摘要
目的比较低位直肠癌应用吻合器保肛手术与Miles手术术后局部复发率及各期5年生存率的差异,探讨低位直肠癌外科治疗的术式选择及应用吻合器保肛手术的适应证。
方法回顾分析2000年3月至2002年3月间在我院手术治疗的196例低位直肠癌病例资料,其中应用吻合器保肛手术者89例,Miles手术者107例。对两种手术治疗组病例分别按AJCC第六版TNM分期标准进行分期,并比较两组患者术后局部复发率及各期5年生存率。
结果①两组病例在性别、年龄、有无肝转移、病理类型、原发肿瘤大小、浸润深度、癌肿部位、组织学分化程度、侵犯肠管周径、有无区域淋巴结转移方面差异均无统计学意义,P>0.05。②两组病例在第六版TNMⅠ、Ⅱ、Ⅲ期中的各期及各亚期间2、5年生存率差异均无统计学意义(P >0.05),而单因素分析Ⅳ期患者切除原发肿瘤后平均生存时间Miles手术(20.10±1.52个月)组优于应用吻合器保肛手术(13.33±0.81个月)组,经Log-rank检验该期两组间的生存率曲线差异有显著统计学意义,P< 0.01。③肿瘤下缘距肛缘5~7cm的低位直肠癌中应用吻合器保肛手术组与Miles手术组患者术后2年内局部复发率及2、5年生存率差异均无统计学意义,P>0.05。
结论①对距肛缘5~7cm的低位直肠癌应根据个体情况、浸润程度、分化程度、淋巴结转移、有无远处转移、侵犯肠管周径及设备的条件等综合状况选择吻合器保肛手术。②对AJCC第六版TNMⅠ、Ⅱ、Ⅲ期低位直肠癌患者可行应用吻合器保肛手术,值得推广应用。但对于全身状况良好、转移负荷较小、肝脏无明显受损的Ⅳ期低位直肠癌患者,应争取采用Miles手术彻底切除原发肿瘤并给予有效的化学治疗。③本研究发现各期肿瘤下切缘长度满足以下条件者可选择低位直肠癌应用吻合器保肛手术:①TNM分期Ⅰ期(T1 N0 M0、T2N0M0),高中分化腺癌,侵犯肠管周径≤1/2周,下切缘距离≥2cm者;②ⅡA期(T3 N0 M0)、ⅡB期(T4 N0 M0)、ⅢA期(T1 / T2N1 M0),侵犯肠管周径>1/2周,高中分化腺癌,下切缘距离为≥2.5cm者;③ⅢB期(T3/ T4 N1 M0)、ⅢC期(T任何N2 M0),侵犯肠管周径≤1/2周,中低分化腺癌,下切缘距离为≥3.0cm作为癌肿远侧肠管切断线,术中快速病检直肠远切端均无癌细胞残留者。值得注意的是,对ⅢB、ⅢC期病例选择保肛手术时严格掌握适应证,不能片面追求保肛而忽视切除的彻底性。
Objective:To compare the difference between local recurrence rate and 5-year survival rate of Miles surgery and anal sphincter preservation surgery using stapler on low rectum cancer. And to explore the indication of the using of stapler for low rectal cancer during sphincter preservation surgery, and the selection of surgical options for low rectal cancer.
Methods:196 cases of low rectal cancer who admitted to China-Japan Union Hospital of Jilin University and accepted operative treatment between March 2000 and March 2002 were analyzed retrospectively. 53 rectal tumours were located in 3-5cm from anus, 61 were located in 5-6cm, 82 in 6-7cm. Miles surgery were performed on 107 patients, and stapling device application on Sphincter-saving surgery were performed on 89 patients. Two groups were conducted in accordance with the new TNM stage, and compare local recurrence rate and 5-year survival rate of the two .
Results:(1)There is no significant difference on gender, age, liver metastasis, pathological type, the primary tumor size, depth of invasion, tumor location, histological degree of penetration, infiltrated circumference of intestine, and the regional lymph node metastasis between the two groups (p>0.05). (2) In accordance with the late TNM,there is no statistically difference between the 2- and 5-year survival rates of the two groups on I, II and III (p>0.05), while in TNM IV,the two ways of the surgery is analyzed by univariate analysis, we found the mean survival duration is longer in Mile’s procedure(20.10±1.52 months versus 13.33±0.81 months), and there is remarkable difference in this issue of two groups handled by the Log-rank survival ratecurve (p<0.01).(3)Inthe patients whose tumors were in 5-7cm from anus, there is no significant difference between the 2- and 5-year survival rates of the two groups (p>0.05).
Conclusion:(1)Stapling device application on sphincter-saving surgery should be performed to consult the individual condition, location of tumor, depth of infiltration, degree of differentiation, with lymph nodes metastasis or not and the instruments.(2)We find out that the sphincter preservation surgery with stapler can be performed to the low rectal cancer in the stage of TNM I, II and III, which is worthy to spread out. But if it’s in TNM IV Patients who have a good performance status , minimal metastatic disease and normalpreoperative liver function tests and complete resection can be carried out , we should resect the primary carcinoma via Mile’s surgery and aggressive systemic chemotherapy.(3)Stapling device application on sphincter-saving surgery in low rectal carcinoma,the resection length of carcinoma's margin matchs each of the following conditions can prognosticate good outcome:①TNM- stageⅠ(T1 N0 M0、T2 N0 M0) , Well-Differentiated and moderately differentiated adenocarcinoma,infiltrated circumference≤1/2,the length≥2.0cm,②ⅡA(T3 N0 M0)、ⅡA(T3 N0 M0)、ⅡB(T4 N0 M0)、ⅢA(T1/T2N1M0),infiltrated circumference > 1/2 ; Well-Differentiated and moderately differentiated adenocarcinoma,the length≥2.5cm.③ⅢB(T3/ T4 N1 M0)、ⅢC(TanyN2 M0) ,infiltrated circumference≤1/2; moderately differentiated and poorly differentiated adenocarcinoma,the length≥3.0cm, pathological examination after surgery,there is no cancer cell residues distal colorectal cancer. However, the choice of surgery indications is very important for carcinomas ofⅢB、ⅢC.Not only preserved anus but ignore the complete removal of carcinoma.
引文
[1] Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics, 2003.CA Cancer J Clin 2003, 53:5-26.
[2] Hu KS, Harrison LB. Adjuvant therapy for resectable rectal ademocarcinoma [J]. Semin Surg Oncol, 2000, 19(4): 336-349.
[3] Crane CH, Skibber J.Preoperative chemoradiation for locally advanced rectal cancer: rationale, technique, and results of treatment.Semin Surg Oncol, 2003, 21(4):265-270.
[4] 毛伟征,主译.AJCC 癌症分期手册.6 版.沈阳:辽宁科学技术出版社,2005:113-119.
[5] Martling AL,Holm T,Rutqvis 1E,et al.Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm [J].Stockholm Colorectal Cancer Study Group, Basingstoke bowel cancer project.Lancet,2000,356:93-96.
[6] Kapiteijin E, Pemberton JH,Farouk R, et al. Surgical treatment of adenocarcinoma of the rectum.Ann Surg, 1998,227:800-811.
[7] Dehni N,McFadden N,McNamara A,et al. Oncologic results following Abdominoperineal resection for adenocarcinoma of the low rectum. Dis Colon Rectum, 2003, 46:867-874.
[8] MERKEL S, MANSMANN U, PAPADOPOULOS T, et al.The prognostic inhomogeneity of colorectal carcinomas stage Ⅲ:a proposal for subdivision of Stage Ⅲ[J].Cancer,2001,92(11):2754.
[9] Greene FL, Stewart AK, Norton HJ. A new TNM staging strategy for node-positive (stage Ⅲ) colon cancer: an analysis of 50,042 patients [J]. Ann Surg, 2002, 236(4): 416~421.
[10]Enker WE,Havenga K,Polyak T,e al.Abdominoperineal resection via Total mesorectal Excision and autonomic nerve preservation for lowRectal cancer.World J surg,1997,21:715-720.
[11]Goligher JG,Dukes CE, Bussey HJR.Local recurrence aftersphincter reserving excision for carcinoma of the rectum and rectosigmoid[J].Br J Surg,1991,39:199.
[12]李月春,韩方海,耿 岩,等.低位直肠癌保肛术适应证选择与评价[J]. 齐鲁医学杂志,2002 ,17 (1) :261.
[13]Andreola S,Leo E,Belli F,et al.Distal in tramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis[J].Dis Colon Rectum,1997,40(1):25-29.
[14]Shiouzu K,Isomoto H,Kake gawa T Distal spread of rectal Cancer and Optimal distal Margin of resection for sphinct erpreserving sugery [J].Cancer,1995,76(3):388-392.
[15]Ono C,Yoshinaga K,Enomoto M,et al.Disonontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ[J].Dis Colon Recnon, 2002, 45(6):744-749.
[16]王成锋,邵永孚,兰忠民,等 1 直肠癌保肛手术的安全切缘[J ].中国肿瘤临床,2001 ,28 (3) :1881.
[17]Nelson H, Petrell N , Carlin A , Et al. Guidelines 2000 for colon andrectal cancer surgery. J N at l Cancer Inst, 2001, 93: 583-596.
[18]Moore HG,Riedel E,Minsky BD,et al Adequacy of1-cm distal margim after restorativeRectal cancer resection with sharp mesorectal excision and preoperative ombinedModality the rapy[J].Ann Surg oncol ,2003,10(1) : 80-85.
[19]Zaheer S,Pemberton JH,Farouk R,et al.Surgical treatment of adenocarc-inoma of the rectum.Ann surg,1998,227:800-811.
[20]Chu Q.D., Davidson R, Rodriguez-Bigas M, Wirtzfeld D, Petrelli N. Is abdominoperineal resection a good option for stage IV adenocarcinoma of the distal rectum? J Surg Onc 2002; 81:3-7.
[21]Khot UP,Lang AW,Murali K,Parker MC.Systematic review of the efficacy and safety of colorectal stents.Br J Surg 2002; 89:1096-1102
[22]韩方海, 吴凌云,等.直肠癌经肛门指诊经验和体会,大肠肛门病外科杂志〔J〕,1998,4 (2): 271.
[23]Kim JC,Cho YK,Kim SY,et al.Comparative study of threedimensional and conventional ultrasonography used in Rectal cancer staging.Surg Endosc, 2002, 16:1280-1285.
[24]廖盛日,戴莹等.腔内超声对直肠癌术前分期诊断的应用价值,中国肿瘤临床杂志,2005,32(4):200-203.
[25]Hildebrandt U, Feifel G. Preoperative staging of rectal cancer by intrarectal ultrasound [J ] . Dis Colon Retum , 2003 ,28 :41.
[26]渡昌彥,寺本龍生,北島政 ,他.大腸癌の画像診斷法[J].臨床外科,1995;50(2):163.
[27]畦倉薰, 齊藤裕二, 上野雅资, 他. 下腸間膜動脈根部リンハ 節及び大動脈周围リンハ節郭清の成绩と适应[J] . 外科, 1997 ;59 (5)∶546.
[28]Laghi A , Ferri M, Catalano C ,et al . Local staging of rectal cancer with MRI using a phased array body coil . Abdom Imaging, 2002 , 27 :425.
[29]Urban M, Rosen HR, Holbling N, et al . MR imaging for the preoperative planning of sphincter saving surgery for tumors of the lower third of the rectum: use of intravenous and endorectal contrast materials. Radiology,2000 , 214 :503.
[30]Siva JH.Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer.Revosp Clin Fac Med sao Paulo, 2002, 57:55-62.
[31]顾晋,赵军. 结直肠癌放射免疫导向手术的临床研究.中华普通外科杂志.2002,17:599.
[32]董新舒,赵鹏,于志伟,等.直肠癌术后局部复发形式及其治疗[J].中国实用外科杂志,2002,22(6);334.
[33]黄黎明,胡佰年,陈魏.直肠癌术后局部复发因素与防治探讨.肿瘤防治杂志,2001,8(1):60.
[1]郁宝铭,沈耀祥,李铭,等.低位直肠癌的外科治疗.中华外科杂志,1995,33(3):164~166.
[2]Nivetvongs S. Management of adenocarcinoma of the low rectum introduction[J.World J Surg, 1992, 16 (3):428-429.
[3]汤钊猷主编.现代肿瘤学.上海:上海医科大学出版社,1993.536.
[4]张文范主编.消化系统癌症手术与综合治疗.沈阳:辽宁科学技术出版社,1999.387.
[5]李世拥,于波,骆成玉,等.经腹经肛门切除低位直肠癌经肛门结肠粘膜吻合术-32 例报告.中华普通外科杂志,2000,15(4):229.
[6]Babcock WW.Experiences with resection of the colore and elimination of colostomy. Am J Surg, 1939, 46 :186.
[7]Bacon HE.Evolution of sphincter muscle preservatin in the operative treatment of rectal and sigmoidal cancer S.G.O, 1945, 81:113.
[8]Mc Dermott F.Long term results of restoration resection and total excision for carcinoma of middle third of the rectum.S G O, 1982, 154:833.
[9]郁宝铭,李东华,沈耀祥,等。直肠癌外科治疗及远期疗效的评估。临床外科杂志,1997,5(2):64~66.
[10]汪建平,低位直肠癌保肛手术的原则与适应证. 临床外科杂志, 2005, 13 (11):678~679.
[11]Knight CD,Griffen FD.An improved technique for low anterior resection of the rectum using EEA stapler[J].Surgery, 1980, 88:710~714.
[12]Griffen FD, Knight CD. Result of double stapling procedure in pelvie surgery, World J Surg, 1992, 16: 866-871.
[13]Lavery IC, Lopez KF, Fazio V, et al. Chances of cure are not compromised with sphincter - saving procedures for cancer of the lower third of the rectum.Surgery, 1997, 122:779 - 785.
[14]黄志强.现代腹部外科学.长沙:湖南科学技术出版社,1997:173~181.
[15]Varma JS,Chan ACW,Li MKN et al.Low anterior resection of the rectum using a double stapling technique.Br J Surg,1990;77(8):888~890.
[16]Feinberg SM , Parker F, Coben Z et al. The double stapling technique for low anterior resection of rectal carcinoma.Dis Colon Rectum,1986; 29(12): 885~890
[17]许玉成,庄 竟,王程虎 等.双吻合器保肛术后吻合口瘘的预防.中国实用外科杂志,2001;21(9):538~539.
[18]李东华,郁宝铭,郑民华.双吻合器在低位直肠癌手术中的价值.腹部外科杂志,1997;10(4):151~152.
[19]Luchtefeld MA.Colorectal anastomotic stenosis.Dis Colon Rectum, 1989, 32(9):733~736.
[20]Parks AG.Per-anal anastomosis.World J Surg, 1982,6 (5):531-538.
[21]Gamagami RA, Chiotasso P, Lazorthes F. continent perineal colostomy after abdominoperineal resection: outcome after 63 cases. Dis Colon Rectum, 1999, 42(5):626-630.
[22]Lazorthes F,et al Br J Surg , 1997;84:1449~1451.
[23]Brown SR , et al Sem in Surg Oncol 2000;19(4):376~385.
[24]Saito N, Ono M, Sugito M,et al.Early results of intersphincteric resection forpatients with very low rectal cancer:an active approach to avoid a permanent colostomy[J].Dis Colon Rectum,2004,47(4):459-466.
[25]Dehni N, et al. Hepatogastroenterology 2000; 47(32): 323-326.
[26]Hida J,Yoshifuji T,Tokoro T,et al.Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer:a five-year follow-up.Dis Colon Rectum, 2004, 47(10): 1578-1585.
[27]Lazorthes F,Gamagami R,Chiotasso P,Istvan G,Muhammad S.Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis.Dis Colon Rectum 1997; 40:1409-1413.
[28]Mantyh C, Hull TL, Fazio VW.Coloplasty in low colorectal anastomosis.Dis Colon Rectum, 2001, 44(1):37-42.
[29]Kusunoki M,Shoji Y, Yanagi H, et al. Function after anoabdominal rectal resection and colonic J pouchanal anastomosis [J].Br J Surg,1991,78:1434.
[30]郁宝铭,低位直肠癌外科治疗的回顾、现状与展望. 中华普通外科杂志 ,2002,17(7):389~391.