局部切除术治疗 T1 期直肠肿瘤：我们是否做得更好？

Local excision for T1 rectal tumours: are we getting better?

机构信息

Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

出版信息

Colorectal Dis. 2020 Dec;22(12):2038-2048. doi: 10.1111/codi.15344. Epub 2020 Oct 20.

DOI:10.1111/codi.15344

PMID:32886836

Abstract

AIM

The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS).

METHODS

Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed.

RESULTS

Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495).

CONCLUSIONS

This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.

摘要

目的

评估三种不同的 T1 直肠肿瘤手术治疗方法（根治性切除术[RR]、开放性局部切除术[open LE]和腹腔镜局部切除术[laparoscopic LE]）对总生存率（OS）的影响。

方法

从国家癌症数据库（2008-2016 年）中选择诊断为 T1 直肠癌的成年人，根据治疗类型（LE 与 RR）进行分层。我们假设腹腔镜 LE 等同于经肛门微创外科（TAMIS）或经肛门内镜微创手术（TEMIS）。主要结局是 5 年 OS。对 LE 组进行了按时间段（2008-2010 年[TAMIS 之前]与 2011-2016 年[TAMIS 之后]）和方法（腹腔镜与开放性）的亚组分析。

结果

在 10053 例患者中，6623 例（65.88%）接受了 LE 治疗（74.33%为腹腔镜 LE，25.67%为开放性 LE），3430 例（34.12%）接受了 RR 治疗。LE 的使用率从 2008 年的 52.69%增加到 2016 年的 69.47%，而 RR 则有所下降（P<0.001）。在未调整分析中，LE 组与 RR 组之间、两个 LE 时间段之间的 5 年 OS 均无显著差异（P=0.639 和 P=0.509），调整分析结果亦如此（LE 与 RR，风险比 1.05，95%置信区间 0.92-1.20，P=0.468；2008-2010 年 LE 与 2011-2016 年 LE，风险比 1.09，95%置信区间 0.92-1.29，P=0.321）。仅在未调整分析中，腹腔镜 LE 与开放性 LE 组相比，OS 有所改善（P=0.006）（风险比 0.94，95%置信区间 0.78-1.12，P=0.495）。