Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer

目的 探讨腹腔镜辅助经肛门全直肠系膜切除术(La-TaTME)治疗中低位直肠癌的临床疗效.方法 采用回顾性横断面研究方法.收集2015年8月至2016年8月北京大学第三医院收治的16例行La-TaTME中低位直肠癌患者的临床资料.同一组医师序贯完成La-TaTME,先行腹腔镜手术,再行经肛门手术.观察指标:(1)手术及术后恢复情况:中转开腹情况、吻合方式、手术时间、术中出血量、术中并发症情况、术后首次下床活动时间、术后进流质食物时间、术后并发症情况、术后住院时间.(2)术后病理学检查情况:手术切除标本长度、肿瘤直径、肿瘤远端肠管切除距离、直肠系膜完整程度、环周切缘、病理学T分期、病理学N分期、淋巴结检出数目、肿瘤细胞分化程度.(3)随访结果.TNMⅢ～Ⅳ期的直肠癌患者,术后接受辅助化疗.术后每3个月门诊随访1次,随访内容为患者生存情况和肿瘤复发情况,随访时间截至2016年12月.计量资料采用M(范围)表示.结果 (1)手术资料及术后恢复情况:16例患者顺利完成手术,无中转开腹患者,其中结肠-直肠吻合10例,结肠-肛管吻合3例,结肠单腔永久性造瘘3例.16例患者手术时间为290 min(215 ～ 420 min),术中出血量为50 mL(30～100 mL).术中1例患者出现并发症,该患者在直肠切除标本并经肛门拖出后,发现乙状结肠断端缺血,经腹腔进一步游离脾曲结肠,切除缺血的乙状结肠约5 cm,再行降结肠-直肠吻合术.术后首次下床活动时间为1 d(1～3 d),术后进食流质食物时间为2d(1～9 d).术后3例患者出现并发症(Clavien-Dindo分级均为2级),其中2例为不完全性小肠梗阻,经过胃肠减压及静脉营养支持治疗后缓解;1例为骶前感染,经过引流以及抗生素治疗后缓解.术后住院时间为7 d(5～21 d).(2)术后病理学检查情况:16例患者手术切除标本长度为18.0 cm(12.0～24.0 cm),肿瘤直径为3.5 cma(0.5～6.8 cm),肿瘤远端肠管切除距离为2.5 cm(1.0～5.0 cm);手术切除标本的直肠系膜质量评估:完整14例,近乎完整2例;环周切缘及远近断端无肿瘤残留.16例患者病理学T分期:0期(新辅助治疗后病理学完全缓解)1例,1期1例,2期4例,3期10例.病理学N分期:0期12例,1期2例,2期2例.淋巴结检出数目为16枚(6～32枚).肿瘤细胞分化程度:未见肿瘤细胞(新辅助治疗后病理学完全缓解)1例,高分化2例,中分化7例,低分化6例.(3)随访结果:16例患者均获得术后随访,中位随访时间为12个月(4～ 16个月),无局部复发及远处转移患者,无死亡患者.结论 La-TaTME为中低位直肠癌患者提供了一种新的、较为安全和有效的手术入路和切除方式,近期疗效较好.Objective To explore the clinical efficacy of laparoscope-assisted transanal total mesorectal excision (La-TaTME) for middle-low rectal cancer.Methods The retrospective cross-sectional study was conducted.The clinical data of 16 patients with middle-low rectal cancer who underwent La-TaTME in the Peking University Third Hospital from August 2015 to August 2016 were collected.Sequential surgery of La-TaTME was applied to patients in the same team,with laparoscopic surgery first and then transanal surgery.Observation indicators:(1) operation and postoperative recovery situations:conversion to open surgery,anastomosis method,operation time,volume of intraoperative blood loss,intraoperative complications,time for out-of-bed activity,time for liquid diet intake,postoperative complications and duration of postoperative hospital stay.(2) postoperative pathological situations:length of surgical specimen,tumor diameter,distance from tumor to resected distant intestinal canal,complete degree of mesorectum,circumferential resection margin,pathological T stage,pathological N stage,number of lymph node detected and tumor cell differentiation.(3) follow-up.Patients in stage Ⅲ-ⅣV of TNM stage of RC underwent postoperative adjuvant chemotherapy.Follow-up using outpatient examination was performed once every 3 months postoperatively to detect the patients' survival and tumor recurrence up to December 2016.Measurement data were represented as M (range).Results (1) Operation and postoperative recovery situations:all the 16 patients underwent successful La-TaTME without conversion to open surgery,including 10 with colorectal anastomosis,3 with colon-canalis analis anastomosis and 3 with permanent colostomy.Operation time and volume of intraoperative blood loss were 290 minutes (range,215-420 minutes) and 50 mL (range,30-100 mL),respectively.One patient had intraoperative complication,showing broken ends ischemia of sigmoid colon after dragging out resected rectum from the anus,following free splenic flexure of colon,about 5 cm ischemic sigmoid colon were resected,and descending colon-rectum anastomosis was performed.Time for out-of-bed activity and time for liquid diet intake were 1 days (range,1-3 days) and 2 days (range,1-9 days),respectively.Among 3 patients with postoperative complications (Ⅱ stage of ClavienDindo),2 with incomplete intestinal obstruction were improved by gastrointestinal decompression and total parenteral nutrition,and 1 with presacral infection was improved by drainage and antibiotic therapy.Duration of postoperative hospital stay was 7 days (range,5-21 days).(2) Postoperative pathological situations:length of surgecal specimen,tumor diameter and distance from tumor to resected distant intestinal canal were respectively 18.0 cm (range,12.0-24.0 cm),3.5 cm (range,0.5-6.8 cm) and 2.5 cm (range,1.0-5.0 cm).Evaluation of mesorectum of surgical specimen:14 patients had complete mesorectum of surgical specimen and 2 had nearly complete mesorectum.There was no residual tumor at circumferential resection margin,proximal and distal ends.Pathological T stage of 16 patients:T0 (pathological complete response after neoadjuvant therapy),T1,T2 and T3 stages were found in 1,1,4 and 10 patients,respectively.Pathological N stage:12,2 and 2 patients were detected in N0,N1 and N2 stages,respectively.Number of lymph node detected was 16 (range,6-32).Tumor cell differentiation:no tumor cell (pathological complete response after neoadjuvant therapy),high-,moderateand low-differentiated tumors were respectively detected in 1,2,7 and 6 patients.(3) Follow-up.All the patients were followed up for 12 months (range,4-16 months).There were no local tumor recurrence or distant metastasis and death.Conclusion La-TaTME may be a new,safe and effective resection for middle-low rectal cancer.北京大学第三医院临床重点项目基金; 首都医科大学附属北京友谊医院科研启动基金(YYQDKT2016-5)Clinical Key Project of Peking University Third Hospital; Clinical Research Launching Project of Beijing Friendship Hospital Affiliated to Capital Medical University中国科学引文数据库(CSCD)7695-7001