低位直肠癌腹腔镜TME手术经直肠取出标本影响因素的分析  

Influencing factors for trans-rectal specimen extraction following laparoscopic total mesorectal excision in patients with low rectal cancer

作　　者：张振宇 朱哲[1] 张园园 倪荔 纪昉 鲁兵 Zhang Zhenyu;Zhu Zhe;Zhang Yuanyuan;Ni Li;Ji Fang;Lu Bing(Department of General Surgery,Department of Colorectal Surgery,Shanghai East Hospital,School of Medicine,Tongji University,Shanghai 200120,China)

机构地区：[1]同济大学医学院,同济大学附属东方医院(上海市东方医院)普外科,肛肠外科,200120

出　　处：《中华结直肠疾病电子杂志》2022年第1期24-29,共6页Chinese Journal of Colorectal Diseases(Electronic Edition)

基　　金：国家自然科学基金(No.82060103);上海市科委课题(No.19411966500)。

摘　　要：目的 探讨低位直肠癌腹腔镜TME手术经直肠取出标本的限制因素。方法 回顾性分析经纳排标准筛选的于2018年6~12月在同济大学附属东方医院接受低位直肠癌腹腔镜保肛手术的有效病例,利用单因素和多因素logistic分析比较经直肠取标本组(LAR-NOSES)和腹部小切口取标本组(Mini-Lapar)在术前基线资料、经CT/MRI测得肿瘤及盆腔局部骨性及软组织参数和术后临床病理分期等特征的差异。结果 本研究最终共纳入有效患者89例,其中Mini-Lapar组48例,LARNOSES组41例,经直肠取标本成功率为46.1%。单因素分析结果显示LAR-NOSES与女性性别(χ^(2)=9.0,P=0.003)、更小的BMI(t=-3.4,P=0.001)、肿瘤距肛缘位置(Z=-2.4,P=0.015)、肿瘤最大直径(t=-3.6,P=0.001)、肿瘤最大纵向长度(t=-3.9,P<0.001)、直肠最大系膜厚度(t=-2.2,P=0.033)及更大的坐骨棘间径(t=3.0,P=0.004)和坐骨结节间径(t=2.6,P=0.011)显著相关。除pT分期外(χ^(2)=6.6,P=0.038),两组在术后肿瘤病理大体、镜下分型分期及Wexner失禁评分方面差异均无统计学意义(P均>0.05)。多因素logistic回归分析提示,BMI(OR=1.36,95%CI=1.09~1.70,P=0.006)、肿瘤距肛缘位置(OR=1.66,95%CI=1.03~2.70,P=0.039)、LTD (OR=2.99,95%CI=1.46~6.14, P=0.003)和坐骨棘间径(OR=0.44, 95%CI=0.25~0.77, P=0.004)是限制腹腔镜低位直肠NOSES成功实施的独立预测因素。结论 直肠标本的尺寸越小、标本取出所经过的软组织通道越短、所经过的骨性通道尺寸越大越有利于LAR-NOSES的成功实现。Objective To explore restricting factors for trans-rectal specimen extraction following laparoscopic low anterior resection in patients with rectal cancer. Methods After retrospective inclusion of eligible patients with low rectal cancer who received laparoscopic low anterior resection at the department of colorectal surgery of Shanghai East Hospital between June and December of 2018, univariate and multivariate analyses were performed to compare the differences between tans-rectal extraction(LARNOSES) group and conventional trans-abdominal specimen extraction(Mini-Lapar) group in preoperative baseline characteristics, tumor-related and pelvic bone-related factors derived by CT/MRI scan as well as clinical-pathological variables. Results Eighty-nine eligible patients were selected in the final analysis including 48 and 41 cases in the Mini-Lapar and LAR-NOSES group, respectively.And the successful transrectal specimen extraction rate was 46.1%(41/89). Univariate analysis showed that LAR-NOSES was associated with female gender(χ^(2)=9.0, P=0.003), a decreased body mass index(BMI)(t=-3.4, P=0.001),tumor distance from anal verge(Z=-2.4, P=0.015), maximum tumor diameter(MTD)(t=-3.6, P=0.001),maximum longitudinal tumor diameter(LTD)(t=-3.9, P<0.001), maximum mesorectal thickness of the rectum(MRL)(t=-2.2, P=0.033), and an increased bispinous(t=3.0,P=0.004) and intertuberal diameter(t=2.6,P=0.011). Meanwhile, no differences were observed in postoperative gross and microscopic parameters,along with Wexner fecal incontinence index(all P values >0.05), except for an earlier pathological T stage(pT)(χ^(2)=6.6, P=0.038) for patients in LAR-NOSES group. Multivariate logistic regression analysis indicated that the BMI(OR=1.36, 95%CI=1.09~1.70, P=0.006), tumor distance from anal verge(OR=1.66, 95%CI=1.03~2.70, P=0.039), LTD(OR=2.99, 95%CI=1.46~6.14, P=0.003) and bispinous diameter(OR=0.44,95%CI=0.25~0.77, P=0.004) were independent predictors for the implementation of LAR-NOSES.Conclusion The implementation of LAR-NOSES may b

关 键 词：直肠肿瘤 腹腔镜 经直肠取标本手术 影像学 多因素分析 

分 类 号：R735.37[医药卫生—肿瘤]