Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
Surg Endosc. 2019 Feb;33(2):557-566. doi: 10.1007/s00464-018-6331-9. Epub 2018 Jul 13.
Various predictors of the difficulty of total mesorectal excision for rectal cancer have been described. Although a bulky mesorectum was considered to pose technical difficulties in total mesorectal excision, no studies have evaluated the influence of mesorectum morphology on the difficulty of total mesorectal excision. Mesorectal fat area at the level of the tip of the ischial spines on magnetic resonance imaging was described as a parameter characterizing mesorectum morphology. This study aimed to evaluate the influence of clinical and anatomical factors, including mesorectal fat area, on the difficulty of total mesorectal excision for rectal cancer.
This study enrolled 98 patients who underwent robotic-assisted laparoscopic low anterior resection with total mesorectal excision for primary rectal cancer, performed by a single expert surgeon, between 2010 and 2015. Magnetic resonance imaging-based pelvimetry data were collected. Linear regression was performed to determine clinical and anatomical factors significantly associated with operative time of the pelvic phase, which was defined as the time interval from the start of rectal mobilization to the division of the rectum.
The median operative time of the pelvic phase was 68 min (range 33-178 min). On univariate analysis, the following variables were significantly associated with longer operative time of the pelvic phase: male sex, larger tumor size, larger visceral fat area, larger mesorectal fat area, shorter pelvic outlet length, longer sacral length, shorter interspinous distance, larger pelvic inlet angle, and smaller angle between the lines connecting the coccyx to S3 and to the inferior middle aspect of the pubic symphysis. On multiple linear regression analysis, only larger mesorectal fat area remained significantly associated with longer operative time of the pelvic phase (p = 0.009).
Mesorectal fat area may serve as a useful predictor of the difficulty of total mesorectal excision for rectal cancer.
已经描述了各种预测直肠癌全直肠系膜切除难度的指标。虽然认为大块状的直肠系膜在全直肠系膜切除中存在技术难度，但尚无研究评估直肠系膜形态对全直肠系膜切除难度的影响。磁共振成像上坐骨棘尖端水平的直肠系膜脂肪面积被描述为一个描述直肠系膜形态的参数。本研究旨在评估临床和解剖因素（包括直肠系膜脂肪面积）对直肠癌全直肠系膜切除难度的影响。
本研究纳入了 2010 年至 2015 年间由一位专家外科医生进行的 98 例接受机器人辅助腹腔镜低位前切除术和全直肠系膜切除的原发性直肠癌患者。收集了基于磁共振成像的骨盆测量数据。进行线性回归分析，以确定与盆腔阶段手术时间显著相关的临床和解剖因素，盆腔阶段手术时间定义为直肠游离开始到直肠分离的时间间隔。
盆腔阶段的中位手术时间为 68 分钟（范围 33-178 分钟）。在单变量分析中，以下变量与盆腔阶段手术时间较长显著相关：男性、更大的肿瘤大小、更大的内脏脂肪面积、更大的直肠系膜脂肪面积、更短的骨盆出口长度、更长的骶骨长度、更短的棘突间距离、更大的骨盆入口角度以及连接尾骨到 S3 和耻骨联合中下部分的线之间的角度更小。在多元线性回归分析中，只有更大的直肠系膜脂肪面积与盆腔阶段手术时间较长显著相关（p=0.009）。
直肠系膜脂肪面积可能是预测直肠癌全直肠系膜切除难度的有用指标。
