经肛门全直肠系膜切除（cTaTME）治疗直肠癌的短期疗效：病例匹配分析。
Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis.
机构信息
Department of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
, Postbus 7075, 1007 MB, Amsterdam, The Netherlands.
出版信息
Surg Endosc. 2019 Jan;33(1):103-109. doi: 10.1007/s00464-018-6280-3. Epub 2018 Jul 2.
BACKGROUND
Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME).
METHODS
All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated.
RESULTS
In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME.
CONCLUSION
TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.
背景
局部切除早期直肠肿瘤作为一种保留直肠的治疗方法越来越受欢迎，尤其是由于肠癌筛查计划导致早期直肠肿瘤的诊断比例上升。然而，“大活检”中预测复发风险高的不利组织学特征可能需要完成全直肠系膜切除术（cTME）。与原发性 TME 相比，完成手术与更高的发病率、较差的标本质量和不太有利的肿瘤学结果相关。经肛门入路可能会改善直肠癌完成手术的结果。本研究的目的是比较经肛门（cTaTME）与传统腹部入路（cTME）对局部切除后的直肠癌根治性完成手术。
方法
对 2012 年至 2017 年间接受 cTaTME 治疗的所有连续直肠癌患者进行病例匹配，根据性别、肿瘤高度、术前放疗和肿瘤分期与 cTME 患者匹配。评估手术、病理和短期术后结果。
结果
共 25 例患者接受了 TaTME 完成手术，并与 25 例 cTME 后患者进行了匹配。两组患者从局部切除到完成手术的中位时间均为 9 周。在 cTaTME 和 cTME 组中，直肠穿孔分别发生在 4%和 28%的患者中（p = 0.049），导致这些患者的标本质量较差。cTaTME 组的淋巴结采集数量（中位数 15；范围 7-47）高于 cTME 组（中位数 10；范围 0-17）。两组间末端结肠造口率无显著差异。主要 30 天发病率（Clavien-Dindo≥III）分别为 20%和 32%（p = 0.321）。cTME 后住院时间明显延长。
结论
全层切除后的 TaTME 是一种很有前途的技术，与传统的完成 TME 相比，直肠穿孔的风险显著降低，标本质量更好。
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