Hamada Madoka, Matsumi Yuki, Inada Ryo, Matsumoto Tomoko, Kita Masato, Boku Shogen, Kurokawa Hiroaki, Tsuta Koji
Department of Gastrointestinal Surgery, Kansai Medical University Hospital, 2-3-1, Shinmachi, Hirakata, Osaka, 573-1191, Japan.
Department of Obstetrics and Gynecology, Kansai Medical University Hospital, Hirakata, Japan.
Int J Colorectal Dis. 2025 Mar 14;40(1):66. doi: 10.1007/s00384-025-04838-5.
These days, various surgical techniques such as trans-anal, trans-perineal total mesorectal excision, and transvaginal natural orifice transluminal endoscopic surgery have been utilized with flexibility, which was not possible before the laparoscopic era.
From January 2014 to January 2023, 40 cases of c(yc)T4b rectal cancer underwent local curative surgery laparoscopically at Kansai Medical University Hospital. In 25 consecutive cases, we adopted multiple approaches (trans-anal total mesorectal excision, transvaginal natural orifice transluminal endoscopic surgery, trans-perineal total mesorectal excision, or prone position first abdominoperineal excision) to remove the deepest part of the tumor indicated by MRI last as the specimen-oriented surgery. The remaining 15 patients underwent top-to-bottom surgery based on standard surgery. The primary endpoint was the local recurrence rate of the specimen-oriented surgery group compared to that of the standard surgery group.
The specimen-oriented surgery group had a median follow-up of 3.9 (0.4-7.4) years with no local recurrence, while the standard surgery group had a median follow-up of 1.5 (0.7-3.7) years with 5 of 15 patients (33%) experiencing more local recurrence than specimen-oriented surgery group (p = 0.005). Comparison of the local recurrence ( +) and ( -) groups showed significant differences in pCRM positive rate, neoadjuvant therapy, tumor size, and approach (specimen-oriented surgery vs. standard surgery) in univariate analysis (p < 0.05). Still, no significant differences were found in the multivariate analysis.
In the laparoscopic setting, local cure of c(yc)T4b rectal cancer requires a different strategy than open surgery, and specimen-oriented surgery may be a promising procedure.
如今，诸如经肛门、经会阴全直肠系膜切除术以及经阴道自然腔道内镜手术等各种外科技术得到了灵活应用，而这在腹腔镜时代之前是不可能的。
2014年1月至2023年1月，40例c（yc）T4b期直肠癌患者在关西医科大学医院接受了腹腔镜下局部根治性手术。在连续25例患者中，我们采用了多种方法（经肛门全直肠系膜切除术、经阴道自然腔道内镜手术、经会阴全直肠系膜切除术或俯卧位先行腹会阴联合切除术），以切除MRI最后显示的肿瘤最深部位作为标本导向手术。其余15例患者接受基于标准手术的自上而下手术。主要终点是标本导向手术组与标准手术组的局部复发率比较。
标本导向手术组的中位随访时间为3.9（0.4 - 7.4）年，无局部复发，而标准手术组的中位随访时间为1.5（0.7 - 3.7）年，15例患者中有5例（33%）出现比标本导向手术组更多的局部复发（p = 0.005）。局部复发（+）组和（-）组的比较显示，在单因素分析中，pCRM阳性率、新辅助治疗、肿瘤大小和手术方式（标本导向手术与标准手术）存在显著差异（p < 0.05）。然而，在多因素分析中未发现显著差异。
在腹腔镜手术中，c（yc）T4b期直肠癌的局部根治需要与开放手术不同的策略，标本导向手术可能是一种有前景的术式。
