Department of Surgery, Duke University, Durham, NC, USA.
Duke University Medical Center, Box 3443, Durham, NC, 27710, USA.
Surg Endosc. 2021 Jan;35(1):275-290. doi: 10.1007/s00464-020-07393-y. Epub 2020 Feb 28.
As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer.
The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers.
35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937).
MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.
随着微创技术在结直肠手术中的应用越来越普遍，人们仍然对微创低位前切除术（MI-LAR）治疗直肠癌的肿瘤学效果和长期结果存在担忧。
从 2010 年至 2015 年国家癌症数据库（NCDB）参与者数据使用文件中查询接受选择性开放低位前切除术（OLAR）或 MI-LAR 治疗直肠腺癌的患者。根据人口统计学、合并症和肿瘤特征进行 1:1 倾向匹配。比较两组之间的结果，并进行 Cox 比例风险模型分析以确定死亡率的独立预测因素。对高容量学术中心进行了亚组分析。
共确定 35809 例接受 LAR 的患者，其中 18265 例（51.0%）接受 MI-LAR。在倾向匹配后，接受 MI-LAR 的患者更不可能有阳性环周径向切缘（CRM）（5.5% vs. 6.6%，p = 0.0094）或阳性远端切缘（3.6% vs. 4.6%，p = 0.0022），且 90 天全因死亡率降低（2.0% vs. 2.6%，p = 0.0238）。MI-LAR 导致住院时间缩短（5 天 vs. 6 天，p<0.0001），但 30 天再入院率增加（7.6% vs. 6.5%，p = 0.0054）。MI-LAR 改善了长期总体生存率（79% vs. 76%，p<0.0001）。Cox 比例风险模型显示 MI-LAR 降低了死亡率风险（HR 0.859，95%CI 0.788-0.937）。
MI-LAR 与 CRM 清除率的提高和长期生存有关。在具有先进腹腔镜技能的经验丰富的外科医生手中，MI-LAR 似乎是一种安全有效的直肠癌治疗方法。
