腹腔镜直肠癌经括约肌间切除术后无造口生存的危险因素分析  

Risk factors of stoma-free survival after laparoscopic intersphincter resection for rectal cancer

作　　者：胡刚 刘军广 邱文龙 梅世文 权继传 庄孟 汤坚强 HU Gang;LIU Jun-guang;QIU Wen-long(Department of Colorectal Surgery,National Cancer Center/National Clinical Re search Center for Cancer/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China)

机构地区：[1]国家癌症中心、国家肿瘤临床医学研究中心、中国医学科学院北京协和医学院肿瘤医院结直肠外科,北京100021 [2]北京大学第一医院普通外科,北京100034

出　　处：《中国实用外科杂志》2023年第3期319-325,共7页Chinese Journal of Practical Surgery

基　　金：国家自然科学基金(No.81903023);吴阶平医学基金会临床科研专项资助基金课题(No.320.6750.2021-04-2);北京自然科学基金海淀前沿项目(No.L222054);北京自然科学基金面上项目(No.4232058);中国医学科学院肿瘤医院“希望之星”人才项目。

摘　　要：目的探讨腹腔镜直肠癌经括约肌间切除(LsISR)术后累积造口还纳率(CSR)、总生存(OS)、无造口生存(SFS)及其危险因素。方法回顾性分析北京大学第一医院2012年1月至2020年12月间收治的392例行LsISR直肠癌病人的临床资料,包括病人基本情况、围手术期资料、术后病理、造口还纳手术相关资料。其中男性248例,女性144例,平均年龄(59.8±11.3)岁,平均体质指数为(23.7±3.12),中位随访时间44个月。采用Log-rank检验法计算LsISR术后CSR、OS及SFS,Cox多因素分析影响OS、SFS的危险因素。结果全组LsISR病人中,共334例行造口,其中331例行预防性造口,3例为吻合口漏后的转流性造口;共295例行造口还纳,其中294例为预防性回肠造口成功还纳,1例为横结肠造口还纳;39例病人造口未能还纳,其中预防性回肠造口无法还纳37例,横结肠造口无法还纳2例。LsISR造口术后3个月、6个月、1年、2年和3年CSR分别为8.7%、43.4%、81.1%、88.0%和88.3%。术后3年和5年OS率分别为93.4%和86.2%;术后3年和5年的SFS分别为85.2%和80.1%。单因素分析显示年龄、肿瘤分化、(y)p T分期和(y)p N分期与LsISR的OS有关,多因素分析显示:年龄>60岁(HR=1.972,95%CI 1.079~3.603,P=0.027)、(y)p T3分期(HR=2.815,95%CI 1.318~6.009,P=0.007)是LsISR术后OS的独立危险因素;新辅助放化疗(nCRT)、肿瘤分化、(y)p T分期和(y)p N分期与LsISR的SFS相关,进一步多因素分析显示nCRT(HR=2.194,95%CI 1.180~4.080,P=0.013)、(y)p T3分期(HR=2.505,95%CI 1.462~4.292,P=0.001)是LsISR术后SFS的独立危险因素。结论低位直肠癌LsISR术后存在造口不能回纳的风险,nCRT、(y)p T3分期是影响SFS的独立危险因素。Objective To explore the cumulative stoma reversal(CSR),overall survival(OS),and stoma-free survival(SFS)and its risk factors after laparoscopic inter sphincter resection(LsISR)for ultralow rectal cancer.Methods Clini⁃cal data of 392 patients with ultra-low rectal cancer admitted to Peking University First Hospital from January 2012 to December 2020 were retrospectively analyzed,including basic information,perioperative data,postoperative pathology,and data related to stoma reversal surgery.There were 248 males and 144 females,with an average age of(59.8±11.3)years and an average BMI of(23.7±3.12).The median follow-up time was 44 months.The Log-rank test was used to calculate CSR,OS and SFS after LsISR operation,and Cox multivariate analysis of the risk factors affecting OS and SFS.Results In the group,a total of 331 patients went preventive ileostomy,3 patients went diverting stoma,295 patients had stoma reversal and 39 became permanent stoma finally. Among them, preventive ileostomy failed in 37 cases and diverting stoma failedin 2 cases. The CSR rates were 8.7%,, 43.4%,81.1%,88.0%, and 88.3% at 3 months,6 months, 1 year, 2 years and 3years after LsISR surgery respectively. The 3 and 5 years OS was 93.4% and 86.2%,and 3 and 5 years SFS were 85.2%and 80.1%, respectively. Univariate analysis showed that age, tumor differentiation,(y)p T stage and(y)p N stage wererelated to OS. Multivariate analysis showed that Age >60 years old(HR=1.972, 95%CI 1.079~3.603,P=0.027)and(y)p T3 stage(HR=2.815,95%CI 1.318~6.009, P=0.007)were independent risk factors for OS after LsISR. Neoadjuvantchemoradiotherapy(nCRT), tumor differentiation,(y)p T stage and(y)p N stage were correlated with SFS after LsISR.Multivariate analysis showed that nCRT(HR=2.194, 95%CI 1.180~4.080, P=0.013)and(y)p T3 stage(HR=2.505,95%CI 1.462~4.292, P=0.001)were independent risk factors for SFS. Conclusion There is a risk for stoma reversalfailure after LsISR for ultralow rectal cancer. nCRT and(y)p T3 stage are independent risk factors for SFS.

关 键 词：直肠癌 经括约肌间切除术 无造口生存 造口还纳 新辅助放化疗 

分 类 号：R6[医药卫生—外科学]