腹腔镜与传统开放Dixon术治疗直肠癌的临床对照研究
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摘要
目的回顾及评价腹腔镜及传统开放手术行Dixon术治疗直肠癌的安全性及有效性。方法回顾性分析安徽医科大学第一附属医院2010年1月—2015年12月期间常规行Dixon术且未行预防性造口的直肠癌患者656例的临床资料,其中腹腔镜274例,传统开放手术382例,比较2组患者的手术时间、术中出血量、术后恢复情况(包括通气时间、饮水时间、下床时间、住院时间等)、并发症(包括胸腔积液、围术期病死率、吻合口瘘、切口感染、术后出血、二次手术等)、病理学指标(包括淋巴结个数、阳性淋巴结个数、切缘情况、TNM分期、肿瘤直径等);并对患者的预后进行随访,随访时间为6～56个月。结果 2组患者中,腹腔镜组有20例(7. 30%)中转开腹。6例患者围手术期死亡,其中腹腔镜组2例。腹腔镜组患者的术中出血量、术后首次排气时间、术后住院天数、第一次下床时间均明显优于开腹组(均P <0. 05)。术后并发症方面,切口感染情况显示腹腔镜手术有一定的优势,而在肠梗阻及腹腔积液的发生率等其他方面,2组差异无统计学意义(均P> 0. 05)。656例患者切除后标本病理检查显示远端切缘有2例阳性,均为开放组患者; 2组淋巴结清扫数目、术后局部复发率、远处转移率和3年生存率比较差异均无统计学意义(均P> 0. 05)。结论腹腔镜Dixon术相比传统开放手术而言安全、可行,围手术期因微创在恢复速度方面优势明显,根治效果及近期中期疗效与开腹手术相近。
Objective To make a review and evaluation for the security and effectiveness about the laparoscopic and conventional open Dixon surgery. Methods Between 2010 to 2015,656 rectal cancer patients underwent Dixon surgery including 274 laparoscopic surgery and 382 conventional open operation in the first affiliated hospital of Anhui Medical University,all of them do not receive preventive stoma. The operation time,peroperative bleeding,postoperative recovery( including time to anal exhaust,time drinking water,time to get out of bed,time to be hospitalized,etc.),postoperative complications( including pleural effusion,perioperative mortality,anastomotic fistula,incision infection,postoperative bleeding,and secondary surgery),pathological indicators( including the number of lymph nodes,number of positive lymph nodes,cutting edge,TNM stage,tumor diameter,etc.) about the two group patients were collected and compared; the follow up time were from 6 months to 56 months to observe the prognosis of patients. Results Twenty patients( 7. 30%) in the laparoscopic group converted to the open surgery. Total 6 patients died in perioperative period,2 of them were the laparoscopic group. Laparoscopic surgery was significantly associated with lower intraoperative blood loss,earlier recovery of bowel function,reduced length of hospital stay and time to feeding liquids,as compared to open surgery,although with increased operative time. It also showed an obvious advantage for postoperative complications of postoperative hemorrhage and the infection,the laparoscopic approach was equal to open approach as regard to bowel obstruction and pyoperitoneum. The pathological examination of 656 patients after resection showed 2 cases of positive distal margin,all of them were from open group. Importantly,there were no significant differences in the number of lymph node dissection,local recurrence rates,distant metastasis rates and 3-year survival rates between the two procedures. Conclusion Laparoscopic Dixon surgery for rectal cancer is feasible and safe,and can make faster recovery,achieve satisfactory oncological outcome and provide similar short-term and long-term outcomes.
Objective To make a review and evaluation for the security and effectiveness about the laparoscopic and conventional open Dixon surgery. Methods Between 2010 to 2015,656 rectal cancer patients underwent Dixon surgery including 274 laparoscopic surgery and 382 conventional open operation in the first affiliated hospital of Anhui Medical University,all of them do not receive preventive stoma. The operation time,peroperative bleeding,postoperative recovery( including time to anal exhaust,time drinking water,time to get out of bed,time to be hospitalized,etc.),postoperative complications( including pleural effusion,perioperative mortality,anastomotic fistula,incision infection,postoperative bleeding,and secondary surgery),pathological indicators( including the number of lymph nodes,number of positive lymph nodes,cutting edge,TNM stage,tumor diameter,etc.) about the two group patients were collected and compared; the follow up time were from 6 months to 56 months to observe the prognosis of patients. Results Twenty patients( 7. 30%) in the laparoscopic group converted to the open surgery. Total 6 patients died in perioperative period,2 of them were the laparoscopic group. Laparoscopic surgery was significantly associated with lower intraoperative blood loss,earlier recovery of bowel function,reduced length of hospital stay and time to feeding liquids,as compared to open surgery,although with increased operative time. It also showed an obvious advantage for postoperative complications of postoperative hemorrhage and the infection,the laparoscopic approach was equal to open approach as regard to bowel obstruction and pyoperitoneum. The pathological examination of 656 patients after resection showed 2 cases of positive distal margin,all of them were from open group. Importantly,there were no significant differences in the number of lymph node dissection,local recurrence rates,distant metastasis rates and 3-year survival rates between the two procedures. Conclusion Laparoscopic Dixon surgery for rectal cancer is feasible and safe,and can make faster recovery,achieve satisfactory oncological outcome and provide similar short-term and long-term outcomes.
引文
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[14] MAJBAR A M,ABID M,ALAOUI M,et al. Impact of conversion to open surgery on early postoperative morbidity after laparoscopic resection for rectal adenocarcinoma:a retrospective study[J]. J Laparoendosc Adv Surg Tech A,2016,26(9):697-701.
[15] TAN W J,CHEW M H,DHARMAWAN A R,et al. Critical appraisal of laparoscopic vs open rectal cancer surgery[J]. World J Gastrointest Surg,2016,8(6):452-460.
[16] ZAHARIE F,CIOROGAR G,ZAHARIE R,et al. Laparoscopic rectal resection versus conventional open approach for rectal cancer-a 4-year experience of a single center[J]. J BUON,2015,20(6):1447-1455.
[17] ZHANG F W,ZHOU Z Y,WANG H L,et al. Laparoscopic versus open surgery for rectal cancer:a systematic review and meta-analysis of randomized controlled trials[J]. Asian Pac J Cancer Prev,2014,15(22):9985-9996.
[18] GUO C,ZHANG Z,REN B,et al. Comparison of the long-term outcomes of patients who underwent laparoscopic versus open surgery for rectal cancer[J]. J BUON,2015,20(6):1440-1446.
[19] ALLAIX M E,GIRAUDO G,FERRARESE A,et al. 10-year oncologic outcomes after laparoscopic or open total mesorectal excision for rectal cancer[J]. World J Surg,2016,40(12):3052-3062.
[2] LIRICI M M,HUSCHER C G. Techniques and technology evolution of rectal cancer surgery:a history of more than a hundred years[J]. Minim Invasive Ther Allied Technol,2016,25(5):226-233.
[3] GUILLOU P J,DARZI A,MONSON J R,et al. Experience with laparoscopic colorectal surgery for maligmant disease[J]. Surg Oncol,1993,2(Suppl 1):43-49.
[4] BECKER T,EGBERTS J E,SCHAFMAYER C,et al. Robot-assisted rectal surgery:hype or progress?[J]. Chirurg,2016,87(7):567-572.
[5] GASH K,BICSAK M,DIXON A. Single-incision laparoscopic surgery for rectal cancer:early results and medium-term oncological outcome[J]. Colorectal Dis,2015,17(12):1071-1078.
[6]王锡山.结直肠肿瘤微创外科的进展[J].中华胃肠外科杂志,2016,19(6):621-623.
[7] FOO D C,CHOI H K,WEI R,et al. Transanal total mesorectal excision with single-incision laparoscopy for rectal cancer[J]. JSLS,2016,20(2):221-228.
[8]季福建,刘选文,刘卓,等.3D腹腔镜系统在进展期直肠癌闭孔淋巴结清扫中的应用[J].中华胃肠外科杂志,2014,17(11):1121-1124.
[9] YEO H L,ABELSON J S,MAO J,et al. Minimally invasive surgery and sphincter preservation in rectal cancer[J]. J Surg Res,2016,202(2):299-307.
[10] HEROOR A,PANJWANI G,CHASKAR R. A study of 101 laparoscopic colorectal surgeries:a single surgeon experience. how important is the learning curve?[J]. Indian J Surg,2015,77(Suppl 3):1275-1279.
[11] GEHRMAN J,BJRHOLT I,ANGENETE E,et al. Health economic analysis of costs of laparoscopic and open surgery for rectal cancer within a randomized trial(COLORⅡ)[J]. Surg Endosc,2016,31(3):1225-1234.
[12] FLESHMAN J,BRANDA M,SARGENT D J,et al. Effect of laparoscopic-assisted resection vs open resection of stageⅡorⅢrectal cancer on pathologic outcomes:the ACOSOG Z6051 randomized clinical trial[J]. JAMA,2015,314(13):1346-1355.
[13] ANTHUBER M,KRIENING B,SCHREMPF M,et al. Laparoscopic rectal resection technique[J]. Chirurg,2016,87(7):560-566.
[14] MAJBAR A M,ABID M,ALAOUI M,et al. Impact of conversion to open surgery on early postoperative morbidity after laparoscopic resection for rectal adenocarcinoma:a retrospective study[J]. J Laparoendosc Adv Surg Tech A,2016,26(9):697-701.
[15] TAN W J,CHEW M H,DHARMAWAN A R,et al. Critical appraisal of laparoscopic vs open rectal cancer surgery[J]. World J Gastrointest Surg,2016,8(6):452-460.
[16] ZAHARIE F,CIOROGAR G,ZAHARIE R,et al. Laparoscopic rectal resection versus conventional open approach for rectal cancer-a 4-year experience of a single center[J]. J BUON,2015,20(6):1447-1455.
[17] ZHANG F W,ZHOU Z Y,WANG H L,et al. Laparoscopic versus open surgery for rectal cancer:a systematic review and meta-analysis of randomized controlled trials[J]. Asian Pac J Cancer Prev,2014,15(22):9985-9996.
[18] GUO C,ZHANG Z,REN B,et al. Comparison of the long-term outcomes of patients who underwent laparoscopic versus open surgery for rectal cancer[J]. J BUON,2015,20(6):1440-1446.
[19] ALLAIX M E,GIRAUDO G,FERRARESE A,et al. 10-year oncologic outcomes after laparoscopic or open total mesorectal excision for rectal cancer[J]. World J Surg,2016,40(12):3052-3062.