2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 Street, 31-501, Kraków, Poland.
Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland.
World J Surg Oncol. 2018 Nov 7;16(1):218. doi: 10.1186/s12957-018-1513-4.
Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.
Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.
Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.
Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.
The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).
尽管在结直肠癌治疗方面取得了进展，但对于毗邻肛门括约肌的肿瘤，仍然没有最佳的治疗策略。本研究旨在评估毗邻肛门括约肌的不利位置的直肠癌手术的肿瘤学和功能结果。
本研究纳入了初始侵犯肛门括约肌或位于肛门括约肌附近的直肠癌患者。患者接受了经腹会阴联合切除术（APR）、经括约肌间切除术或经肛门全直肠系膜切除术（TaTME）。主要研究终点为围手术期数据：手术时间、失血量、并发症、住院时间（LOS）和 30 天死亡率。次要研究终点为功能结局，即肛门控便功能障碍造口还纳术后 6 个月的肛门功能。
在毗邻肛门括约肌的癌症患者中，13 例（25%）接受了 APR，14 例（27%）接受了经括约肌间切除术，25 例（48%）接受了 TaTME 治疗。APR 的手术时间为 240（210-270 IQR），经括约肌间切除术为 212.5（170-260 IQR），TaTME 为 270（240-330 IQR）（p=0.018）。APR 的围手术期发病率为 31%，经括约肌间切除术为 36%，TaTME 组为 12%（p=0.181）。TaTME 组标本中 92%达到了完整直肠系膜切除，经括约肌间切除术为 93%，APR 组为 78%（p=0.72）。APR 中环形切缘的中位数为 6mm（4-7 IQR），经括约肌间切除术为 7.5mm（2.5-10 IQR），TaTME 组为 4mm（2.8-8 IQR）。所有接受经括约肌间切除术的患者均出现了严重的低位前切除综合征（LARS）。TaTME 组有 4 例出现轻度 LARS，21 例出现重度 LARS。
保肛直肠切除术是一种可行的替代 APR 的方法，具有良好的临床、病理和肿瘤学结果。经括约肌间切除术和 TaTME 在临床病理结果方面似乎相当。肛门功能结果还有待进一步研究。
本研究在泰国临床试验注册中心（2018 年 7 月 23 日，注册号 TCTR20180724001）进行了回顾性注册。
