近侧扩大切除手术治疗新辅助放化疗后局部进展期直肠癌疗效分析  

Efficacy analysis of proximally extended resection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy

作　　者：秦启元 邝颖仪[1] 马腾辉[1] 吴雅丽 王怀明[1] 皮艳娜[2] 王辉[1] 王磊[1] 

机构地区：[1]中山大学附属第六医院结直肠外科,广州510065 [2]中山大学附属第六医院麻醉科,广州510065

出　　处：《中华胃肠外科杂志》2017年第11期1256-1262,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：国家自然科学基金面上项目（81573078）;中山大学临床医学研究5010计划项目（2017008）

摘　　要：目的探讨近侧扩大切除手术治疗新辅助放化疗后直肠癌的近期手术效果及安全性。方法检索中山大学附属第六医院结直肠癌数据库中2016年5月至2017年6月期间接受新辅助放化疗（放疗单次剂量1.8-2.0 Gy，常规分割25-28次；同步予以氟尿嘧啶为基础的化疗）及保留肛门的直肠癌根治手术的局部进展期直肠癌病例资料，排除结肠多源发癌、术中发现远处转移、需联合脏器切除或急诊手术者。其中31例患者接受近侧扩大切除手术，剔除2例扩大切除失败者，入组29例（扩大切除组）；采用1∶1的倾向性评分匹配法，选择同期29例接受新辅助放化疗及常规切缘手术的直肠癌患者（常规切缘组）。回顾性分析两组患者的临床资料；采用t检验、χ2检验或秩和检验比较两组患者的基线资料和围手术期疗效。结果两组患者的基线资料具有可比性。扩大切除组较常规切缘组获取的病理标本更长[（18.8 ± 5.1）cm比（11.6 ± 3.4）cm，t = 6.314，P = 0.000]，近切缘距离更长[（14.8 ± 5.5）cm比（8.2 ± 3.0）cm，t = 5.725，P = 0.000]，但手术时间更久[（322.4 ± 100.7）min比（254.6 ± 70.3）min，t = 2.975，P = 0.004]，术中出血量更多[100（225）ml比100（50）ml，Z = -2.403，P = 0.016]。两组间远切缘距离、切缘阳性、清扫淋巴结总数、术后镇痛时间、引流管放置时间、首次排气时间、首次经口进食时间、术后住院天数差异均无统计学意义（均P 〉 0.05）。扩大切除组术后吻合口相关并发症发生率为3.4%（1/29），低于常规切除组的17.2%（5/29），但差异未达到统计学意义（P = 0.194）。结论直肠癌新辅助放化疗后实施近侧扩大切除手术安全有效，并可潜在减少术后吻合口并发症的风险。Objective To evaluate the short-term outcomes and perioperative safety of proximally extended resection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy. Methods From colorectal cancer database in The Sixth Affiliated Hospital of Sun Yat-sen University, a cohort of patients who underwent neoadjuvant chemoradiotherapy （1.8-2.0 Gy per day, 25-28 fractions, concurrent fluorouraeil-based chemotherapy） followed by curative sphincter-preserving surgery for locally advanced rectal cancer between May 2016 and June 2017 were retrospectively identified. Exclusion criteria were synchronous colon cancer, intraoperatively confirmed distal metastasis, multiple visceral resection, and emergency operation. Thirty-one patients underwent proximal extended resection and two were excluded for incomplete extended resection, then 29 patients were enrolled as the extended group. Using propensity scores matching with 1：1 ration, 29 locally advanced rectal cancer patients who underwent conventional resection after neoadjuvant chemoradiotherapy at the same time were matched as the conventional group. Clinical data of two groups were analyzed, and the baseline characteristics and short-term outcomes were compared using the t test, X2 test, or Mann-Whitney U test. Results Two groups were well balanced with respect to the baseline characteristics after propensity score matching. As compared with conventional group, patients in extended group had longer surgical specimen [（18.8± 5.1） cm vs.（ll.6 ± 3.4） cm, t = 6.314, P = 0.000] and longer proximal resection margin [（14.8 ＋ 5.5） cm vs.（8.2 ± 3.0） cm, t = 5.725, P = 0.000], but also had longer total operating time [（322.4 ± 100.7） min vs.（254.6 ± 70.3） min, t = 2.975, P= 0.004] and more intraoperative blood loss [100 （225） ml vs. 100 （50） ml, Z = -2.403, P = 0.016]. No significant differences were observed in the length of distal resection margin, ratio of positive resection margin, number of retrieved lymph node, time of analge

关 键 词：直肠肿瘤 新辅助放化疗 外科治疗 围手术期安全性 

分 类 号：R735.37[医药卫生—肿瘤]