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中华结直肠疾病电子杂志 ›› 2022, Vol. 11 ›› Issue (04) : 310 -318. doi: 10.3877/cma.j.issn.2095-3224.2022.04.007

论著

不同取标本途径在直肠癌微创手术中的疗效对比
胡国睿1, 冯震1, 王波1, 任双义1,()   
  1. 1. 116027 大连医科大学附属第二医院胃肠外科
  • 收稿日期:2022-01-18 出版日期:2022-08-25
  • 通信作者: 任双义

Comparison of different methods of specimen collection in minimally invasive surgery for rectal cancer

Guorui Hu1, Zhen Feng1, Bo Wang1, Shuangyi Ren1()   

  1. 1. Department of Gastrointestinal Surgery, the Second Hospital of Dalian Medical University, Dalian 116027, China
  • Received:2022-01-18 Published:2022-08-25
  • Corresponding author: Shuangyi Ren
引用本文:

胡国睿, 冯震, 王波, 任双义. 不同取标本途径在直肠癌微创手术中的疗效对比[J/OL]. 中华结直肠疾病电子杂志, 2022, 11(04): 310-318.

Guorui Hu, Zhen Feng, Bo Wang, Shuangyi Ren. Comparison of different methods of specimen collection in minimally invasive surgery for rectal cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2022, 11(04): 310-318.

目的

对常规直肠癌经辅助切口取标本与经自然腔道取标本手术(NOSES)进行比较,探讨NOSES的近远期疗效。

方法

回顾性分析2018年1月至2020年12月大连医科大学附属第二医院胃肠外科行直肠癌微创手术的217例患者的临床资料,根据标本取出方式不同分为NOSES组(研究组)和传统经腹部辅助切口组(对照组)。采用PSM平衡两组患者术前基本资料,研究组和对照组各纳入患者63例,比较两组患者的围手术期资料、术后病理资料及远期随访资料。

结果

研究组患者腹壁切口更短(t=-19.791,P<0.001),术后离床时间更早(t=-5.978,P<0.001),胃肠道功能恢复更快(t=-7.656,P<0.001),疼痛评分更低(术后12 h:t=-4.372,P<0.001;术后24 h:t=-5.835,P<0.001),两组对比差异均存在统计学意义。研究组患者切口并发症发生率明显低于对照组,差异存在统计学意义[(0)vs.(9.5%),χ2=4.375;P=0.028]。采用Clavien-Dindo分级标准对术后并发症进行分类,研究组共8例术后并发症(12.7%),其中CD Ⅰ级并发症3例(4.8%),CD Ⅱ级并发症2例(3.2%),CD Ⅲ级并发症3例(4.8%);研究组术后并发症发生率较对照组低,但差异无统计学意义[(12.7%)vs.(22.2%),χ2=1.983;P=0.159]。对比两组患者的术后病理资料及远期随访资料,在淋巴结检出总数(t=0.603,P=0.548)、近切缘(t=-0.110,P=0.912)及远切缘长度(t=-0.126,P=0.900)、总生存率(χ2=0.002,P=0.962)及无病生存率(χ2=0.625,P=0.429)上,差异均无统计学意义。

结论

NOSES安全可行,具有术后疼痛轻、损伤小、胃肠道功能恢复较快等优点,具有与传统经辅助切口取标本手术相似的长期肿瘤学结果。

Objective

Demonstrated the short- and long-term efficacy of NOSES by comparing abdominal incision for specimen extraction and natural orifice specimen extraction surgery (NOSES) in the treatment of rectal cancer.

Methods

We retrospectively analyzed the clinical data of 217 patients who underwent NOSES or conventional minimally invasive surgery in the department of gastrointestinal surgery of the Second Affiliated Hospital of Dalian Medical University from January 2018 to December 2020. According to the different methods of the removal of surgical specimen, all patients were divided into the following groups: NOSES group (experimental group) and the auxiliary incision group (control group). PSM was used to balance the baseline data, there were 63 patients in the NOSES group and 63 patients in the auxiliary incision group, respectively; perioperative data, pathological data and the long-term efficacy were analyzed among two groups.

Results

Compared to the auxiliary incision group, patients in the NOSES group had shorter incision lengths (t=-19.791, P<0.001), earlier out-of-bed time (t=-5.978, P<0.001), shorter postoperative gastrointestinal recovery time (t=-7.656, P<0.001) and lower VAS score of the incision pain (postoperative 12 h: t=-4.372, P<0.001; postoperative 24 h: t=-5.835, P<0.001), these differences were statistically significant. The incidence of incision complications in the NOSES group was significantly lower than that in the auxiliary incision group(0 vs. 9.5%, χ2=4.375; P=0.028). Postoperative complications were graded by Clavien-Dindo classification, postoperative complications occurred in 8 patients in the NOSES group (12.7%), the amounts of Clavien-Dindo grade Ⅰ, Ⅱ and Ⅲ complications were 3 (4.8%), 2 (3.2%) and 3 (4.8%); compared to the auxiliary incision group, the NOSES group had lower rate of postoperative complications, but no difference was statistically significant (12.7% vs. 22.2%, χ2=1.983; P=0.159). Compared the pathological data and the long-term efficacy of two groups, there were all no significant differences in the number of dissected lymph nodes (t=0.603, P=0.548), the length of proximal margin (t=-0.110, P=0.912) and distal resection margin (t=-0.126, P=0.900), overall survival (χ2=0.002, P=0.962) and disease-free survival (χ2=0.625, P=0.429).

Conclusion

NOSES has obviously advantages of less postoperative pain, smaller damage and earlier postoperative recovery, provides satisfactory efficacy and acceptable safety, and similar long-term oncologic outcomes compared with conventional minimally invasive surgery.

图1 切除拖出式手术步骤。1A:离断远端直肠;1B:置入无菌保护套经肛拉出至体外;1C:将标本拉出至体外;1D:乙状结肠与直肠行端端手工吻合
图2 拉出切除式手术步骤。2A:离断远端直肠;2B:置入无菌保护套经肛拉出至体外;2C:将标本拉出至体外;2D:结肠断端埋入抵钉座并还纳回腹腔;2E:闭合直肠残端;2F:乙状结肠与直肠行端端吻合
表1 两组患者的术前基本资料对比[
xˉ
±s,例(%)]
表2 PSM后两组患者围手术期资料对比[
xˉ
±s,例(%)]
基本特征 研究组(n=63) 对照组(n=63) 检验值 P
手术时间(min) 154.05±36.22 161.64±47.30 t=-1.011 0.314
失血量(mL) 51.11±30.33 61.75±39.98 t=-1.682 0.095
切口长度(cm) 2.00±0.68 5.23±1.10 t=-19.791 <0.001
保护性造口 χ2=0.670 0.413
18(28.6) 14(22.2)
45(71.4) 49(77.8)
术后离床时间(h) 13.32±4.37 18.94±6.05 t=-5.978 <0.001
术后排气时间(h) 19.73±5.23 33.02±12.74 t=-7.656 <0.001
术后排便时间(h) 28.24±7.29 45.29±16.37 t=-7.550 <0.001
术后进流食时间(h) 19.24±4.04 27.62±14.17 t=-4.514 <0.001
VAS评分 <0.001
术后12 h 2.52±1.35 3.64±1.50 t=-4.372
术后24 h 1.65±1.42 3.27±1.69 t=-5.835
术后并发症 8(12.7) 14(22.2) χ2=1.983 0.159
腹腔出血 0(0) 2(3.2) χ2=0.508 0.496
吻合口漏 4(6.3) 4(6.3) - 1.000a
A级 0(0) 0(0)
B级 1(1.6) 2(3.2)
C级 3(4.8) 2(3.2)
腹腔感染 4(6.3) 4(6.3) - 1.000a
切口相关并发症 0(0) 6(9.5) χ2=4.375 0.028
红肿 0(0) 1(1.6)
脂肪液化 0(0) 1(1.6)
感染 0(0) 3(4.8)
出血 0(0) 0(0)
切口疝 0(0) 1(1.6)
其他并发症 4(6.3) 4(6.3) - 1.000a
发热 1(1.6) 1(1.6)
肺炎 1(1.6) 1(1.6)
肠梗阻 1(1.6) 1(1.6)
乳糜漏 1(1.6) 1(1.6)
尿潴留 0(0) 0(0)
Clavien-Dindo并发症分级 χ2=3.132 0.193
Ⅰ级 3(4.8) 7(11.1)
Ⅱ级 2(3.2) 5(7.9)
Ⅲ级 3(4.8) 2(3.2)
术后拔管时间(d) 13.19±10.21 12.94±7.50 t=0.159 0.874
术后住院时间(d) 6.98±3.50 7.95±6.61 t=-1.028 0.307
表3 PSM后两组患者术后病理资料比较[
xˉ
±s,例(%)]
图3 两组患者长期生存结果比较。3A:倾向评分匹配后研究组与对照组总生存情况对比(χ2=0.002,P=0.962);3B:倾向评分匹配后研究组与对照组无病生存情况对比(χ2=0.625,P=0.429)
表4 两组患者远期随访结果比较
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