Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
Ann Surg. 2021 Sep 1;274(3):e236-e244. doi: 10.1097/SLA.0000000000003663.
The purpose of this study was to investigate the impact of tie level on oncological outcomes in rectal cancer surgery.
Theoretically, a high tie of the inferior mesenteric artery could facilitate removal of apical node metastases and improve tumor staging accuracy. However, no appropriately sized randomized controlled trial exists and results from observational studies are not consistent.
All stage I-III rectal cancer patients who underwent abdominal surgery with curative intention in 2007 to 2014 were identified and followed, using the Swedish Colorectal Cancer Registry. Primary outcome was cancer-specific survival, whereas overall and relative survival, locoregional and distant recurrence, and lymph node harvest were secondary outcomes, with high tie as exposure. We used propensity score matching to emulate a randomized controlled trial, and then performed Cox regression analyses to estimate hazard ratios (HRs) with confidence intervals (CIs).
Some 8287 patients remained for analysis, of which 37% had high tie surgery. After propensity score matching, the 5-year cancer-specific survival rate was overall 86% and we found no association between the level of tie and cancer-specific (HR 0.92, 95% CI 0.79-1.07) or overall (HR 0.98, 95% CI 0.89-1.08) survival, nor to locoregional (HR 0.85, 95% CI 0.59-1.23) or distant (HR 1.01, 95% CI 0.88-1.15) recurrence, nor to relative survival (HR 1.05, 95% CI 0.85-1.28). Stratification and sensitivity analyses were similarly insignificant, after adjustment for confounding. Total lymph node harvest was, however, increased after high tie surgery (P < 0.01), but no differences were seen regarding positive nodes (P = 0.72).
In this nationwide cohort study, the level of tie did not influence any patient-oriented oncological outcome, neither overall nor in node-positive patients. This would allow the patient's anatomical configuration and the surgeon's preferences to determine the level of tie.
本研究旨在探讨直肠系膜结扎水平对直肠癌手术患者肿瘤学结局的影响。
从理论上讲，肠系膜下动脉高位结扎可促进清除顶端淋巴结转移灶，提高肿瘤分期准确性。然而，目前尚无合适的随机对照试验，观察性研究结果也不一致。
利用瑞典结直肠癌登记处，对 2007 年至 2014 年间接受根治性腹部手术的所有Ⅰ-Ⅲ期直肠癌患者进行了识别和随访。主要结局为癌症特异性生存，次要结局为总生存、相对生存、局部复发、远处复发和淋巴结清扫，以结扎水平为暴露因素。采用倾向评分匹配模拟随机对照试验，然后进行 Cox 回归分析，以置信区间（CI）估计风险比（HR）。
共纳入 8287 例患者进行分析，其中 37%的患者接受了高位结扎手术。在倾向评分匹配后，5 年癌症特异性生存率总体为 86%，我们未发现结扎水平与癌症特异性生存（HR 0.92，95%CI 0.79-1.07）或总生存（HR 0.98，95%CI 0.89-1.08）、局部复发（HR 0.85，95%CI 0.59-1.23）或远处复发（HR 1.01，95%CI 0.88-1.15）相关，也与相对生存（HR 1.05，95%CI 0.85-1.28）无关。分层和敏感性分析在调整混杂因素后也无显著差异。然而，高位结扎术后总淋巴结清扫量增加（P<0.01），但阳性淋巴结数量无差异（P=0.72）。
在这项全国性队列研究中，结扎水平并未影响任何以患者为导向的肿瘤学结局，无论是总体结局还是在淋巴结阳性患者中均无影响。这将允许根据患者的解剖结构和外科医生的偏好来确定结扎水平。
