术前放化疗对直肠癌括约肌间切除术后肛门功能的影响
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摘要
目的评估术前放化疗是否会降低接受肛门括约肌间切除术(intersphincteric resection,ISR)的低位直肠癌患者术后的肛门功能。方法收集89例低位直肠癌患者,根据患者所接受的治疗方式分为手术组41例和放化疗组48例。手术组患者直接接受ISR治疗,放化疗组在术前接受长程放化疗。所有患者均临时性回肠造口。所有患者均在术前1周和术后6个月时进行肛门直肠测压检查,并于术后6个月进行前切除综合征评分。结果放化疗组患者放化疗后最大缩榨压(P=0.005)和残余压(P=0.007)均减低,排便的最大耐受量也降低(P=0.040)。术后6个月时放化疗组患者的静息压(OR=1.024,P=0.047)、排便感觉阈(OR=1.035,P=0.045)和最大耐受量(OR=1.030,P=0.011)减低的程度均大于手术组。26例(29.2%)患者在术后6个月时回肠造口不能还纳。通过前切除综合征评分表评估患者术后的症状发现,放化疗后的患者术后前切除综合征发生率增高(80.5%vs 66.7%),但其严重程度与手术组比较,差异无统计学意义(P=0.091)。结论术前放化疗会降低ISR术后肛门功能,降低生活质量。
Objective To evaluate whether preoperative chemoradiotherapy would reduce anal function in patients with low rectal cancer after intersphincteric resection(ISR). Methods Eighty-nine patients with low locally advanced rectal cancer underwent ISR. According to the preoperative therapy, patients were divided into two groups: the operation group(n=41), patients received ISR directly; and the chemoradiotherapy group(n=48), patients received long-term chemoradiotherapy before opeartion. All patients had a temporary ileostomy. All patients underwent anorectal manometry at 1 week before operation and 6 months after operation, and low anterior resection syndrome(LARS) score was performed 6 months after operation. Results The maximal compressive pressure(P=0.005) and residual pressure(P=0.007) were significantly decreased after chemoradiotherapy. Meanwhile, the maximal tolerant dose of defecation is also decreased(P=0.040). The decrease of resting pressure(OR=1.024, P=0.047), defecation sensory threshold(OR=1.035, P=0.045) and maximal tolerance(OR=1.030, P=0.011) in the chemoradiotherapy group at 6 months postoperatively were significantly greater than those in the operation group. The ileostomy in 26 patients(29.2%) cannot be closed at 6 months postoperatively. According to the LARS score, patients treated with chemoradiotherapy suffered more low anterior syndrome(80.5% vs 66.7%). However, the severity in the two groups had no significant difference(P=0.091). Conclusion Preoperative chemoradiotherapy can decrease anal function and quality of life after ISR.
Objective To evaluate whether preoperative chemoradiotherapy would reduce anal function in patients with low rectal cancer after intersphincteric resection(ISR). Methods Eighty-nine patients with low locally advanced rectal cancer underwent ISR. According to the preoperative therapy, patients were divided into two groups: the operation group(n=41), patients received ISR directly; and the chemoradiotherapy group(n=48), patients received long-term chemoradiotherapy before opeartion. All patients had a temporary ileostomy. All patients underwent anorectal manometry at 1 week before operation and 6 months after operation, and low anterior resection syndrome(LARS) score was performed 6 months after operation. Results The maximal compressive pressure(P=0.005) and residual pressure(P=0.007) were significantly decreased after chemoradiotherapy. Meanwhile, the maximal tolerant dose of defecation is also decreased(P=0.040). The decrease of resting pressure(OR=1.024, P=0.047), defecation sensory threshold(OR=1.035, P=0.045) and maximal tolerance(OR=1.030, P=0.011) in the chemoradiotherapy group at 6 months postoperatively were significantly greater than those in the operation group. The ileostomy in 26 patients(29.2%) cannot be closed at 6 months postoperatively. According to the LARS score, patients treated with chemoradiotherapy suffered more low anterior syndrome(80.5% vs 66.7%). However, the severity in the two groups had no significant difference(P=0.091). Conclusion Preoperative chemoradiotherapy can decrease anal function and quality of life after ISR.
引文
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[11] 艾旭,龙舟,马旭,等.腹腔镜下拉下式和双吻合器直肠超低位前切除术对直肠癌患者肛门功能及术后并发症的影响比较[J].实用肿瘤杂志,2019,34(1):43-47.
[12] 李艺伟,蔡三军.局部进展期直肠癌综合治疗的临床思考[J].实用肿瘤杂志,2017,32(2):105-109.
[13] Bosset JF,Collette L,Calais G,et al.Chemotherapy with preoperative radiotherapy in rectal cancer[J].N Engl J Med,2006,355(11):1114-1123.
[14] Gerard JP,Conroy T,Bonnetain F,et al.Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers:results of FFCD 9203[J].J Clin Oncol,2006,24(28):4620-4625.
[15] Pollack J,Holm T,Cedermark B,et al.Long-term effect of preoperative radiation therapy on anorectal function[J].Dis Colon Rectum,2006,49(3):345-352.
[16] Matsushita K,Yamada K,Sameshima T,et al.Prediction of incontinence following low anterior resection for rectal carcinoma[J].Dis Colon Rectum,1997,40(5):575-579.
[17] Kakodkar R,Gupta S,Nundy S.Low anterior resection with total mesorectal excision for rectal cancer:functional assessment and factors affecting outcome[J].Colorectal Dis,2006,8(8):650-656.
[2] Chau A,Maggiori L,Debove C,et al.Toward the end of abdominoperineal resection for rectal cancer?An 8-year experience in 189 consecutive patients with low rectal cancer[J].Ann Surg,2014,260(5):801-805;discussion 805-806.
[3] Schiessel R,Karner-Hanusch J,Herbst F,et al.Intersphincteric resection for low rectal tumors[J].Br J Surg,1994,81(9):1376-1378.
[4] Fujimoto Y,Akiyoshi T,Kuroyanagi H,et al.Safety and feasibility of laparoscopic intersphincteric resection for very low rectal cancer[J].J Gastrointest Surg,2010,14(4):645-650.
[5] Emmertsen KJ,Laurberg S.Low anterior resection syndrome score:development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer[J].Ann Surg,2012,255(5):922-928.
[6] Sauer R,Becker H,Hohenberger W,et al.Preoperative versus postoperative chemoradiotherapy for rectal cancer[J].N Engl J Med,2004,351(17):1731-1740.
[7] R?del C,Martus P,Papadoupolos T,et al.Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer[J].J Clin Oncol,2005,23(34):8688-8696.
[8] Lazorthes F.Quality of life after surgery for rectal cancer[J].Eur J Cancer,2014,50(69 Suppl 3):S5.
[9] Krouse RS,Herrinton LJ,Grant M,et al.Health-related quality of life among long-term rectal cancer survivors with an ostomy:manifestations by sex[J].J Clin Oncol,2009,27(28):4664-4670.
[10] Klose J,Tarantino I,Kulu Y,et al.Sphincter-preserving surgery for low rectal cancer:do we overshoot the mark?[J].J Gastrointest Surg,2017,21(5):885-891.
[11] 艾旭,龙舟,马旭,等.腹腔镜下拉下式和双吻合器直肠超低位前切除术对直肠癌患者肛门功能及术后并发症的影响比较[J].实用肿瘤杂志,2019,34(1):43-47.
[12] 李艺伟,蔡三军.局部进展期直肠癌综合治疗的临床思考[J].实用肿瘤杂志,2017,32(2):105-109.
[13] Bosset JF,Collette L,Calais G,et al.Chemotherapy with preoperative radiotherapy in rectal cancer[J].N Engl J Med,2006,355(11):1114-1123.
[14] Gerard JP,Conroy T,Bonnetain F,et al.Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers:results of FFCD 9203[J].J Clin Oncol,2006,24(28):4620-4625.
[15] Pollack J,Holm T,Cedermark B,et al.Long-term effect of preoperative radiation therapy on anorectal function[J].Dis Colon Rectum,2006,49(3):345-352.
[16] Matsushita K,Yamada K,Sameshima T,et al.Prediction of incontinence following low anterior resection for rectal carcinoma[J].Dis Colon Rectum,1997,40(5):575-579.
[17] Kakodkar R,Gupta S,Nundy S.Low anterior resection with total mesorectal excision for rectal cancer:functional assessment and factors affecting outcome[J].Colorectal Dis,2006,8(8):650-656.