Collin Åsa, Dahlbäck Cecilia, Folkesson Joakim, Buchwald Pamela
Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
BJS Open. 2024 Jul 2;8(4). doi: 10.1093/bjsopen/zrae071.
The quality of the total mesorectal excision specimen in rectal cancer surgery is assessed with a three-tier grade (mesorectal, intramesorectal and muscularis propria). This study aimed to analyse the prognostic impact of the total mesorectal excision grade on survival, and to identify risk factors for intramesorectal and muscularis propria resection in a population-based setting.
All patients in the Swedish Colorectal Cancer Registry with rectal cancer stage I-III ≤ 10 cm from the anal verge, diagnosed 2015-2019, undergoing total mesorectal excision were analysed. Clinical, surgical and pathological data were retrieved and analysed for the following primary outcomes: local and distant recurrence and overall and relative survival; secondary outcomes were risk factors for total mesorectal excision grading (intramesorectal or muscularis propria resection). Of note, postoperative death < 30 days or recurrence within 90 days were exclusion criteria for survival and recurrence analysis. Recurrence-free patients with less than 3 years follow-up, and patients lacking data regarding recurrence, were also excluded from recurrence analyses.
Overall, of 7979 patients treated during the study interval, 1499 patients were eligible for recurrence, 2441 patients for survival and 2476 patients for risk-factor analyses, of which 75% were graded mesorectal, 17% intramesorectal and 8% muscularis propria. Median follow-up for survival was 42 (1-77) months. The worst total mesorectal excision grading (muscularis propria resection) was an independent risk factor for local recurrence in multivariable analysis (HR 2.73, 95% c.i. 1.07 to 7.0, P = 0.036). Total mesorectal excision grade had no impact on distant recurrence or survival. Female sex, tumour level <5 cm, abdominoperineal resection, minimally invasive surgery (laparoscopic and robotic), high blood loss, long duration of surgery and intraoperative perforation were independent risk factors for worse total mesorectal excision grading (intramesorectal and/or muscularis propria resection) in multivariable analyses.
Muscularis propria resection increases the risk of local recurrence but does not seem to affect distant recurrence or survival.
直肠癌手术中直肠系膜全切除标本的质量采用三级分级法（直肠系膜、系膜内和固有肌层）进行评估。本研究旨在分析直肠系膜全切除分级对生存的预后影响，并在基于人群的背景下确定系膜内和固有肌层切除的危险因素。
对瑞典结直肠癌登记处中2015年至2019年诊断为I - III期、距肛缘≤10 cm的直肠癌且接受直肠系膜全切除的所有患者进行分析。检索并分析临床、手术和病理数据，以获取以下主要结局：局部和远处复发、总生存和相对生存；次要结局是直肠系膜全切除分级（系膜内或固有肌层切除）的危险因素。值得注意的是，术后30天内死亡或90天内复发是生存和复发分析的排除标准。随访时间不足3年的无复发患者以及缺乏复发数据的患者也被排除在复发分析之外。
总体而言，在研究期间接受治疗的7979例患者中，1499例患者符合复发分析条件，2441例患者符合生存分析条件，2476例患者符合危险因素分析条件，其中75%为直肠系膜分级，17%为系膜内分级，8%为固有肌层分级。生存分析的中位随访时间为42（1 - 77）个月。在多变量分析中，最差的直肠系膜全切除分级（固有肌层切除）是局部复发的独立危险因素（HR 2.73，95%置信区间1.07至7.0，P = 0.036）。直肠系膜全切除分级对远处复发或生存无影响。在多变量分析中，女性、肿瘤位置<5 cm、腹会阴联合切除术、微创手术（腹腔镜和机器人手术）、高失血量、手术时间长和术中穿孔是直肠系膜全切除分级较差（系膜内和/或固有肌层切除）的独立危险因素。
固有肌层切除增加了局部复发的风险，但似乎不影响远处复发或生存。
