Rasulov A O, Dzhumabaev Kh E, Kozlov N A, Suraeva Yu E, Mamedli Z Z, Kulushev V M, Gordeev S S, Kuzmichev D V, Polynovsky A V
Blokhin National Medical Cancer Research Center of Healthcare Ministry of Russia, Moscow, Russia.
Khirurgiia (Mosk). 2018(6):4-21. doi: 10.17116/hirurgia201864-21.
To compare short-term outcomes after transanal total mesorectumectomy (Ta-TME) and laparoscopic (Lap-TME) procedure in 'difficult' patients.
Prospective nonrandomized trial included patients with confirmed middle-/low rectum adenocarcinoma T1-4aN0-2M0 for the period November 2013 - September 2016. We identified 20 out of 55 in TA-TME and 14 out of 54 patients in Lap-TME group as those of 'difficult' subgroup: male, BMI ≥25 кг/м, previous chemoradiotherapy (CRT).
Time of surgery, blood loss, conversions rate, postoperative morbidity and length of hospital-stay were similar in both groups. Hardware anastomoses were more frequent in TA-TME compared with LAP-TME group (78.9% vs. 50%, p=0.086). Specimen quality was more favorable in TA-TME group: Grade I 10% in Ta-TME group vs. 28.6% in Lap-TME group; 'positive' CRM 5% vs. 14.3%, р=0.365. Within-group analysis did not reveal any differences between 'difficult' and 'typical' patients by surgical and pathomorphological characteristics in TA-TME group in contrast to Lap-TME group. Median of follow-up was 24.6 (IR 10.6-40.2) and 23.8 (IR 12.1-39.9) months for TA-TME and Lap-TME groups, respectively. Local recurrence occurred in 1 (1.8%) 'difficult' patient after Ta-TME. Distant metastases were observed in 1 (1.8%) patient of Ta-TME and 2 (3.7%) patients of Lap-TME group. Actuarial 3-years reccurence-free survival was 95.7% for Ta-TME and 93.9% for Lap-TME group, respectively (p=0.923).
TA-TME is advisable for 'difficult' patients. Further multicenter randomized trials are necessary to specify the effectiveness of TA-TME in these patients.
比较经肛门全直肠系膜切除术（Ta-TME）与腹腔镜全直肠系膜切除术（Lap-TME）在“困难”患者中的短期疗效。
前瞻性非随机试验纳入了2013年11月至2016年9月期间确诊为中/低位直肠腺癌T1-4aN0-2M0的患者。我们将Ta-TME组55例患者中的20例和Lap-TME组54例患者中的14例确定为“困难”亚组：男性，BMI≥25kg/m²，既往接受过放化疗（CRT）。
两组的手术时间、失血量、中转率、术后发病率和住院时间相似。与LAP-TME组相比，Ta-TME组器械吻合更为频繁（78.9%对50%，p=0.086）。Ta-TME组标本质量更优：Ta-TME组I级为10%，Lap-TME组为28.6%；CRM“阳性”分别为5%和14.3%，p=0.365。与Lap-TME组不同，Ta-TME组的组内分析未显示“困难”患者与“典型”患者在手术和病理形态学特征上存在任何差异。Ta-TME组和Lap-TME组的中位随访时间分别为24.6（四分位间距10.6-40.2）个月和23.8（四分位间距12.1-39.9）个月。Ta-TME术后1例（1.8%）“困难”患者出现局部复发。Ta-TME组1例（1.8%）患者和Lap-TME组2例（3.7%）患者出现远处转移。Ta-TME组和Lap-TME组的3年无复发生存率分别为95.7%和93.9%（p=0.923）。
对于“困难”患者，建议采用Ta-TME。有必要进行进一步的多中心随机试验以明确Ta-TME在这些患者中的有效性。
