两步翻出直肠法在低位直肠癌经自然腔道取标本手术中的应用(附39例报告)
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摘要
目的:比较腹腔镜低位直肠癌根治经自然腔道取标本手术(NOSES)中两步翻出直肠法和传统一步翻出直肠法的围手术期及近期疗效。方法:回顾性分析63例行腹腔镜低位直肠癌NOSES患者的临床资料,其中39例患者采用两步翻出直肠法取出直肠标本(两步翻出直肠法组),24例患者采用传统一步翻出直肠法(传统一步翻出直肠法组),并结合文献复习观察两步翻出直肠法在低位直肠癌经自然腔道取标本手术中应用的可行性。结果:记录2组患者肿瘤最大直径、翻出成功率、肿瘤破碎率、手术时间、术中出血量、术后首次排气时间、吻合口漏发生率和短期随访结果。两步翻出直肠法组39例标本均从肛门顺利翻出,切除后完成吻合,顺利完成低位直肠癌NOSES,而传统一步翻出直肠法组24例中有3例翻出失败,2组翻出成功率比较差异有统计学意义(P=0.024);翻出后两步翻出直肠法组患者肿瘤破碎率低于传统一步翻出直肠法组(P=0.004),两步翻出直肠法组患者手术时间少于传统一步翻出直肠法组(t=4.266,P<0.01)。2组患者肿瘤最大直径(t=-0.406,P=0.686)、术中出血量(t=-1.247,P=0.217)、术后首次排气时间(t=-0.144,P=0.886)和术后吻合口漏发生率(P=1.000)比较差异均无统计学意义。随访3～24个月,两步翻出直肠法组和传统一步翻出直肠法组患者直肠癌复发率(P=0.140)及肿瘤转移率(P=0.360)比较差异无统计学意义。结论:两步翻出直肠法在低位直肠癌NOSES中能降低直肠翻出难度,减少手术时间,获得良好的近期疗效。
Objective:To compare the perioperative and recent curative effects of laparoscopic radical resection of low rectal rectal carcinoma by natural orifice specimen extraction surgery(NOSES)with two-step procedure to turn rectum out from the abdominal cavity and traditional one-step procedure to turn rectum out from abdominal cavity.Methods:The clinical data of 63 patients who were treated by laparoscopic radical resection of low rectal rectal carcinoma by NOSES were analyzed retrospectively.A total of 39 patients were treated with the method of two-step procedure to turn rectum out from the abdominal cavity(two-step procedure group)and 24 patients were treated with the traditional one-step procedure to turn rectum out from the abdominal cavity(traditional one-step procedure group).Results:The maximum tumor diameters,the successful rates,tumor fragmentation rates,operation time,intraperative bleeding loss,postoperative exhaust time,anastomotic leakage rates after operation,and the shortterm-follow-up results of the patients in two groups were recovered.The specimens of 39 patients in two-step procedure group were successfully pulled out from the anus,the anastomosis was finishehed after resection,and the NOSES of low rectal carcinoma was successfully completed,while 3 cases were failed of 24 cases in traditional onestep procedure group,the successful rate was decreased(P=0.024).After the specimen were pulled out from the anus,the fragmentation rate of the patients in two-step procedure group was lower than that in traditional one-step procedure group(P=0.004).The operation time of the patients in two-step procedure group was less than that in traditional one-step procedure group(t=4.266,P<0.01).There were no significant differences in the maximum diameters of tumor(t=-0.406,P=0.686),intraoperative bleeding loss(t=1.799,P=0.075),postoperative exhaust time(t=-0.144,P=0.886),postoperative anastomotic leakage rate(P=1.000)of the patients between two groups.During 3 to 24 months of follow-up,there were no significant differences in the recurrence rate(P = 0.140)and metastatic rate of carcinoma(P = 0.36)of the patients between two groups.Conclusion:Two-step procedure to turn rectum out from the abdominal cavity can reduce the pressure on the tumor during turning the rectum out,which can save the operation time and get good short-term curative effect during the radical resection of low rectal carcinoma by NOSES.
Objective:To compare the perioperative and recent curative effects of laparoscopic radical resection of low rectal rectal carcinoma by natural orifice specimen extraction surgery(NOSES)with two-step procedure to turn rectum out from the abdominal cavity and traditional one-step procedure to turn rectum out from abdominal cavity.Methods:The clinical data of 63 patients who were treated by laparoscopic radical resection of low rectal rectal carcinoma by NOSES were analyzed retrospectively.A total of 39 patients were treated with the method of two-step procedure to turn rectum out from the abdominal cavity(two-step procedure group)and 24 patients were treated with the traditional one-step procedure to turn rectum out from the abdominal cavity(traditional one-step procedure group).Results:The maximum tumor diameters,the successful rates,tumor fragmentation rates,operation time,intraperative bleeding loss,postoperative exhaust time,anastomotic leakage rates after operation,and the shortterm-follow-up results of the patients in two groups were recovered.The specimens of 39 patients in two-step procedure group were successfully pulled out from the anus,the anastomosis was finishehed after resection,and the NOSES of low rectal carcinoma was successfully completed,while 3 cases were failed of 24 cases in traditional onestep procedure group,the successful rate was decreased(P=0.024).After the specimen were pulled out from the anus,the fragmentation rate of the patients in two-step procedure group was lower than that in traditional one-step procedure group(P=0.004).The operation time of the patients in two-step procedure group was less than that in traditional one-step procedure group(t=4.266,P<0.01).There were no significant differences in the maximum diameters of tumor(t=-0.406,P=0.686),intraoperative bleeding loss(t=1.799,P=0.075),postoperative exhaust time(t=-0.144,P=0.886),postoperative anastomotic leakage rate(P=1.000)of the patients between two groups.During 3 to 24 months of follow-up,there were no significant differences in the recurrence rate(P = 0.140)and metastatic rate of carcinoma(P = 0.36)of the patients between two groups.Conclusion:Two-step procedure to turn rectum out from the abdominal cavity can reduce the pressure on the tumor during turning the rectum out,which can save the operation time and get good short-term curative effect during the radical resection of low rectal carcinoma by NOSES.
引文
[1]王成正,吴恒龙,周迎春,等.腹腔镜辅助TME与开腹TME治疗超低位直肠癌的临床效果分析[J].中华普外科手术学杂志:电子版,2017,11(6):500-503.
[2]李博.腹腔镜直肠癌根治术29例疗效观察[J].吉林大学学报:医学版,2011,37(2):392-392.
[3]中国NOSES联盟,中国医师协会结直肠肿瘤专业委员会NOSES专委会.结直肠肿瘤经自然腔道取标本手术专家共识(2017)[J].中华结直肠疾病电子杂志,2017,6(4):266-272.
[4]何亮,陈羽佳,孙东辉.TEM器械联合塑料保护套经肛门取标本法在直肠癌NOSES中应用七例[J].中华结直肠疾病电子杂志,2018,7(4):373-376.
[5]YANG J P,TONG W H,WANG Q,et al.Laparoscopic radical resection of low rectal carcinoma integrating transanal endoscopic microsurgery:a case report[J].Indian J Surg,2013,75(Suppl 1):280-282.
[6]Steinemannn D C,Muller P C,Probst P,et al.Metaanalysis of hybrid natural-orifice transluminan endoscopic surgery versus laparoscopic surgery[J].Br J Surg,2017,104(8):977-989
[7]廖皓宇,周艳霞.腹腔镜辅助下直肠外翻拖出式手术在中低位直肠癌治疗中的无瘤技术效果[J].系统医学,2018,3(5):135-137.
[8]宋强,傅义刚,岳世华,等.低位直肠癌翻出切除肛外吻合21例分析[J].中国实用外科杂志,2002,22(7):435-435.
[9]王健,王永洪,王依宁,等.腹腔镜中低位直肠癌全直肠系膜切除术的临床分析[J].中华普外科手术学杂志:电子版,2016,10(4):311-314.
[10]朱毅忠.直肠癌经肛门TME根治术与常规腹腔镜TME术式的对比研究[J].中华普外科手术学杂志:电子版,2018,12(5):441-444.
[11]袁智勇,黄昌纯,王磊.中晚期直肠癌腹腔镜TME手术的疗效评价[J].中华普外科手术学杂志:电子版,2018,12(4):349-351.
[12]李华.腹腔镜辅助下直肠外翻拖出式手术治疗直肠癌的临床效果研究[J].中华保健医学杂志,2017,19(6):489-491.
[13]姚远,李青科,马国明,等.经肛门内镜显微手术治疗直肠癌的疗效观察[J].实用临床医药杂志,2017,21(21):126-127.
[14]张立泽,乔翠霞,刘鹏林,等.经肛门内镜微创手术治疗直肠肿瘤疗效的临床分析(附26例报道)[J].中国普外基础与临床杂志,2016,23(9):1129-1131.
[15]许超宇,王健,吴洌,等.经自然通道保护性取出标本的腹腔镜直肠癌根治术59例的临床研究[J].中国继续医学教育,2015,7(3):33-34.
[16]Alam A H,Soyer V,Sabuncuoglu M Z,et al.Natural orifice specimen extraction(NOSE)and transanal extracorporeal anvil placement during laparoscopic low anterior resection[J].Tech Coloproctol,2014,18(7):669-671.
[17]王世贺.腹腔镜辅助下直肠外翻拖出式手术在直肠肿瘤治疗中的应用价值[J].黑龙江医药,2017,30(1):179-180.
[18]吴传福,郎建华,黄维贤,等.低位或超低位直肠癌腹腔镜下经肛门外翻拖出切除吻合术的临床体会[J].中国继续医学教育,2017,9(16):138-139.
[19]马飞霞,张苏展.经自然腔道标本取出结直肠肿瘤手术[J].中华结直肠疾病电子杂志,2016,5(6):507-511.
[20]廖皓宇,周艳霞.腹腔镜辅助下直肠外翻拖出式手术在中低位直肠癌治疗中的无瘤技术效果[J].系统医学,2018,3(5):135-137.
[2]李博.腹腔镜直肠癌根治术29例疗效观察[J].吉林大学学报:医学版,2011,37(2):392-392.
[3]中国NOSES联盟,中国医师协会结直肠肿瘤专业委员会NOSES专委会.结直肠肿瘤经自然腔道取标本手术专家共识(2017)[J].中华结直肠疾病电子杂志,2017,6(4):266-272.
[4]何亮,陈羽佳,孙东辉.TEM器械联合塑料保护套经肛门取标本法在直肠癌NOSES中应用七例[J].中华结直肠疾病电子杂志,2018,7(4):373-376.
[5]YANG J P,TONG W H,WANG Q,et al.Laparoscopic radical resection of low rectal carcinoma integrating transanal endoscopic microsurgery:a case report[J].Indian J Surg,2013,75(Suppl 1):280-282.
[6]Steinemannn D C,Muller P C,Probst P,et al.Metaanalysis of hybrid natural-orifice transluminan endoscopic surgery versus laparoscopic surgery[J].Br J Surg,2017,104(8):977-989
[7]廖皓宇,周艳霞.腹腔镜辅助下直肠外翻拖出式手术在中低位直肠癌治疗中的无瘤技术效果[J].系统医学,2018,3(5):135-137.
[8]宋强,傅义刚,岳世华,等.低位直肠癌翻出切除肛外吻合21例分析[J].中国实用外科杂志,2002,22(7):435-435.
[9]王健,王永洪,王依宁,等.腹腔镜中低位直肠癌全直肠系膜切除术的临床分析[J].中华普外科手术学杂志:电子版,2016,10(4):311-314.
[10]朱毅忠.直肠癌经肛门TME根治术与常规腹腔镜TME术式的对比研究[J].中华普外科手术学杂志:电子版,2018,12(5):441-444.
[11]袁智勇,黄昌纯,王磊.中晚期直肠癌腹腔镜TME手术的疗效评价[J].中华普外科手术学杂志:电子版,2018,12(4):349-351.
[12]李华.腹腔镜辅助下直肠外翻拖出式手术治疗直肠癌的临床效果研究[J].中华保健医学杂志,2017,19(6):489-491.
[13]姚远,李青科,马国明,等.经肛门内镜显微手术治疗直肠癌的疗效观察[J].实用临床医药杂志,2017,21(21):126-127.
[14]张立泽,乔翠霞,刘鹏林,等.经肛门内镜微创手术治疗直肠肿瘤疗效的临床分析(附26例报道)[J].中国普外基础与临床杂志,2016,23(9):1129-1131.
[15]许超宇,王健,吴洌,等.经自然通道保护性取出标本的腹腔镜直肠癌根治术59例的临床研究[J].中国继续医学教育,2015,7(3):33-34.
[16]Alam A H,Soyer V,Sabuncuoglu M Z,et al.Natural orifice specimen extraction(NOSE)and transanal extracorporeal anvil placement during laparoscopic low anterior resection[J].Tech Coloproctol,2014,18(7):669-671.
[17]王世贺.腹腔镜辅助下直肠外翻拖出式手术在直肠肿瘤治疗中的应用价值[J].黑龙江医药,2017,30(1):179-180.
[18]吴传福,郎建华,黄维贤,等.低位或超低位直肠癌腹腔镜下经肛门外翻拖出切除吻合术的临床体会[J].中国继续医学教育,2017,9(16):138-139.
[19]马飞霞,张苏展.经自然腔道标本取出结直肠肿瘤手术[J].中华结直肠疾病电子杂志,2016,5(6):507-511.
[20]廖皓宇,周艳霞.腹腔镜辅助下直肠外翻拖出式手术在中低位直肠癌治疗中的无瘤技术效果[J].系统医学,2018,3(5):135-137.