Okamura Ryosuke, Hida Koya, Yamaguchi Tomohiro, Akagi Tomonori, Konishi Tsuyoshi, Yamamoto Michio, Ota Mitsuyoshi, Matoba Shuichiro, Bando Hiroyuki, Goto Saori, Sakai Yoshiharu, Watanabe Masahiko, Watanabe Kazuteru, Otsuka Koki, Takemasa Ichiro, Tanaka Keitaro, Ikeda Masataka, Matsuda Chu, Fukuda Meiki, Hasegawa Junichi, Akamoto Shintaro, Shiozawa Manabu, Tsuruta Atsushi, Akiyoshi Takashi, Kato Takeshi, Tsukamoto Shunsuke, Ito Masaaki, Naito Masaki, Kanazawa Akiyoshi, Takahashi Takao, Ueki Takashi, Hayashi Yuri, Morita Satoshi, Yamaguchi Takashi, Nakanishi Masayoshi, Hasegawa Hirotoshi, Okamoto Ken, Teraishi Fuminori, Sumi Yasuo, Tashiro Jo, Yatsuoka Toshimasa, Nishimura Yoji, Okita Kenji, Kobatake Takaya, Horie Hisanaga, Miyakura Yasuyuki, Ro Hisashi, Nagakari Kunihiko, Hidaka Eiji, Umemoto Takehiro, Nishigori Hideaki, Murata Kohei, Wakayama Fuminori, Makizumi Ryoji, Fujii Shoichi, Sunami Eiji, Kobayashi Hirotoshi, Nakagawa Ryosuke, Enomoto Toshiyuki, Ohnuma Shinobu, Higashijima Jun, Ozawa Heita, Ashida Keigo, Fujita Fumihiko, Uehara Keisuke, Maruyama Satoshi, Ohyama Masato, Yamamoto Seiichiro, Hinoi Takao, Yoshimitsu Masanori, Okajima Masazumi, Tanimura Shu, Kawasaki Masayasu, Ide Yoshihito, Hazama Shoichi, Watanabe Jun, Inagaki Daisuke, Toyokawa Akihiro
Department of Surgery Kyoto University Kyoto Japan.
Division of Colon and Rectal Surgery Shizuoka Cancer Center Hospital Shizuoka Japan.
Ann Gastroenterol Surg. 2017 Aug 14;1(3):199-207. doi: 10.1002/ags3.12032. eCollection 2017 Sep.
Sphincter-preserving procedures (SPPs) for surgical treatment of low-lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II-III rectal cancer between 2010 and 2011. Patients with tumors 2-5 cm from the anal verge and clinical stage T3-4 were eligible. Primary outcome was 3-year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77-1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3-year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42-1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.
低位直肠癌手术治疗中的保肛手术（SPPs）已经取得了显著进展。然而，与腹会阴联合切除术（APR）相比，其对局部进展期低位直肠癌的肿瘤学安全性仍存在争议。我们回顾性分析了2010年至2011年间1500例连续接受择期II-III期直肠癌切除术患者的队列数据。距肛缘2-5 cm且临床分期为T3-4的肿瘤患者符合条件。主要结局是3年局部复发率，并通过倾向评分匹配将混杂效应降至最低。该研究纳入了794例患者（456例保肛手术和338例腹会阴联合切除术）。匹配前，接受腹会阴联合切除术的患者更可能患有低位和进展期病变，而保肛手术更多在术前治疗后、通过腹腔镜手术以及在病例数量较多的机构进行。匹配后，398例患者（保肛手术和腹会阴联合切除术各199例）被纳入分析样本。保肛手术组和腹会阴联合切除组的术后发病率相似（38%对39%；相对危险度0.98，95%置信区间0.77-1.27）。保肛手术组有8例患者切缘阳性（分别为远端切缘1例和径向切缘7例），腹会阴联合切除组有12例患者切缘阳性。两组的3年局部复发率无差异（11%对14%；风险比0.77，95%置信区间0.42-1.41）。在这项观察性研究中，通过调整可能的混杂因素确保了可比性。我们的结果表明，局部进展期低位直肠癌的保肛手术和腹会阴联合切除术在肿瘤学局部控制方面具有明显相当的效果。
