Department of Colorectal Surgery, Cleveland Clinic Blvd, 2950, Weston, Fl 33331, USA.
Surg Endosc. 2010 Apr;24(4):933-8. doi: 10.1007/s00464-009-0702-1. Epub 2009 Oct 23.
To investigate the feasibility of laparoscopic total mesorectal excision (TME) in mid and lower rectal cancers following neoadjuvant chemoradiation (nCRT).
The laparoscopic approach for colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases following nCRT.
All patients with rectal cancer who underwent nCRT were identified; no operations for rectal carcinoma were performed laparoscopically between 1997 and 2005. The laparoscopic cases were matched to open cases based on gender, procedure, age, and body mass index (BMI). The medical records were reviewed and short-term outcome was compared between these two groups. Statistical analysis was performed using SPSS 15 software.
Between 2002 and 2008, 64 patients were identified, including 32 patients who underwent laparoscopic surgery and 32 who had a laparotomy. There was no difference between the two groups based on gender, procedure, age, BMI or American Society of Anesthesiologists (ASA) classification. The procedures performed within each group included 8 abdominoperineal resections and 24 anterior resections, which included 20 colonic J-pouch-anal anastomoses and 4 straight coloanal anastomoses. In the laparoscopic group, 12 patients underwent totally laparoscopic operations, 12 were either laparoscopic-assisted or hand-assisted procedures, and 8 were converted to laparotomy. The reasons for conversion included bleeding, splenic injury, and difficult anatomy. There were no differences in comorbidities, tumor location, tumor size, tumor stage or radiation dose between the two groups. Operative time was longer in the laparoscopic group (267 + or - 76 versus 205 + or - 49 min, p < 0.001). Operative blood loss, complication rate, and mortality rate were all similar between the two groups. However, the laparoscopic group benefited from shorter length of stay (6.1 + or - 2.4 versus 7.6 + or - 2.3 days, p = 0.012), earlier first bowel movement (1.9 + or - 1 versus 3.3 + or - 2.4 days, p = 0.006), and shorter time to regular diet (3.9 + or - 2.1 versus 5.8 + or - 2.5 days, p = 0.003). There was no difference in lymph node harvest (both positive node harvest and total lymph node harvest), distal margin or radial margin.
In our experience, laparoscopic TME for mid and lower rectal cancer is feasible and safe. Patients benefit from the short-term advantages of laparoscopy, including shorter length of hospital stay, time to tolerating a regular diet, and time to first bowel movement or stoma function. Although there were no short-term differences in oncologic parameters, the long-term oncologic outcome requires further investigation.
探讨新辅助放化疗（nCRT）后中低位直肠癌行腹腔镜全直肠系膜切除术（TME）的可行性。
腹腔镜治疗结肠癌已被广泛接受。一些研究表明，腹腔镜 TME 手术治疗直肠癌有优势。然而，腹腔镜在 nCRT 后病例中的作用尚未明确界定。
所有接受 nCRT 的直肠癌患者均被识别；1997 年至 2005 年间，没有进行腹腔镜直肠癌手术。根据性别、手术方式、年龄和体重指数（BMI），将腹腔镜病例与开放病例相匹配。回顾病历并比较两组的短期结果。使用 SPSS 15 软件进行统计分析。
2002 年至 2008 年间，共识别出 64 例患者，其中 32 例行腹腔镜手术，32 例行剖腹手术。两组在性别、手术方式、年龄、BMI 或美国麻醉医师协会（ASA）分级方面无差异。每组进行的手术包括 8 例腹会阴联合切除术和 24 例前切除术，其中包括 20 例结肠 J 袋-肛门吻合术和 4 例直结肠吻合术。在腹腔镜组中，12 例患者行全腹腔镜手术，12 例为腹腔镜辅助或手助手术，8 例转为剖腹手术。中转的原因包括出血、脾损伤和解剖困难。两组间合并症、肿瘤位置、肿瘤大小、肿瘤分期或放疗剂量无差异。腹腔镜组的手术时间较长（267 +或-76 分钟与 205 +或-49 分钟，p<0.001）。两组的手术出血量、并发症发生率和死亡率相似。然而，腹腔镜组受益于较短的住院时间（6.1 +或-2.4 天与 7.6 +或-2.3 天，p=0.012）、较早的首次排便（1.9 +或-1 天与 3.3 +或-2.4 天，p=0.006）和较短的常规饮食时间（3.9 +或-2.1 天与 5.8 +或-2.5 天，p=0.003）。两组间淋巴结清扫（阳性淋巴结清扫和总淋巴结清扫）、远端切缘和环周切缘无差异。
根据我们的经验，中低位直肠癌的腹腔镜 TME 是可行且安全的。患者受益于腹腔镜的短期优势，包括较短的住院时间、耐受常规饮食的时间、首次排便或造口功能的时间。虽然在肿瘤学参数方面没有短期差异，但长期肿瘤学结果需要进一步研究。
