CAJ | 학술논문

目的探讨骨盆径线对全直肠系膜切除术(TME)的限制性作用,筛选可用来预测手术困难程度的测量指标.方法收集2009年1月至2011年1月上海长海医院结直肠外科单一手术组收治的69例TME手术患者的病例资料,其中男性55例,女性14例.以骨盆MDCT薄层扫描为基础,利用软件进行骨盆三维重建并测量一系列骨盆径线与角度(15项骨盆测量指标).手术均为开放性手术,其中前切除术19例,低位前切除术29例,腹会阴联合切除术21例.以手术时间和术中出血量作为评价手术困难程度的指标,通过单因素分析筛选有价值的骨盆测量径线；在多元回归分析中,观察骨盆径线对手术时间和术中出血量的影响.结果 69例患者手术时间为(139.9±32.4)min,术中出血量为(228.8±150.6) ml.多因素分析显示,坐骨棘间径、入口前后径和骶尾间距是影响手术时间的主要因素,耻骨联合上下径和骶尾间距是影响术中出血量的主要因素(均P＜0.05).3种术式中,前切除术的多元回归分析结果有较高价值,其手术时间的影响因素是骶骨上下径和坐骨棘间径(回归方程的校正决定系数Rc2=0.460,P=0.003)；其术中出血量的影响因素是入口前后径、骶骨上下径和骶骨耻骨角(Rc2=0.358,P=0.022).测量参数综合分析,入口前后径与骶尾间距的比值影响手术时间与出血量,该比值女性病例显著大于男性；女性病例该比值大于1时,手术时间明显缩短(P＝0.050);男性病例大于0.9时,术中出血量明显减少(P=0.021).结论骨盆宽、浅者TME手术时间和出血量明显减少;深、窄的骨盆或骶骨弯曲度较大的骨盆会增加手术难度.测量入口前后径与骶尾间距的比值可以预测TME手术的难易度.
목적 탐토골분경선대전직장계막절제술(TME)적한제성작용,사선가용래예측수술곤난정도적측량지표.방법 수집2009년1월지2011년1월상해장해의원결직장외과단일수술조수치적69례TME수술환자적병례자료,기중남성55례,녀성14례.이골분MDCT박층소묘위기출,이용연건진행골분삼유중건병측량일계렬골분경선여각도(15항골분측량지표).수술균위개방성수술,기중전절제술19례,저위전절제술29례,복회음연합절제술21례.이수술시간화술중출혈량작위평개수술곤난정도적지표,통과단인소분석사선유개치적골분측량경선；재다원회귀분석중,관찰골분경선대수술시간화술중출혈량적영향.결과 69례환자수술시간위(139.9±32.4)min,술중출혈량위(228.8±150.6) ml.다인소분석현시,좌골극간경、입구전후경화저미간거시영향수술시간적주요인소,치골연합상하경화저미간거시영향술중출혈량적주요인소(균P＜0.05).3충술식중,전절제술적다원회귀분석결과유교고개치,기수술시간적영향인소시저골상하경화좌골극간경(회귀방정적교정결정계수Rc2=0.460,P=0.003)；기술중출혈량적영향인소시입구전후경、저골상하경화저골치골각(Rc2=0.358,P=0.022).측량삼수종합분석,입구전후경여저미간거적비치영향수술시간여출혈량,해비치녀성병례현저대우남성；녀성병례해비치대우1시,수술시간명현축단(P＝0.050);남성병례대우0.9시,술중출혈량명현감소(P=0.021).결론 골분관、천자TME수술시간화출혈량명현감소;심、착적골분혹저골만곡도교대적골분회증가수술난도.측량입구전후경여저미간거적비치가이예측TME수술적난역도.
Objective To investigate the limiting effect of pelvic diameters on the technical difficulty of total mesorectal excision (TME) for rectal cancer by computed tomography pelvimetry.Methods From January 2009 to January 2011,69 patients with rectal cancer underwent TME in the Department of Proctology at the Changhai Hospital in Shanghai.There were 55 males and 14 females.Using three dimensional reconstruction software,pelvic dimensions of rectal cancer patients were measured based on pelvic MDCT thin-slice computed tomography.All the patients were measured for 15 pelvic parameters,including the length of pelvic inlet,the length of pubic symphysis,the interspinous distance,the distance from sacral promontory to tip of coccyx,etc.All the procedures were open surgery,including anterior resection (n=19),low anterior resection and ileostomy (n=29) and abdominal perineal resection (n=21).Duration of the operation and blood loss at surgery were recorded as evaluation indicators of the technical difficulty of total mesorectal excision.By univariate analysis significant pelvic parameters were selected.Multiple regression analysis was used to investigate the relationship between pelvic parameters and blood loss or duration of operation.Results The mean operative time was (139.9±32.4) min and the mean intraoperative blood loss was (228.8±150.6) ml.Multivariate analysis showed that the interspinous distance,the length of pelvic inlet,the distance from sacral promontory to the tip of coccyx were the main factors affecting the operation time,and that the length of pubic symphysis and the distance from sacral promontory to the tip of coccyx were the main factors affecting the amount of blood loss (all P＜0.05).Among the 3 procedures,the multivariate analysis for low anterior resection appeared to be most valuable,in which operative time was associated with the distance from sacral promontory to the tip of coccyx and the interspinous distance (adjusted coefficient of determination of the regression equation,Rc2=0.460,P=0.003).Factors associated with intraoperative blood loss were the length of pelvic inlet,the distance from sacral promontory to the tip of coccyx,and the sacrum-pubis angle (Rc2=0.358,P=0.022).Comprehensive analysis of the measurement parameters showed that the ratio between the length of pelvic inlet and the distance from sacral promontory to the tip of coccyx was associated with the operative time and blood loss.This ratio was significantly higher in female patients than that in males.In females with a ratio greater than 1,the operative time was significantly shorter (P=0.050),and the intraoperative blood loss was significantly less in males with a ratio greater than 0.9 (P=0.021).Conclusions Operative time and intraoperative blood loss for total mesorectal excision are more favorable in patients with a wide and shadow pelvis.Surgical difficulty is increased in deep and narrow pelvis or those with major sacrum curvature.The difficulty of total mesorectal excision procedure can be predicted by measuring the length of pelvic inlet and the distance from sacral promontory to the tip of coccyx.