直肠癌行肛提肌外腹会阴联合切除术研究进展
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摘要
肛提肌外腹会阴联合切除术(ELAPE)是治疗低位进展期直肠癌的重要术式。近年来,ELAPE手术方式和技术在逐渐发展,其突出的优点是手术简单、精准、根治性有所提高。腹腔镜和机器人手术系统行ELAPE亦取得肯定效果。多数研究认为,ELAPE降低了环周切缘阳性率、肿瘤穿孔发生率,并可能进一步降低局部复发率和提高存活率。由于切除了更多的肿瘤周围组织,ELAPE可能会增加术后会阴部伤口并发症、泌尿生殖功能障碍和骶尾部慢性疼痛的发生,但有关生活质量研究认为,ELAPE术后病人总体生活质量与传统经腹会阴联合切除术(APR)无显著差别。个体化ELAPE手术可能降低术后并发症发生率。应用生物补片重建盆底有助于缩短住院时间,减少住院花费。笔者认为,ELAPE从理念上强调了沿肛门外括约肌-提肛肌外侧筋膜平面切除的重要性,尽可能保留坐骨直肠窝脂肪,以解剖学基础指导手术,符合肿瘤根治的精准原则。
Extralevator abdominoperineal excision(ELAPE),has been described as a method for improving the outcome ofadvanced low rectal cancer, probably because of more pelvic dissection and less positive circumferential resection margin(CRM). However, ELAPE might result in a significantlyincreased rate of perineal wound complications, urinary andsexual dysfunction and chronic perineal pain. Several studiessuggest that ELAPE is not associated with deterioration inquality of life when compared with conventional APR.Individual ELAPE has the potential to reduce the risk ofchronic perineal pain and sexual dysfunction withoutinfluenced the radical effect. Biologic meshes using inperineal reconstruction significantly reduce the operative time,length of stay in hospital and the cost per patient.Laparoscopic or robotic assistance enables ELAPE withacceptable perioperative and pathological outcomes. Althoughseveral studies show no benefit for ELAPE regardingoncological outcomes, ELAPE is still a milestone operationbased on accurate surgery principle.
Extralevator abdominoperineal excision(ELAPE),has been described as a method for improving the outcome ofadvanced low rectal cancer, probably because of more pelvic dissection and less positive circumferential resection margin(CRM). However, ELAPE might result in a significantlyincreased rate of perineal wound complications, urinary andsexual dysfunction and chronic perineal pain. Several studiessuggest that ELAPE is not associated with deterioration inquality of life when compared with conventional APR.Individual ELAPE has the potential to reduce the risk ofchronic perineal pain and sexual dysfunction withoutinfluenced the radical effect. Biologic meshes using inperineal reconstruction significantly reduce the operative time,length of stay in hospital and the cost per patient.Laparoscopic or robotic assistance enables ELAPE withacceptable perioperative and pathological outcomes. Althoughseveral studies show no benefit for ELAPE regardingoncological outcomes, ELAPE is still a milestone operationbased on accurate surgery principle.
引文
[1]Holm T,Ljung A,H?ggmark T,et al.Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer[J].Br J Surg,2007,94(2):232-238.
[2]West NP,Finan PJ,Anderin C,et al.Evidence of the Oncologic Superiority of Cylindrical Abdominoperineal Excision for Low Rectal Cancer[J].J Clin Oncol,2008,26(21):3517-3522.
[3]West NP,Anderin C,Smith KJ,et al.Multicentre experience with extralevator abdominoperineal excision for low rectal cancer[J].Br J Surg,2010,97(4):588-599.
[4]叶颖江,申占龙,曹键,等.提肛肌外腹会阴联合切除术在低位直肠癌治疗中的初步应用[J].中国实用外科杂志,2012,32(6):456-458.
[5]Anderin C,Martling A,Lagergren J,et al.Short term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum[J].Colorectal Dis,2012,14(9):1060-1064.
[6]王振军,高志刚,韩加刚,等.柱状经腹会阴直肠癌切除术及其改进(附10例报告)[J].中国实用外科杂志,2009,29(4):348-351.
[7]Marshall MJ,Smart NJ,Daniels IR.Biologic meshes in perineal reconstruction following extra-levator abdominoperineal excision(el APE)[J].Colorectal Dis,2012,14(suppl 3):12-18.
[8]韩加刚,王振军,魏广辉,等.个体化柱状腹会阴联合切除术治疗低位直肠癌的初步探索[J].中华外科杂志,2013,51(3):335-338.
[9]Vaughan-Shaw PG,King AT,Cheung T,et al.Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting:analysis of short-term outcomes and quality of life[J].Ann R Coll Surg Engl,2011,93(6):451-459.
[10]Marecik SJ,Zawadzki M,Desouza AL,et al.Robotic cylindrical abdominoperineal resection with transabdominal levator transection[J].Dis Colon Rectum,2011,54(10):1320-1325.
[11]肖毅,徐徕,邱辉忠,等.术中不更换体位腹腔镜下经肛提肌外腹会阴联合直肠癌切除术的可行性分析[J].中华外科杂志,2014,52(11):826-830.
[12]高志刚,杨勇,王振军,等.手套通路经肛门微创手术治疗直肠肿瘤临床研究[J].中国实用外科杂志,2013,33(8):680-682.
[13]Han JG,Wang ZJ,Wei GH,et al.Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer[J].Am J Surg,2012,204(3):274-282.
[14]Han JG,Wang ZJ,Qian Q,et al.A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer[J].Dis Colon Rectum,2014,57(12):1333-1340.
[15]Yu HC,Peng H,He XS,et al.Comparison of short-and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer:a systematic review and meta-analysis[J].Int J Colorectal Dis,2014,29(2):183-191.
[16]Huang A,Zhao H,Ling T,et al.Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection:a meta-analysis[J].Int J Colorectal Dis,2014,29(3):321-327.
[17]Ortiz H Ciga MA,Armendariz P,et al.Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer[J].Br J Surg,2014,101(7):874-882.
[18]Prytz M,Angenete E,Bock D,et al.Extralevator Abdominoperineal Excision for Low Rectal Cancer-Extensive Surgery to be Used With Discretion Based on 3-Year Local Recurrence Results:A Registry-based,Observational National Cohort Study[J].Ann Surg,2015,DOI:10.1097/SLA.0000000000001237.
[19]Welsch T,Mategakis V,Contin P,et al.Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications[J].Int J Colorectal Dis,2013,28(4):503-510
[20]Vaughan-Shaw PG,Cheung T,Knight JS,et al.A prospective case-control study of extralevator abdominoperineal excision(ELAPE)of the rectum versus conventional laparoscopic and open abdominoperineal excision:comparative analysis of short-term outcomes and quality of life[J].Tech Coloproctol,2012,16(5):355-362.
[21]Jensen KK,Rashid L,Pilsgaard B,et al.Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations:single-centre experience including clinical examination and interview[J].Colorectal Dis,2014,16(3):192-197.
[2]West NP,Finan PJ,Anderin C,et al.Evidence of the Oncologic Superiority of Cylindrical Abdominoperineal Excision for Low Rectal Cancer[J].J Clin Oncol,2008,26(21):3517-3522.
[3]West NP,Anderin C,Smith KJ,et al.Multicentre experience with extralevator abdominoperineal excision for low rectal cancer[J].Br J Surg,2010,97(4):588-599.
[4]叶颖江,申占龙,曹键,等.提肛肌外腹会阴联合切除术在低位直肠癌治疗中的初步应用[J].中国实用外科杂志,2012,32(6):456-458.
[5]Anderin C,Martling A,Lagergren J,et al.Short term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum[J].Colorectal Dis,2012,14(9):1060-1064.
[6]王振军,高志刚,韩加刚,等.柱状经腹会阴直肠癌切除术及其改进(附10例报告)[J].中国实用外科杂志,2009,29(4):348-351.
[7]Marshall MJ,Smart NJ,Daniels IR.Biologic meshes in perineal reconstruction following extra-levator abdominoperineal excision(el APE)[J].Colorectal Dis,2012,14(suppl 3):12-18.
[8]韩加刚,王振军,魏广辉,等.个体化柱状腹会阴联合切除术治疗低位直肠癌的初步探索[J].中华外科杂志,2013,51(3):335-338.
[9]Vaughan-Shaw PG,King AT,Cheung T,et al.Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting:analysis of short-term outcomes and quality of life[J].Ann R Coll Surg Engl,2011,93(6):451-459.
[10]Marecik SJ,Zawadzki M,Desouza AL,et al.Robotic cylindrical abdominoperineal resection with transabdominal levator transection[J].Dis Colon Rectum,2011,54(10):1320-1325.
[11]肖毅,徐徕,邱辉忠,等.术中不更换体位腹腔镜下经肛提肌外腹会阴联合直肠癌切除术的可行性分析[J].中华外科杂志,2014,52(11):826-830.
[12]高志刚,杨勇,王振军,等.手套通路经肛门微创手术治疗直肠肿瘤临床研究[J].中国实用外科杂志,2013,33(8):680-682.
[13]Han JG,Wang ZJ,Wei GH,et al.Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer[J].Am J Surg,2012,204(3):274-282.
[14]Han JG,Wang ZJ,Qian Q,et al.A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer[J].Dis Colon Rectum,2014,57(12):1333-1340.
[15]Yu HC,Peng H,He XS,et al.Comparison of short-and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer:a systematic review and meta-analysis[J].Int J Colorectal Dis,2014,29(2):183-191.
[16]Huang A,Zhao H,Ling T,et al.Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection:a meta-analysis[J].Int J Colorectal Dis,2014,29(3):321-327.
[17]Ortiz H Ciga MA,Armendariz P,et al.Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer[J].Br J Surg,2014,101(7):874-882.
[18]Prytz M,Angenete E,Bock D,et al.Extralevator Abdominoperineal Excision for Low Rectal Cancer-Extensive Surgery to be Used With Discretion Based on 3-Year Local Recurrence Results:A Registry-based,Observational National Cohort Study[J].Ann Surg,2015,DOI:10.1097/SLA.0000000000001237.
[19]Welsch T,Mategakis V,Contin P,et al.Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications[J].Int J Colorectal Dis,2013,28(4):503-510
[20]Vaughan-Shaw PG,Cheung T,Knight JS,et al.A prospective case-control study of extralevator abdominoperineal excision(ELAPE)of the rectum versus conventional laparoscopic and open abdominoperineal excision:comparative analysis of short-term outcomes and quality of life[J].Tech Coloproctol,2012,16(5):355-362.
[21]Jensen KK,Rashid L,Pilsgaard B,et al.Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations:single-centre experience including clinical examination and interview[J].Colorectal Dis,2014,16(3):192-197.