Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milano, Italy.
Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73 Goryodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.
Updates Surg. 2021 Jun;73(3):1103-1114. doi: 10.1007/s13304-020-00898-0. Epub 2020 Oct 17.
Locally advanced rectal cancer often requires an extended resection beyond the total mesorectal excision plane (bTME) to obtain clear resection margins. We classified three types of bTME rectal cancer following local disease diffusion: radial (adjacent pelvic organs), lateral (pelvic lateral lymph nodes) and longitudinal (below 3.5 cm from the anal verge, submitted to intersphincteric resection). The primary aim of this study was to evaluate the application of robotic surgery to the three types of bTME regarding the short and long-term oncological outcomes. Secondary aim was to identify survival prognostic factors for bTME rectal cancers. A total of 137 patients who underwent robotic-assisted bTME procedures between 2008 and 2018 were extracted from a prospectively collected database. Patient-related, operative and pathological factors were assessed. Morbidity was moderately high with 66% of patients reporting postoperative complications. Median follow up was 47 months (IQR, 31.5-66.5). Local recurrence rate was 15.3% with a statistical difference between the three types of bTME (p = 0.041). Disease progression/distant metastasis rate was 33.6%. Overall survival was significantly different (p = 0.023) with 1- and 3-years rates of: 77.8% and 55.0% (radial; n = 19); 96.6% and 84.8% (lateral; n = 30); 97.7% and 86.9% (longitudinal; n = 88). No statistical difference was observed for disease-free survival (p = 0.897). Local recurrence-free survival was significantly different between the groups (p = 0.031). Multivariate analysis showed that (y)pT (p = 0.028; HR (95% CI) 5.133 (1.192-22.097)), (y)pN (p = 0.014; HR (95% CI) 2.835 (1.240-6.482)) and type of bTME were associated to OS whilst (y)pT (p = 0.072) and type of bTME were not associated to LRFS.
局部进展期直肠癌常需要超出全直肠系膜切除平面（bTME）的扩大切除以获得清晰的切缘。我们根据局部疾病扩散将三种类型的 bTME 直肠癌分类：放射状（相邻盆腔器官）、侧向（盆腔侧淋巴结）和纵向（距肛门缘 3.5cm 以下，行括约肌间切除术）。本研究的主要目的是评估机器人手术在三种 bTME 类型中的应用，以评估短期和长期的肿瘤学结果。次要目的是确定 bTME 直肠癌的生存预后因素。从 2008 年至 2018 年期间前瞻性收集的数据库中提取了 137 例接受机器人辅助 bTME 手术的患者。评估了与患者相关、手术和病理因素。发病率较高，有 66%的患者报告术后并发症。中位随访时间为 47 个月（IQR，31.5-66.5）。局部复发率为 15.3%，三种类型的 bTME 之间存在统计学差异（p=0.041）。疾病进展/远处转移率为 33.6%。总生存率有显著差异（p=0.023），1 年和 3 年的生存率为：77.8%和 55.0%（放射状；n=19）；96.6%和 84.8%（侧方；n=30）；97.7%和 86.9%（纵向；n=88）。无病生存率无统计学差异（p=0.897）。局部无复发生存率在各组之间有显著差异（p=0.031）。多变量分析显示，（y）pT（p=0.028；HR（95%CI）5.133（1.192-22.097））、（y）pN（p=0.014；HR（95%CI）2.835（1.240-6.482））和 bTME 类型与 OS 相关，而（y）pT（p=0.072）和 bTME 类型与 LRFS 无关。
