经会阴微创 APE：多中心队列的初步结果。
Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort.
机构信息
Department of Surgery, Amsterdam UMC, Vrije Universiteit, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.
出版信息
Tech Coloproctol. 2020 Aug;24(8):823-831. doi: 10.1007/s10151-020-02234-5. Epub 2020 Jun 16.
BACKGROUND
Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE) METHODS: This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien-Dindo ≥ 3), histopathology results, and perineal wound healing.
RESULTS
A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention.
CONCLUSIONS
TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.
背景
经腹会阴联合切除术（APE）治疗直肠癌的阳性切缘率和术后发病率相对较高，特别是与会阴伤口愈合问题有关。目前尚不清楚这些手术的会阴部分采用微创方法是否可以在不影响肿瘤学结果的情况下改善术后结果。本研究的目的是评估经会阴微创腹会阴联合切除术（TpAPE）的可行性。
方法
这是一项多中心回顾性队列研究，纳入所有接受原发低位直肠癌 TpAPE 治疗的患者。主要终点是术中并发症发生率。次要终点包括主要发病率（Clavien-Dindo≥3）、组织病理学结果和会阴伤口愈合。
结果
五个中心共进行了 32 例 TpAPE 手术。17 例（53%）患者行双侧经会阴外括约肌切开术（ELAPE），7 例（22%）行单侧 ELAPE，8 例（25%）行 APE。5 例（16%）发生术中并发症，3 例（9%）发生严重术后发病率。无围手术期死亡。4 例（13%）患者切缘阳性（R1），2 例（6%）标本穿孔。单侧经会阴外括约肌切开术组的标本质量较差，R1 切除比例高于双侧 ELAPE 或标准 APE 组。无并发症的会阴伤口愈合率为 53%（n=17），3 例（9%）患者需要再次手术干预。
结论
TpAPE 似乎可行，围手术期发病率可接受，会阴伤口裂开率相对较低，而组织病理学结果仍不理想。需要通过前瞻性试验进一步评估该技术的可行性，该试验应标准化手术、适应证、结果审核，并由具有丰富经肛门全直肠系膜切除术经验的外科医生进行。
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