NOSES与女性性别（χ2=9.0，P=0.003）、更小的BMI（t=-3.4，P=0.001）、肿瘤距肛缘位置（Z=-2.4，P=0.015）、肿瘤最大直径（t=-3.6，P=0.001）、肿瘤最大纵向长度（t=-3.9，P＜0.001）、直肠最大系膜厚度（t=-2.2，P=0.033）及更大的坐骨棘间径（t=3.0，P=0.004）和坐骨结节间径（t=2.6，P=0.011）显著相关。除pT分期外（χ2=6.6，P=0.038），两组在术后肿瘤病理大体、镜下分型分期及Wexner失禁评分方面差异均无统计学意义（P均＞0.05）。多因素logistic回归分析提示，BMI（OR=1.36，95%CI=1.09~1.70，P=0.006）、肿瘤距肛缘位置（OR=1.66，95%CI=1.03~2.70，P=0.039）、LTD（OR=2.99，95%CI=1.46~6.14，P=0.003）和坐骨棘间径（OR=0.44，95%CI=0.25~0.77，P=0.004）是限制腹腔镜低位直肠NOSES成功实施的独立预测因素。

结论

直肠标本的尺寸越小、标本取出所经过的软组织通道越短、所经过的骨性通道尺寸越大越有利于LAR-NOSES的成功实现。

关键词: 直肠肿瘤, 腹腔镜, 经直肠取标本手术, 影像学, 多因素分析
Objective

To explore restricting factors for trans-rectal specimen extraction following laparoscopic low anterior resection in patients with rectal cancer.

Methods

After retrospective inclusion of eligible patients with low rectal cancer who received laparoscopic low anterior resection at the department of colorectal surgery of Shanghai East Hospital between June and December of 2018, univariate and multivariate analyses were performed to compare the differences between tans-rectal extraction (LAR-NOSES) group and conventional trans-abdominal specimen extraction (Mini-Lapar) group in preoperative baseline characteristics, tumor-related and pelvic bone-related factors derived by CT/MRI scan as well as clinical-pathological variables.

Results

Eighty-nine eligible patients were selected in the final analysis including 48 and 41 cases in the Mini-Lapar and LAR-NOSES group, respectively.And the successful trans-rectal specimen extraction rate was 46.1% (41/89). Univariate analysis showed that LAR-NOSES was associated with female gender (χ2=9.0, P=0.003), a decreased body mass index (BMI) (t=-3.4, P=0.001), tumor distance from anal verge (Z=-2.4, P=0.015),maximum tumor diameter (MTD) (t=-3.6, P=0.001), maximum longitudinal tumor diameter (LTD) (t=-3.9, P＜0.001), maximum mesorectal thickness of the rectum (MRL) (t=-2.2, P=0.033), and an increased bispinous (t=3.0,P=0.004) and intertuberal diameter (t=2.6,P=0.011). Meanwhile, no differences were observed in postoperative gross and microscopic parameters, along with Wexner fecal incontinence index (all P values >0.05), except for an earlier pathological T stage (pT) (χ2=6.6, P=0.038) for patients in LAR-NOSES group. Multivariate logistic regression analysis indicated that the BMI (OR=1.36, 95%CI=1.09~1.70, P=0.006), tumor distance from anal verge (OR=1.66, 95%CI=1.03~2.70, P=0.039), LTD (OR=2.99, 95%CI=1.46~6.14, P=0.003) and bispinous diameter (OR=0.44, 95%CI=0.25~0.77, P=0.004) were independent predictors for the implementation of LAR-NOSES.

Conclusion

The implementation of LAR-NOSES may be favored by decreased specimen size, shortened soft tissue route and wider pelvic channel.

Key words: Rectal neoplasms, Laparoscopy, Trans-rectal specimen extraction surgery, Radiology, Multivariate analysis
图1 经直肠取标本手术步骤。1A：纱线条结扎肠管切缘；1B：超声刀横断远侧肠壁；1C：置入保护套并自肛门拖出；1D：置入吻合器钉砧；1E：标本从保护套内拖出；1F：自肛门管型吻合器吻合肠管
表1 纳入对象的临床基本特征
临床特征 小切口（n=48） NOSES（n=41） χ2/t/Z值 P值
性别 χ2=9.0 0.003

女

 10 21

男

 38 20
年龄（岁） 61.2±12.6 59.9±11.7 t=-0.5 0.622
BMI（kg/m2） 24.1±3.2 22.0±2.5 t=-3.4 0.001
肿瘤位置（cm） 6.0（4.0-7.0） 5.0（2.0-7.0） Z=-2.4 0.015
CEA χ2=0.4 0.536

阴性

 36 33

阳性

 12 8
MTD（cm） 4.5±1.2 3.6±1.1 t=-3.6 0.001
LTD（cm） 3.7±0.8 3.0±0.7 t=-3.9 <0.001
MRL（cm） 3.2±0.8 2.7±0.9 t=-2.2 0.033
骨盆入口前后径（cm） 11.0±0.8 11.4±0.9 t=1.8 0.074
坐骨棘间径（cm） 9.1±0.9 9.8±1.2 t=3.0 0.004
坐骨结节间径（cm） 7.6±1.0 8.2±1.2 t=2.6 0.011
标本长度（cm） 16.6±0.9 18.3±0.8 t=0.9 0.358
大体分型 χ2=4.0 0.133

隆起型

 14 20

溃疡型

 27 15

浸润型

 7 6
分化程度 χ2=0.4 0.536

G1+2

 36 33

G3+4

 12 8
脉管侵犯 χ2=2.1 0.145

阴性

 42 31

阳性

 6 10
神经侵犯 χ2=0 0.837

阴性

 39 34

阳性

 9 7
PLNC 1.5±2.5 1.3±2.6 t=-0.4 0.684
pT分期 χ2=6.6 0.038

T1

 2 9

T2

 17 13

T3

 29 19
pN分期 χ2=1.3 0.529

N0

 25 25

N1

 17 10

N2

 6 6
TNM分期 χ2=1.5 0.477

Ⅰ

 14 17

Ⅱ

 11 8

Ⅲ

 23 16
Wexner失禁评分 3.9±2.5 4.0±2.4 t=-0.2 0.746
表2 多因素logistic回归分析结果
协变量 OR* 95%CI P值
BMI（kg/m2） 1.36 1.09~1.70 0.006
肿瘤距肛缘位置（cm） 1.66 1.03~2.70 0.039
LTD（cm） 2.99 1.46~6.14 0.003
坐骨棘间径（cm） 0.44 0.25~0.77 0.004
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