目的 探讨肛提肌标识在直肠癌腹会阴联合切除术中的作用.方法 回顾性分析2001年1月至2008年1月南京医科大学第一附属医院收治的109例直肠癌患者的临床资料,其中55例采用传统方法手术(传统法组),54例采用肛提肌标识法进行手术(肛提肌标识法组).手术遵循直肠癌全系膜切除术原则,锐性分离直肠系膜,整块切除.两组患者术前肠道准备、麻醉选择、患者体位、腹部切口、会阴部切口、会阴部缝合与Miles术相同.传统法组用电刀或超声刀切开会阴部脂肪组织,自尾骨的前方进入盆腔,与腹部手术医师会合,靠近盆壁切断两侧肛提肌未进行标识则进行后续手术操作.肛提肌标识法组采用电刀切开肛门周围间隙脂肪组织,分离两侧坐骨肛管间隙脂肪组织,切断后方肛尾韧带,直达肛提肌平面,标识肛提肌后进行后续手术操作.术后病理检查为Ⅰ期者进行随访观察;术后病理检查为Ⅱ期者,如组织学分化差、T4期、血管淋巴管浸润、检出淋巴结数目＜12枚,则行辅助化疗,如无则进行随访观察;术后病理检查为Ⅲ、Ⅳ期者,行术后化疗.术后第1年,每3个月复查1次血常规、肝肾功能、胸部X线片和肝胆B超.1年后每6个月复查1次上述检查;每年复查1次CT和肠镜检查.随访时间截至2012年12月.计数资料采用x2检验,计量资料采用t检验,Kaplan-Meier法绘制生存曲线,生存率比较采用Log-rank检验.结果 两组患者顺利完成手术,传统法组患者和肛提肌标识法组患者的会阴手术时间分别为(60±15) min和(30±10) min,术中出血量分别为(300 ±60) mL和(30±20) mL,两组比较,差异有统计学意义(t=3.936,5.687,P＜0.05).传统法组患者中,3例直肠破损,2例尿道(阴道)破损,10例切口感染;而肛提肌标识法组患者中,只有9例切口感染.109例患者中,术后化疗周期少于12个疗程者30例,6个疗程及以上者41例.中位随访时间为56个月(15 ～95个月).109例患者中,10例失访,15例局部复发,30例远处转移,35例死亡.1、3、5年累积生存率分别为93.4％、76.0％、65.6％.传统法组和肛提肌标识法组患者5年生存率分别为65.2％和66.3％,两组比较,差异无统计学意义(x2=4.210,P＞0.05).结论 在直肠癌腹会阴联合切除术中,与传统手术方法比较,肛提肌标识法手术解剖清晰,视野好,手术时间短,术中出血量少,不易误伤直肠或尿道(阴道).
目的 探討肛提肌標識在直腸癌腹會陰聯閤切除術中的作用.方法 迴顧性分析2001年1月至2008年1月南京醫科大學第一附屬醫院收治的109例直腸癌患者的臨床資料,其中55例採用傳統方法手術(傳統法組),54例採用肛提肌標識法進行手術(肛提肌標識法組).手術遵循直腸癌全繫膜切除術原則,銳性分離直腸繫膜,整塊切除.兩組患者術前腸道準備、痳醉選擇、患者體位、腹部切口、會陰部切口、會陰部縫閤與Miles術相同.傳統法組用電刀或超聲刀切開會陰部脂肪組織,自尾骨的前方進入盆腔,與腹部手術醫師會閤,靠近盆壁切斷兩側肛提肌未進行標識則進行後續手術操作.肛提肌標識法組採用電刀切開肛門週圍間隙脂肪組織,分離兩側坐骨肛管間隙脂肪組織,切斷後方肛尾韌帶,直達肛提肌平麵,標識肛提肌後進行後續手術操作.術後病理檢查為Ⅰ期者進行隨訪觀察;術後病理檢查為Ⅱ期者,如組織學分化差、T4期、血管淋巴管浸潤、檢齣淋巴結數目＜12枚,則行輔助化療,如無則進行隨訪觀察;術後病理檢查為Ⅲ、Ⅳ期者,行術後化療.術後第1年,每3箇月複查1次血常規、肝腎功能、胸部X線片和肝膽B超.1年後每6箇月複查1次上述檢查;每年複查1次CT和腸鏡檢查.隨訪時間截至2012年12月.計數資料採用x2檢驗,計量資料採用t檢驗,Kaplan-Meier法繪製生存麯線,生存率比較採用Log-rank檢驗.結果 兩組患者順利完成手術,傳統法組患者和肛提肌標識法組患者的會陰手術時間分彆為(60±15) min和(30±10) min,術中齣血量分彆為(300 ±60) mL和(30±20) mL,兩組比較,差異有統計學意義(t=3.936,5.687,P＜0.05).傳統法組患者中,3例直腸破損,2例尿道(陰道)破損,10例切口感染;而肛提肌標識法組患者中,隻有9例切口感染.109例患者中,術後化療週期少于12箇療程者30例,6箇療程及以上者41例.中位隨訪時間為56箇月(15 ～95箇月).109例患者中,10例失訪,15例跼部複髮,30例遠處轉移,35例死亡.1、3、5年纍積生存率分彆為93.4％、76.0％、65.6％.傳統法組和肛提肌標識法組患者5年生存率分彆為65.2％和66.3％,兩組比較,差異無統計學意義(x2=4.210,P＞0.05).結論 在直腸癌腹會陰聯閤切除術中,與傳統手術方法比較,肛提肌標識法手術解剖清晰,視野好,手術時間短,術中齣血量少,不易誤傷直腸或尿道(陰道).
목적 탐토항제기표식재직장암복회음연합절제술중적작용.방법 회고성분석2001년1월지2008년1월남경의과대학제일부속의원수치적109례직장암환자적림상자료,기중55례채용전통방법수술(전통법조),54례채용항제기표식법진행수술(항제기표식법조).수술준순직장암전계막절제술원칙,예성분리직장계막,정괴절제.량조환자술전장도준비、마취선택、환자체위、복부절구、회음부절구、회음부봉합여Miles술상동.전통법조용전도혹초성도절개회음부지방조직,자미골적전방진입분강,여복부수술의사회합,고근분벽절단량측항제기미진행표식칙진행후속수술조작.항제기표식법조채용전도절개항문주위간극지방조직,분리량측좌골항관간극지방조직,절단후방항미인대,직체항제기평면,표식항제기후진행후속수술조작.술후병리검사위Ⅰ기자진행수방관찰;술후병리검사위Ⅱ기자,여조직학분화차、T4기、혈관림파관침윤、검출림파결수목＜12매,칙행보조화료,여무칙진행수방관찰;술후병리검사위Ⅲ、Ⅳ기자,행술후화료.술후제1년,매3개월복사1차혈상규、간신공능、흉부X선편화간담B초.1년후매6개월복사1차상술검사;매년복사1차CT화장경검사.수방시간절지2012년12월.계수자료채용x2검험,계량자료채용t검험,Kaplan-Meier법회제생존곡선,생존솔비교채용Log-rank검험.결과 량조환자순리완성수술,전통법조환자화항제기표식법조환자적회음수술시간분별위(60±15) min화(30±10) min,술중출혈량분별위(300 ±60) mL화(30±20) mL,량조비교,차이유통계학의의(t=3.936,5.687,P＜0.05).전통법조환자중,3례직장파손,2례뇨도(음도)파손,10례절구감염;이항제기표식법조환자중,지유9례절구감염.109례환자중,술후화료주기소우12개료정자30례,6개료정급이상자41례.중위수방시간위56개월(15 ～95개월).109례환자중,10례실방,15례국부복발,30례원처전이,35례사망.1、3、5년루적생존솔분별위93.4％、76.0％、65.6％.전통법조화항제기표식법조환자5년생존솔분별위65.2％화66.3％,량조비교,차이무통계학의의(x2=4.210,P＞0.05).결론 재직장암복회음연합절제술중,여전통수술방법비교,항제기표식법수술해부청석,시야호,수술시간단,술중출혈량소,불역오상직장혹뇨도(음도).
Objective To investigate the effects of levator ani muscle exposure in abdominal periueal resection for rectal cancer.Methods The clinical data of 109 patients with rectal cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2001 to January 2008 were retrospectively analyzed.There were 55 patients received traditional procedure (conventional method group) and 54 patients received modified procedure with levator ani muscle exposure (levator ani muscle exposure group).The mesorectum was sharply dissected according to the total mesorectal excision principle.It is essential to remove the rectum along with the mesorectum up to the level of the levators.Preoperative bowel preparation,anesthesia,body position,abdominal incision,perineal incision and suture of the 2 groups were the same as Miles procedure.In the conventional method group,the superficial dissection was carried out with electrocautery or ultracision harmonic scalpel.The presacral space was entered by dividing the rectococcygeus muscle,commencing at the level of the tip of the coccygeus.The levators were then divided near the pelvic wall attachments and next procedures were performed without levator ani muscle exposure.In levator ani muscle exposure group,once the ischiorectal fat was cleared by electrocautery,the planes of levator ani muscle were identified and exposed after dividing the rectococcygeus muscle and next procedures were performed.The patients in stage Ⅰ only needed to follow-up; the patients in stage Ⅱ had to receive chemotherapy with following situation:poor differentiation,T4 stage,blood vessel or lymphatic invasion,number of lymph nodcs detected ＜ 12.Patients in stage Ⅲ or Ⅳ needed adjuvant chemotherapy.The follow-up evaluation included blood routine examination,hepatic and renal function examination,chest radiography,hepatobiliary ultrasonographic evaluation and determination of CEA levels (once every 3 months in the first year after operation,and once every 6 months after one year).Abdominal CT scan and colonoscopy should be employed every year.All the patients were followed up till December of 2012.All data were analyzed using the chi-square test or t test.The survival curve was drawn using the Kaplan-Meier method,and the prognosis was analyzed using the Log-rank test.Results The operation time were (60 ± 15)minutes and (30 ± 10) minutes in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =3.936,P ＜ 0.05).The intraoperative blood loss were (300 ± 60) mL and (30±20) mL in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =5.687,P ＜ 0.05).Three patients were with rectal injury,1 with urethral injury,1 with vaginal injury,and 10 with incision infection in the conventional method group.There were 9 patients with incision infection in the levator ani muscle exposure group.The course of chemotherapy was under 12 in 30 patients,and above 6 in 41 patients.The median time of follow-up of the patients was 56 months (range,15-95 months).Of the 109 patients,10 missed the follow-up,15 patients had local recurrence,30 had distal metastasis,and 35 patients died.The 1-,3-,5-year cumulative survival rates were 93.4％,76.0％ and 65.6％.The 5-year survival rates were 65.2％ and 66.3％ for patients in the conventional method group and the levator ani muscle exposure group,with no significant difference between the 2 groups (x2=4.210,P ＞0.05).Conclusion Levator ani muscle exposure method provides clearer vision of operational field,shorter operation time,less blood loss and less injury to the rectum or urinary tract (vagina).
