Dušek T, Ferko A, Orhalmi J, Chobola M, Nikolov D H, Hovorková E, Cermáková E
Chirurgicka klinika Fakultni nemocnice Hradec Kralove a Lekarske Fakulty UK v Hradci Kralove.
Rozhl Chir. 2013 Jun;92(6):312-9.
The issue of achieving radical circumferential margin in laparoscopic rectal surgery has not yet been satisfactorily clarified. In this paper we have focused on circumferential margin assessment and the quality of the mesorectal excision, comparing laparoscopic and open resection for cancer of the middle and lower rectum.
The results of surgical procedures for middle and low rectal cancer were analysed. All the interventions were performed at the Department of Surgery, Teaching Hospital in Hradec Kralove, during the period from January 2011 to December 2012. The data were prospectively collected and entered in the Rectal Cancer Registry. Age, gender, BMI, tumour localisation and topography, the clinical stage, preoperative chemoradiotherapy and response to it, the type of surgery, distal and circumferential margin characteristics, mesorectal excision quality, pT and pN were compared for laparoscopic and open surgery.
A total of 161 patients were operated on for rectal cancer during the abovementioned period. 94 patients were included in the trial following selection. Laparoscopy was used in 40 patients and open surgery in 54 patients. Laparoscopic approach was performed in 33 (82.5%) low anterior resections (including four intersphincteric resections), 6 (15%) abdominoperineal amputations and 1 (2.5%) Hartmanns procedure. Open surgery was used for 26 (48.1%) low anterior resections, 21 (38.9%) APR and 7 (13%) Hartmanns procedures. Complete mesorectal excision was achieved in 45% of the laparoscopic resections vs. 46.3% of open resections. Nearly complete excision was performed in 22.5% and 11.1%, respectively. Finally, incomplete excision was described in 30% vs. 38.9%. No available data for TME was detected in three patients. The differences in TME were not statistically significant. Positive circumferential margin was found in 5 (12.5%) patients in the laparoscopy group; on the contrary, in the group undergoing open surgery, pCRO+ was found in 15 (27.8%) patients. Here, too, the results were not statistically significant. When patients without preoperative chemoradiotherapy were excluded, the relationship between ypCRM in the laparoscopy and open surgery group was on the border of statistical significance (Fischer=0.0556).
As has been shown in our trial, the outcomes of laparoscopic and open approach in rectal cancer treatment are very similar. Particularly, mesorectal excision quality and negative CRM results have proven that the laparoscopic technique is safe and comparable to open surgery in rectal cancer treatment.
腹腔镜直肠手术中实现根治性环周切缘的问题尚未得到令人满意的阐明。在本文中，我们聚焦于环周切缘评估和直肠系膜切除的质量，比较腹腔镜与开放手术治疗中低位直肠癌的情况。
分析中低位直肠癌手术的结果。所有干预措施均于2011年1月至2012年12月期间在赫拉德茨克拉洛韦教学医院外科进行。数据前瞻性收集并录入直肠癌登记册。比较腹腔镜手术和开放手术患者的年龄、性别、体重指数、肿瘤定位和形态、临床分期、术前放化疗及其反应、手术类型、远端和环周切缘特征、直肠系膜切除质量、pT和pN。
在上述期间，共有161例患者接受了直肠癌手术。经筛选，94例患者纳入试验。40例患者采用腹腔镜手术，54例患者采用开放手术。腹腔镜手术用于33例（82.5%）低位前切除术（包括4例括约肌间切除术）、6例（15%）腹会阴联合切除术和1例（2.5%）哈特曼手术。开放手术用于26例（48.1%）低位前切除术、21例（38.9%）腹会阴联合切除术和7例（13%）哈特曼手术。45%的腹腔镜切除术和46.3%的开放切除术实现了完整的直肠系膜切除。分别有22.5%和11.1%的手术实现了近乎完整的切除。最后，30%的腹腔镜手术和38.9%的开放手术存在切除不完整的情况。3例患者未获得直肠系膜切除的可用数据。直肠系膜切除的差异无统计学意义。腹腔镜组5例（12.5%）患者发现环周切缘阳性；相反，开放手术组15例（27.8%）患者发现环周切缘阳性。此处结果也无统计学意义。排除未接受术前放化疗的患者后，腹腔镜手术组和开放手术组ypCRM之间的关系接近统计学意义临界值（Fischer=0.0556）。
如我们的试验所示，腹腔镜和开放手术治疗直肠癌的结果非常相似。特别是，直肠系膜切除质量和阴性环周切缘结果证明，腹腔镜技术在直肠癌治疗中是安全的，且与开放手术相当。
