目的 探讨外翻脱出式切除术在腹腔镜直肠癌超低前切除术中的应用价值及临床疗效.方法 回顾性分析2010年7月至2013年7月中国医科大学附属盛京医院收治的27例超低位直肠癌患者的临床资料.采用外翻脱出式切除术施行腹腔镜直肠癌超低前切除术.记录患者平均手术时间、平均术中出血量、平均淋巴结清扫数目、平均切缘长度、平均标本长度、术后病理学检查结果、术后首次离床活动时间、术后首次肛门排气时间、术后胃管拔除时间、术后并发症发生情况.术后1周VAS疼痛评分、术后1个月采用Wexner大便失禁评分评估大便失禁程度.术前及术后3、12个月行肛门功能检测.采用门诊及电话方式进行随访,术后2年内每3个月随访1次,之后每年随访1次,随访内容包括肿瘤的复发转移、Wexner大便失禁评分以及肛门测压情况.随访时间截至2014年10月.符合正态分布的计量资料以-x±s和均数(范围)表示,重复测量数据采用重复测量的方差分析.结果 27例患者均顺利完成手术,无手术方式更改及术中意外发生.本组患者平均手术时间为140 min(115 ～ 173min),平均术中出血量为27 mL(15～ 55 mL),术中平均清扫淋巴结数目为17枚(14～ 20枚),平均远端切缘长度为1.7 cm(1.3 ～2.2 cm),平均切除标本长度为18.5 cm(14.7～ 22.4 cm).术后TNM分期:T2N0M0期19例,T2N1M0期3例,T3N0M0期4例,T3N1 M0期1例.患者术后平均首次离床活动时间为8.8 h(7.0～ 13.0 h),术后平均首次肛门排气时间为51 h(30 ～79 h).27例患者术后均即刻拔除胃管,24 h进全流质饮食,48 h进半流质饮食.1例男性患者术后3d发生尿潴留,1例患者术后9d发生吻合口漏,均经对症支持治疗后痊愈.患者术后1～6d的平均疼痛评分分别为5.6、4.6、4.0、3.2、2.2、1.3分.患者平均住院时间为11.1 d(7.0～19.0d).术后2周患者腹部切口愈合良好.27例患者均获得随访,平均随访时间为24.8个月(15.0 ～32.0个月),无肿瘤转移或复发.术后1个月Wexner大便失禁评分平均为2.6分(1.0 ～4.0分).肛门测压结果显示:术前、术后3个月、术后12个月的最大静息压分别为(267±23)mmHg(1 mmHg =0.133 kPa)、(266±40) mmHg、(267±33) mmHg,最大收缩压分别为(305±23) mmHg、(300±38) mmHg、(315±30) mmHg,术前与术后变化趋势比较,差异无统计学意义(F =0.510,1.390,P＞0.05);静息向量容积分别为(45594±1 981)cm(mmHg)2、(40 310±3 465) cm(mmHg)2、(40 385±3 379) cm (mmHg)2,收缩向量容积分别为(98 480±8 165) cm(mmHg)2、(78 461 ±6 777) cm(mmHg)2、(82 082±10 383) cm(mmHg)2,术前与术后变化趋势比较,差异有统计学意义(F =26.845,48.090,P＜0.05).结论 外翻脱出式切除术运用于腹腔镜直肠癌超低前切除术,在严格掌握手术适应证的前提下,其具有较传统腹腔镜低位直肠癌手术更微创、美观的优势,且安全性、肿瘤根治性及肛门功能的保护作用满意.
目的 探討外翻脫齣式切除術在腹腔鏡直腸癌超低前切除術中的應用價值及臨床療效.方法 迴顧性分析2010年7月至2013年7月中國醫科大學附屬盛京醫院收治的27例超低位直腸癌患者的臨床資料.採用外翻脫齣式切除術施行腹腔鏡直腸癌超低前切除術.記錄患者平均手術時間、平均術中齣血量、平均淋巴結清掃數目、平均切緣長度、平均標本長度、術後病理學檢查結果、術後首次離床活動時間、術後首次肛門排氣時間、術後胃管拔除時間、術後併髮癥髮生情況.術後1週VAS疼痛評分、術後1箇月採用Wexner大便失禁評分評估大便失禁程度.術前及術後3、12箇月行肛門功能檢測.採用門診及電話方式進行隨訪,術後2年內每3箇月隨訪1次,之後每年隨訪1次,隨訪內容包括腫瘤的複髮轉移、Wexner大便失禁評分以及肛門測壓情況.隨訪時間截至2014年10月.符閤正態分佈的計量資料以-x±s和均數(範圍)錶示,重複測量數據採用重複測量的方差分析.結果 27例患者均順利完成手術,無手術方式更改及術中意外髮生.本組患者平均手術時間為140 min(115 ～ 173min),平均術中齣血量為27 mL(15～ 55 mL),術中平均清掃淋巴結數目為17枚(14～ 20枚),平均遠耑切緣長度為1.7 cm(1.3 ～2.2 cm),平均切除標本長度為18.5 cm(14.7～ 22.4 cm).術後TNM分期:T2N0M0期19例,T2N1M0期3例,T3N0M0期4例,T3N1 M0期1例.患者術後平均首次離床活動時間為8.8 h(7.0～ 13.0 h),術後平均首次肛門排氣時間為51 h(30 ～79 h).27例患者術後均即刻拔除胃管,24 h進全流質飲食,48 h進半流質飲食.1例男性患者術後3d髮生尿潴留,1例患者術後9d髮生吻閤口漏,均經對癥支持治療後痊愈.患者術後1～6d的平均疼痛評分分彆為5.6、4.6、4.0、3.2、2.2、1.3分.患者平均住院時間為11.1 d(7.0～19.0d).術後2週患者腹部切口愈閤良好.27例患者均穫得隨訪,平均隨訪時間為24.8箇月(15.0 ～32.0箇月),無腫瘤轉移或複髮.術後1箇月Wexner大便失禁評分平均為2.6分(1.0 ～4.0分).肛門測壓結果顯示:術前、術後3箇月、術後12箇月的最大靜息壓分彆為(267±23)mmHg(1 mmHg =0.133 kPa)、(266±40) mmHg、(267±33) mmHg,最大收縮壓分彆為(305±23) mmHg、(300±38) mmHg、(315±30) mmHg,術前與術後變化趨勢比較,差異無統計學意義(F =0.510,1.390,P＞0.05);靜息嚮量容積分彆為(45594±1 981)cm(mmHg)2、(40 310±3 465) cm(mmHg)2、(40 385±3 379) cm (mmHg)2,收縮嚮量容積分彆為(98 480±8 165) cm(mmHg)2、(78 461 ±6 777) cm(mmHg)2、(82 082±10 383) cm(mmHg)2,術前與術後變化趨勢比較,差異有統計學意義(F =26.845,48.090,P＜0.05).結論 外翻脫齣式切除術運用于腹腔鏡直腸癌超低前切除術,在嚴格掌握手術適應證的前提下,其具有較傳統腹腔鏡低位直腸癌手術更微創、美觀的優勢,且安全性、腫瘤根治性及肛門功能的保護作用滿意.
목적 탐토외번탈출식절제술재복강경직장암초저전절제술중적응용개치급림상료효.방법 회고성분석2010년7월지2013년7월중국의과대학부속성경의원수치적27례초저위직장암환자적림상자료.채용외번탈출식절제술시행복강경직장암초저전절제술.기록환자평균수술시간、평균술중출혈량、평균림파결청소수목、평균절연장도、평균표본장도、술후병이학검사결과、술후수차리상활동시간、술후수차항문배기시간、술후위관발제시간、술후병발증발생정황.술후1주VAS동통평분、술후1개월채용Wexner대편실금평분평고대편실금정도.술전급술후3、12개월행항문공능검측.채용문진급전화방식진행수방,술후2년내매3개월수방1차,지후매년수방1차,수방내용포괄종류적복발전이、Wexner대편실금평분이급항문측압정황.수방시간절지2014년10월.부합정태분포적계량자료이-x±s화균수(범위)표시,중복측량수거채용중복측량적방차분석.결과 27례환자균순리완성수술,무수술방식경개급술중의외발생.본조환자평균수술시간위140 min(115 ～ 173min),평균술중출혈량위27 mL(15～ 55 mL),술중평균청소림파결수목위17매(14～ 20매),평균원단절연장도위1.7 cm(1.3 ～2.2 cm),평균절제표본장도위18.5 cm(14.7～ 22.4 cm).술후TNM분기:T2N0M0기19례,T2N1M0기3례,T3N0M0기4례,T3N1 M0기1례.환자술후평균수차리상활동시간위8.8 h(7.0～ 13.0 h),술후평균수차항문배기시간위51 h(30 ～79 h).27례환자술후균즉각발제위관,24 h진전류질음식,48 h진반류질음식.1례남성환자술후3d발생뇨저류,1례환자술후9d발생문합구루,균경대증지지치료후전유.환자술후1～6d적평균동통평분분별위5.6、4.6、4.0、3.2、2.2、1.3분.환자평균주원시간위11.1 d(7.0～19.0d).술후2주환자복부절구유합량호.27례환자균획득수방,평균수방시간위24.8개월(15.0 ～32.0개월),무종류전이혹복발.술후1개월Wexner대편실금평분평균위2.6분(1.0 ～4.0분).항문측압결과현시:술전、술후3개월、술후12개월적최대정식압분별위(267±23)mmHg(1 mmHg =0.133 kPa)、(266±40) mmHg、(267±33) mmHg,최대수축압분별위(305±23) mmHg、(300±38) mmHg、(315±30) mmHg,술전여술후변화추세비교,차이무통계학의의(F =0.510,1.390,P＞0.05);정식향량용적분별위(45594±1 981)cm(mmHg)2、(40 310±3 465) cm(mmHg)2、(40 385±3 379) cm (mmHg)2,수축향량용적분별위(98 480±8 165) cm(mmHg)2、(78 461 ±6 777) cm(mmHg)2、(82 082±10 383) cm(mmHg)2,술전여술후변화추세비교,차이유통계학의의(F =26.845,48.090,P＜0.05).결론 외번탈출식절제술운용우복강경직장암초저전절제술,재엄격장악수술괄응증적전제하,기구유교전통복강경저위직장암수술경미창、미관적우세,차안전성、종류근치성급항문공능적보호작용만의.
Objective To explore the application value and clinical efficacy of the transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultra-low rectal cancer.Methods The clinical data of 27 patients with ultra-low rectal cancer who underwent transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultra-low rectal cancer at the Shengjing Hospital of China Medical University from July 2010 to July 2013 were analyzed retrospectively.The average operation time, average volume of intraoperative blood loss, average number of lymph nodes dissection, average distance to resection margin, average length of resected specimen, results of postoperative pathological examination, time for postoperative outoff-bed activity, time to anal exsufflation, gastric tube removal time and postoperative complications were recorded.The visual analogue scale (VSA) pain score and Wexner score for evaluating fecal incontinence were performed at postoperative week 1 and at postoperative month 1, respectively.The anal function was tested at postoperative month 3 and 12.The follow-up including tumor metastasis and recurrence, Wexner score and anorectal anometry was performed by outpatient examination and telephone interview once every 3 months for 2 years after operation and then once every year up to October 2014.Measurement data with normal distribution was presented as-x ± s and average (range).Repeated measures data were analyzed by the repeated measures ANOVA.Results All the patients received successful operations without procedure change or intraoperative accident.The average operating time, average volume of intraoperative blood loss, average number of lymph nodes dissection, average distance to distal resection margin and average length of resected specimen were 140 minutes (range, 115-173 mintues), 27 mL(range, 15-55 mL), 17(range, 14-20), 1.7 cm(range, 1.3-2.2 cm) and 18.5 cm(range, 14.7-22.4 cm), respectively.Postoperative TNM stages: T2N0M0 was detected in 19 patients, T2N1M0 in 3 patients,T3N0M0 in 4 patients and T3N1M0 in 1 patients.The time for postoperative out-off-bed activity and time to anal exsufflation were 8.8 hours (range, 7.0-13.0 hours) and 51 hours (range, 30-79 hours).Twenty-seven patients had the gastric tube removal after operation with fluid diet intake at postoperative hour 24 and semi-fluid diet intake at postoperative hour 48.One male patient was complicated with urinary retention at postoperative day 3 and 1 with anastomotic leakage at postoperative day 9, they were cured by symptomatic treatment.VSA pain scores in all patients from 1 day to 6 days postoperatively were 5.6, 4.6, 4.0, 3.2, 2.2 and 1.3.The average duration of hospital stay was 11.1 days (range, 7.0-19.0 days).Patients had good healing of abdominal incision at postoperative week 2.All the patients were followed up for a average time of 24.8 months (range, 15.0-32.0 months) without tumor metastasis and recurrence.Wexner score was 2.6 (range, 1.0-4.0) at postoperative month 1.The results of anorectal anometry: maximum anorectal resting pressure (MARP) and maximum anorectal systolic pressure were (267 ±23)mmHg (1 mmHg =0.133 kPa) and (305 ± 23)mmHg before operation, (266 ± 40)mmHg and (300 ± 38)mmHg at postoperative month 3, (267 ± 33)mmHg and (315 ± 30)mmHg at postoperative month 12, respectively, with no significant difference in the changing trend between pre-and post-operation (F =0.510, 1.390, P ＞ 0.05).Anorectal resting vector volume and anorectal systolic vector volume were (45 594 ± 1 981) cm (mmHg) 2 and (98 480 ± 8 165) cm (mmHg) 2 before operation, (40 310 ±3 465)cm(mmHg)2 and (78 461 ±6 777)cm(mmHg)2 at postoperative month 3, (40 385 ± 3 379) cm(mmHg) 2 and (82 082 ± 10 383) cm(mmHg) 2 at postoperative month 12, respectively, with significant differences in the changing trend between pre-and post-operation (F =26.845, 48.090, P ＜ 0.05).Conclusion Transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultra-low rectal cancer is safe, aesthetic and minimally invasive compared with the traditional laparoscopic surgery, with the advantages of radical cure of tumor and protection of anal function.
