中低位直肠肿瘤全系膜切除不吻合术：低 Hartmann 手术还是经括约肌间盆腔会阴联合切除术？

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann's Operation or Intersphincteric Abdomino-Perineal Excision?

机构信息

1 Department of Surgery, Örebro University Hospital, Örebro, Sweden.

2 Department of Urology, Örebro University Hospital, Örebro, Sweden.

出版信息

Scand J Surg. 2019 Sep;108(3):233-240. doi: 10.1177/1457496918812219. Epub 2018 Nov 25.

DOI:10.1177/1457496918812219

PMID:30474501

Abstract

BACKGROUND AND AIMS

In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann's procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired.

MATERIAL AND METHODS

A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann's procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival.

RESULTS

There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann's procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann's procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann's procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien-Dindo 3-4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann's procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively.

CONCLUSION

The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann's procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

摘要

背景与目的

在中低位直肠癌中，虽然低位直肠吻合术是可行的，但有时会被避免。本研究旨在比较低位 Hartmann 手术与经括约肌间腹会阴直肠切除术在接受全直肠系膜切除术治疗中低位直肠癌的患者中的应用，这些患者行低位吻合术在技术上是可行的，但由于患者相关原因而不希望行该术式。

材料与方法

在一个结直肠外科中心，对 64 例连续接受低位 Hartmann 手术（n=34）或经括约肌间腹会阴直肠切除术（n=30）的中低位直肠癌患者进行了比较，比较内容包括患者人口统计学特征、短期肿瘤学结果、术后 3 个月和 24 个月的手术结果以及长期总生存率。

结果

在经括约肌间腹会阴直肠切除术与 Hartmann 手术之间，患者年龄、性别分布、体重指数、术前放疗、肿瘤水平或癌症分期无显著差异。与经括约肌间腹会阴直肠切除术相比，Hartmann 手术的手术时间更短，中位时间分别为 174 和 256 分钟（P<0.001），术中出血量更大，分别为 600 和 500 毫升（P=0.045）。淋巴结数量和环周切缘均无显著差异。与经括约肌间腹会阴直肠切除术相比，Hartmann 手术的再次手术需求为 24%，而 3%，（P=0.020），Clavien-Dindo 3-4 级并发症发生率为 32%，而 10%，（P=0.031），盆腔脓肿发生率为 21%，而 10%，（P=0.313），90 天内死亡率为 3%，而 0%，（P=0.938）。在经括约肌间腹会阴直肠切除术组，有 13%的患者在术后 3 个月时会阴切口未愈合，而在 Hartmann 手术组，有 15%的患者在术后 2 年时存在直肠残端慢性分泌。