局部晚期低位直肠癌经肛提肌外腹会阴联合切除术的前瞻性多中心临床研究

A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer.

作者信息

Han Jia Gang, Wang Zhen Jun, Qian Qun, Dai Yong, Zhang Zhi Quan, Yang Jin Shan, Li Fei, Li Xiao Bin

机构信息

1Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China 2Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China 3Department of General Surgery, Qilu Hospital of Shandong University, Shandong, People's Republic of China 4Department of General Surgery, the First Hospital of Huairou District, Beijing, People's Republic of China 5Department of General Surgery, the People's Hospital of Daxing District, Beijing, People's Republic of China 6Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China 7Department of General Surgery, Luhe Teaching Hospital, Capital Medical University, Beijing, People's Republic of China.

出版信息

Dis Colon Rectum. 2014 Dec;57(12):1333-40. doi: 10.1097/DCR.0000000000000235.

DOI:10.1097/DCR.0000000000000235

PMID:25379997

Abstract

BACKGROUND

Recent studies have shown that extralevator abdominoperineal resection has the potential for reduced circumferential resection margin involvement, intraoperative bowl perforation, and local recurrence rates; however, it has been suggested that extended resection may be associated with increased morbidity because of the formation of a larger perineal defect.

OBJECTIVE

This study was undertaken to demonstrate the feasibility and complications of extralevator abdominoperineal resection for locally advanced low rectal cancer in China.

DESIGN

This was a prospective cohort study.

SETTING

The study was conducted at 7 university hospitals throughout China.

PATIENTS

A total of 102 patients underwent this procedure for primary locally advanced low rectal cancer between August 2008 and October 2011.

MAIN OUTCOME MEASURES

The main outcome measures comprised circumferential resection margin involvement, intraoperative perforation, postoperative complications, and local recurrence.

RESULTS

The most common complications included sexual dysfunction (40.5%), perineal complications (23.5%), urinary retention (18.6%), and chronic perineal pain (13.7%). Chronic perineal pain was associated with coccygectomy (p < 0.001), and the pain gradually eased over time. Reconstruction of the pelvic floor with biological mesh was associated with a lower rate of perineal dehiscence (p = 0.006) and overall perineal wound complications (p = 0.02) in comparison with primary closure. A positive circumferential margin was demonstrated in 6 (5.9%) patients, and intraoperative perforations occurred in 4 (3.9%) patients. All circumferential margin involvements and intraoperative perforations were located anteriorly. The local recurrence was 4.9% at a median follow-up of 44 months (range, 18-68 months).

LIMITATIONS

This was a nonrandomized, uncontrolled study.

CONCLUSIONS

Extralevator abdominoperineal resection performed in the prone position for low rectal cancer is a relatively safe approach with acceptable circumferential resection margin involvement, intraoperative perforations, and local recurrences. Reconstruction of the pelvic floor with biological mesh might lower the rate of perineal wound complications (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A161).

摘要

背景

近期研究表明，经肛提肌外腹会阴联合切除术有可能降低环周切缘受累、术中肠穿孔及局部复发率；然而，有人提出扩大切除术可能因形成更大的会阴缺损而导致发病率增加。

目的

本研究旨在证明经肛提肌外腹会阴联合切除术治疗中国局部进展期低位直肠癌的可行性及并发症。

设计

这是一项前瞻性队列研究。

地点

该研究在中国7所大学医院进行。

患者

2008年8月至2011年10月期间，共有102例患者因原发性局部进展期低位直肠癌接受了该手术。

主要观察指标

主要观察指标包括环周切缘受累、术中穿孔、术后并发症及局部复发。

结果

最常见的并发症包括性功能障碍（40.5%）、会阴并发症（23.5%）、尿潴留（18.6%）及慢性会阴疼痛（）。慢性会阴疼痛与尾骨切除术相关（p<0.001），且疼痛随时间逐渐缓解。与一期缝合相比，使用生物补片重建盆底可降低会阴裂开率（p=0.006）及总体会阴伤口并发症发生率（p=0.02）。6例（5.9%）患者环周切缘阳性，4例（3.9%）患者术中发生穿孔。所有环周切缘受累及术中穿孔均位于前方。中位随访44个月（范围18 - 68个月）时，局部复发率为4.9%。