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中华临床医师杂志(电子版)

中华临床医师杂志(电子版) ›› 2023, Vol. 17 ›› Issue (05) : 529 -534. doi: 10.3877/cma.j.issn.1674-0785.2023.05.006

临床研究

腹腔镜低位直肠癌远端切缘不足导致保肛失败的危险因素分析及补救策略
王光林, 于淼, 孟泽松, 胡旭华, 王飞飞, 李保坤, 曹龙飞, 冯鋆, 张娟, 王贵英†()   
  1. 050010　河北石家庄，河北医科大学第四医院外二科
    050017　河北石家庄，河北医科大学基础医学院
    050010　河北石家庄，河北医科大学第四医院外二科；050051　河北石家庄，河北医科大学第三医院胃肠外科
  • 收稿日期:2022-04-03 出版日期:2023-05-15
  • 通信作者: 王贵英
  • 基金资助:
    河北省医学科学研究课题计划(20210028); 河北省科技厅项目重点项目(206Z7705G); 天津医科大学2019年度医院管理创新研究项目(2019YG04)

Risk factors and remedial measures for failure of anal preservation caused by inadequate distal resection margin in laparoscopic surgery for low rectal cancer

Guanglin Wang, Miao Yu, Zesong Meng, Xuhua Hu, Feifei Wang, Baokun Li, Longfei Cao, Jun Feng, Juan Zhang, Guiying Wang†()   

  1. The Second Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang 050010, China
    School of Basic Medicine, Hebei Medical University, Shijiazhuang 050017, China
    The Second Department of Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang 050010, China; Department of Gastrointestinal Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
  • Received:2022-04-03 Published:2023-05-15
  • Corresponding author: Guiying Wang
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引用本文：

王光林, 于淼, 孟泽松, 胡旭华, 王飞飞, 李保坤, 曹龙飞, 冯鋆, 张娟, 王贵英. 腹腔镜低位直肠癌远端切缘不足导致保肛失败的危险因素分析及补救策略[J]. 中华临床医师杂志(电子版), 2023, 17(05): 529-534.

Guanglin Wang, Miao Yu, Zesong Meng, Xuhua Hu, Feifei Wang, Baokun Li, Longfei Cao, Jun Feng, Juan Zhang, Guiying Wang. Risk factors and remedial measures for failure of anal preservation caused by inadequate distal resection margin in laparoscopic surgery for low rectal cancer[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(05): 529-534.

目的

探讨腹腔镜低位直肠癌因远端切缘不足导致保肛失败的危险因素分析及其补救策略。

方法

回顾性分析河北医科大学第四医院外二科2017年10月至2019年6月诊断为低位直肠癌，术前分期为T1-4aN0-2M0，且行腹腔镜低位直肠癌保肛手术的患者203人。其中165人行腹腔镜低位直肠癌Dixon手术（Dixon组），38人因远端切缘（distal resection margin，DRM）＜1 cm导致保肛失败，再次行补救性肛门内括约肌切除术（salvage intersphincteric resection，sISR），保留患者肛门功能（sISR组）。应用卡方检验及多因素回归分析对患者性别，BMI，肿瘤距肛门距离，肿瘤大小，肿瘤中心位置，直肠系膜脂肪面积（mesorectal fat area，MFA）及坐骨结节间距离（intertubercle distance，IT）与DRM＜1 cm进行统计学分析，找出导致DRM＜1 cm危险因素；比较2组患者的住院时间，住院费用及并发症发生率；应用Wexner评分比较2组患者还纳后的肛门功能；比较2组患者术后2年的疾病转移率及复发率。

结果

患者BMI，MFA，IT，肿瘤距肛缘距离及肿瘤中心位置可能是导致DRM＜1 cm的危险因素，结果有统计学意义（P＜0.05）；2组相比，平均住院时间，平均住院费用及术后并发症发生率，均差异无统计学意义（P＞0.05）；还纳术后应用Wexner评分评估2组患者肛门功能，结果差异无统计学意义（P＞0.05）；观察2组患者2年疾病转移率及复发率，结果差异无统计学意义（P＞0.05）。

结论

低位直肠癌患者的BMI，IT，MFA，肿瘤距肛缘距离及肿瘤中心位置可能使腹腔镜低位直肠癌Dixon手术的DRM＜1 cm，而导致保肛失败。sISR可在再次保留患者的肛门功能，未增加住院时间、住院费用、术后并发症及患者术后2年的疾病复发率与转移率。

关键词: 低位直肠癌, 肛门内括约肌切除术, 肛门功能
Objective

To explore the risk factors and remedial measures for failure of anal preservation caused by inadequate distal resection margin in laparoscopic surgery for low rectal cancer.

Methods

A retrospective analysis was performed on 203 patients who were diagnosed as having low rectal cancer (preoperatively staged as T1-4aN0-2M0) at our center from October 2017 to June 2019 and underwent laparoscopic rectal cancer surgery. Among the patients included, 165 underwent laparoscopic Dixon surgery for low rectal cancer (Dixon group) and 38 underwent salvage intersphincteric anal sphincteric resection (sISR group) due to distal resection margin (DRM) <1 cm, which resulted in the failure of anus function preservation. Using the chi-square test and multivariate regression analysis, the association of gender, body mass index (BMI), tumor distance to the anus, tumor size, tumor center location, mesorectal fat area (MFA), and intertubercle distance (IT) with DRM＜1 cm was statistically analyzed to identify the risk factors for failure of anal preservation. Duration of hospitalization, hospitalization cost, and the incidence of complications were compared between the two groups. Wexner score was used to compare the anal function of the two groups after stoma closure. The metastasis rate and recurrence rate at 2 years after operation were compared between the two groups.

Results

BMI, IT, MFA, distance between tumor and anal margin, and location of tumor center were significantly associated with DRM＜1 cm (P＜0.05). There was no significant difference in average length of hospitalization, average hospitalization cost, or the incidence of postoperative complications between the two groups (P＜0.05). Wexner score was used to evaluate the anal function after stoma closure, and there was no statistical difference between the two groups (P＞0.05). There was no statistical difference in 2-year metastasis rate or recurrence rate between the two groups (χ2=0.772, P=0.084).

Conclusion

BMI, IT, MFA, tumor distance to anal margin, and tumor center location in low rectal cancer patients may lead to DRM＜1 cm resulting in the failure of anal preservation in laparoscopic Dixon surgery for low rectal cancer, and sISR can preserve the anal function of patients again, without increasing the average length of hospital stay, hospitalization costs, postoperative complications, and the disease 2-year recurrence rate and metastasis rate after surgery.

Key words: Low rectal cancer, Internal anal sphincterectomy, Anal function
表1 影响腹腔镜低位直肠癌Dixon术DRM＜1 cm的单因素分析
相关因素 DRM＜1 cm DRM≥1 cm χ2值 P值
性别 3.23 0.07
男性 22 69
女性 16 96
BMI（kg/m2） 5.05 0.03
≥28 31 103
＜28 7 62
肿瘤大小（cm） 1.51 0.22
≥4 21 73
＜4 17 92
IT（cm） 5.74 0.02
＜10.1 25 73
≥10.1 13 92
MFA（cm2） 6.35 6.35
＞20.7 29 89
≤20.7 9 76
肿瘤距肛缘距离（cm） 16.33 ＜0.01
≥4 24 47
＞4 14 118
肿瘤中心位置 5.06 0.03
前壁 27 84
后壁 11 81
表2 腹腔镜低位直肠癌Dixon术DRM＜1 cm的多因素Logistic分析结果
危险因素 分类 β值 SE值 Wald χ2 P值 OR值
BMI（kg/m2） ＜28或≥28 1.23 0.50 4.81 0.01 5.83
IT（cm） ＜10.1或≥10.1 1.51 0.52 4.011 0.03 4.81
MFA（cm2） ≤20.7或＞20.7 1.87 0.54 16.18 0.02 22.53
肿瘤距肛缘距离（cm） ≤4或＞4 1.45 0.45 6.73 0.01 19.14
肿瘤中心位置 前壁/后壁 1.19 0.58 1.93 0.04 2.76
表3 2组患者术后2年疾病复发率与转移率比较
sISR手术组 Dixon手术组 χ2值 P值
远处转移（例） 3/37 14/160 0.02 0.90
局部复发（例） 0/37 1/160 0.42 0.52
1
Saito N, Ito M, Kobayashi A, et al. Long-term outcomes after inter-sphincteric resection for low-lying rectal cancer [J]. Ann Surg Oncol, 2014, 21(11): 3608-3615.
2
Wilkinson N. Management of Rectal Cancer [J]. Surg Clin North Am, 2020, 100(3): 615-628.
3
Shirouzu K, Murakami N, Akagi Y. Intersphincteric resection for very low rectal cancer: a review of the updated literature [J]. Ann Gastroenterol Surg, 2017, 1(1): 24-32.
4
Xv Y, Fan J, Ding Y, et al. Latest advances in Intersphincteric resection for low rectal cancer [J]. Gastroenterol Res Pract, 2020, 2020: 8928109.
5
Essangri H, Majbar MA, Benkabbou A, et al. Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery [J]. Surgery, 2021, 170(1): 47-52.
6
Yamamoto T, Kawada K, Kiyasu Y, et al. Prediction of surgical difficulty in minimally invasive surgery for rectal cancer by use of MRI pelvimetry [J]. BJS Open, 2020, 4(4): 666-677.
7
Escal L, Nougaret S, Guiu B, et al. MRI-based score to predict surgical difficulty in patients with rectal cancer [J]. Br J Surg, 2018, 105(1): 140-146.
8
Hong JS, Brown KGM, Waller J, et al. The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review [J]. Tech Coloproctol, 2020, 24(10): 991-1000.
9
汤坚强, 陈贺凯, 刘军广, 等. 经闭孔神经前入路腹腔镜下低位直肠离断技术的安全性及有效性 [J]. 中华胃肠外科杂志, 2022, 25(1): 8.
10
Butiurca VO, Molnar C, Copotoiu C, et al. Long term results of modified Intersphincteric resections for low rectal cancer: a single center experience [J]. Medicina (Kaunas), 2019, 55(12): 764.
11
Park IJ, Kim JC. Intersphincteric resection for patients with low-lying rectal cancer: oncological and functional outcomes [J]. Ann Coloproctol, 2018, 34(4): 167-174.
12
Molnar C, Nicolescu C, Grigorescu BL, et al. Comparative oncological outcomes and survival following surgery for low rectal cancer-a single center experience [J]. Rom J Morphol Embryol, 2019, 60(3): 847-852.
13
Collard M, Lefevre JH. Ultimate functional preservation with Intersphincteric resection for rectal cancer [J]. Front Oncol, 2020, 5(10): 297.
14
Li J, An Y, Wu G, et al. Incidence and risk factors for anastomotic leakage after anterior resection for rectal cancer [J]. Zhonghua Wei Chang Wai Ke Za Zhi, 2018, 21(4): 413-418.
15
Cheng S, He B, Zeng X, et al. Prediction of anastomotic leakage after anterior rectal resection [J]. Pak J Med Sci, 2019, 35(3): 830-835.
16
Kuo LJ, Ngu JC, Huang YJ, et al. Anorectal complications after robotic intersphincteric resection for low rectal cancer [J]. Surg Endosc, 2017, 31(11): 4466-4471.
17
Shiokawa H, Funahashi K, Kaneko H, et al. Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus [J]. J Anus Rectum Colon, 2018, 1(1): 29-34.
18
Beppu N, Fumihiko K, Hiroshi D, et al. Functional outcomes of patients treated with intensive medications for bowel and pain control for low-lying rectal cancer who received preoperative chemoradiotherapy [J]. Dig Surg, 2016, 33(5): 431-438.
19
Biviano I, Balla A, Badiali D, et al. Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer [J]. Colorectal Dis, 2017, 19(6): 177-185.
20
Grupa VEM, Kroon HM, Ozmen I, et al. Current practice in Australia and New Zealand for defunctioning ileostomy after rectal cancer surgery with anastomosis: analysis of the binational colorectal cancer audit [J]. Colorectal Dis, 2021, 23(6): 1421-1433.
21
Gadan S, Brand JS, Rutegård M, et al. Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer-a nationwide register-based cohort study [J]. Int J Colorectal Dis, 2021, 36(7): 1433-1442.
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