Weiser Martin R, Quah Hak-Mien, Shia Jinru, Guillem José G, Paty Philip B, Temple Larissa K, Goodman Karyn A, Minsky Bruce D, Wong W Douglas
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Ann Surg. 2009 Feb;249(2):236-42. doi: 10.1097/SLA.0b013e318195e17c.
The aim of this study was to evaluate oncologic outcome in patients with locally advanced distal rectal cancer treated with preoperative chemoradiation followed by low anterior resection (LAR)/stapled coloanal anastomosis, LAR/intersphincteric dissection/hand-sewn coloanal anastomosis, or abdominoperineal resection (APR).
Distal rectal cancer presents a surgical challenge, and the goals of treatment often include tumor eradication without sacrifice of the anal sphincters. The technique of intersphincteric resection removes the internal anal sphincter to gain additional distal rectal margin in hopes of avoiding a permanent stoma.
We analyzed 148 patients with stage II and III rectal cancers (endorectal ultrasound staged uT3-4 and/or uN1) located < or =6 cm from the anal verge, treated by preoperative chemoradiation and total mesorectal excision from 1998 to 2004. Eighty-five patients (57%) had sphincter-preserving resection (41, LAR/stapled coloanal anastomosis; 44, LAR/intersphincteric resection/hand-sewn coloanal anastomosis); 63 patients had APR.
Patients undergoing APR were older, with more poorly differentiated tumors evidencing less response to chemoradiation and more likely to require extended resection. Complete resection with negative histologic margins was achieved in 92%; circumferential margins were positive in 2 (5%) of 44 in the intersphincteric resection group and 8 (13%) of 63 in the APR group. Distal margins were positive in 2 (5%) of 44 in the intersphincteric resection group. With median follow-up of 47 months, there were a total of 7 local recurrences (5%): 1, 0, and 6 in the stapled anastomosis, intersphincteric resection, and APR groups, respectively. Estimated 5-year recurrence-free survival for the stapled anastomosis, intersphincteric resection, and APR groups were 85%, 83%, and 47% respectively (P = 0.001).
In low rectal cancer, sphincter preservation is facilitated by a significant response to preoperative chemoradiation and intersphincteric resection, without compromise of margins or outcome. In those who have a less favorable response, abdominoperineal resection is more likely to be required and is associated with poorer outcome.
本研究旨在评估术前接受放化疗后行低位前切除术（LAR）/吻合器结肠肛管吻合术、LAR/括约肌间切除术/手工缝合结肠肛管吻合术或腹会阴联合切除术（APR）的局部晚期低位直肠癌患者的肿瘤学结局。
低位直肠癌带来了手术挑战，治疗目标通常包括根除肿瘤且不牺牲肛门括约肌。括约肌间切除术通过切除肛门内括约肌来获得更多的直肠远端切缘，以期避免永久性造口。
我们分析了1998年至2004年间148例距肛缘≤6 cm的II期和III期直肠癌患者（直肠内超声分期为uT3 - 4和/或uN1），这些患者接受了术前放化疗及全直肠系膜切除术。85例患者（57%）接受了保留括约肌的切除术（41例行LAR/吻合器结肠肛管吻合术；44例行LAR/括约肌间切除术/手工缝合结肠肛管吻合术）；63例患者接受了APR。
接受APR的患者年龄较大，肿瘤分化程度较差，对放化疗反应较小，且更可能需要扩大切除范围。92%的患者实现了组织学切缘阴性的完整切除；括约肌间切除组44例中有2例（5%）环周切缘阳性，APR组63例中有8例（13%）环周切缘阳性。括约肌间切除组44例中有2例（5%）远端切缘阳性。中位随访47个月，共有7例局部复发（5%）：吻合器吻合术组、括约肌间切除组和APR组分别为1例、0例和6例。吻合器吻合术组、括约肌间切除组和APR组的估计5年无复发生存率分别为85%、83%和47%（P = 0.001）。
在低位直肠癌中，术前放化疗和括约肌间切除术对保留括约肌有显著帮助，且不影响切缘或预后。对于那些反应欠佳的患者，更可能需要行腹会阴联合切除术，且预后较差。
