Milsom J W, Böhm B, Hammerhofer K A, Fazio V, Steiger E, Elson P
Department of Colorectal Surgery, The Cleveland Clinic Foundation, OH 44195-5044, USA.
J Am Coll Surg. 1998 Jul;187(1):46-54; discussion 54-5. doi: 10.1016/s1072-7515(98)00132-x.
Uncontrolled studies using laparoscopic techniques in colorectal surgery have not demonstrated clear advantages to these procedures compared with conventional ones, and surgeons are concerned about unusual early recurrences reported after laparoscopic colorectal cancer surgery.
We conducted a prospective, randomized trial in one surgical department comparing laparoscopic (LAP) and conventional (CON) techniques in 109 patients undergoing bowel resection for colorectal cancers or polyps. Postoperatively, all patients underwent measurement of pulmonary function tests every 12 hours, and were treated identically on a highly controlled protocol with regard to analgesic administration, feeding, and postoperative care.
Of the 55 patients assigned to LAP and 54 to the CON group, there were 42 and 38 with cancer, respectively (the other patients had large adenomas). Overall recovery of 80% of forced expiratory volume in 1 second and forced vital capacity was a median of 3 days for LAP and 6.0 days for CON (p = 0.01). LAP patients used significantly less morphine than CON patients up to the second day after surgery (0.78 +/- 0.32 versus 0.92 +/- 0.34 mg/kg per day, p = 0.02). Flatus returned a median of 3.0 days after LAP versus 4.0 days after CON surgery (p = 0.006). Tumor margins were clear in all patients. After a median followup of 1.5 years (LAP) and 1.7 years (CON), there were no port site recurrences in the LAP group. Seven cancer-related deaths have occurred (three in the LAP group, four in the CON group).
Within this prospective, randomized trial, laparoscopic techniques were as safe as conventional surgical techniques and offered a faster recovery of pulmonary and gastrointestinal function compared with conventional surgery for selected patients undergoing large bowel resection for cancer or polyps. There were no apparent shortterm oncologic disadvantages. Longer followup is needed to fully assess oncologic outcomes.
在结直肠手术中，与传统手术相比，使用腹腔镜技术的非对照研究并未显示出这些手术有明显优势，并且外科医生担心腹腔镜结直肠癌手术后报告的异常早期复发情况。
我们在一个外科科室进行了一项前瞻性随机试验，比较了109例因结直肠癌或息肉接受肠切除手术患者的腹腔镜（LAP）和传统（CON）技术。术后，所有患者每12小时进行一次肺功能测试测量，并在镇痛给药、喂养和术后护理方面按照高度控制的方案进行相同的治疗。
在分配到LAP组的55例患者和CON组的54例患者中，分别有42例和38例患有癌症（其他患者有大腺瘤）。一秒用力呼气量和用力肺活量总体恢复至80%时，LAP组的中位时间为3天，CON组为6.0天（p = 0.01）。直到术后第二天，LAP组患者使用的吗啡明显少于CON组患者（分别为0.78±0.32与0.92±0.34毫克/千克/天，p = 0.02）。LAP组术后排气恢复的中位时间为3.0天，而CON组为4.0天（p = 0.006）。所有患者的肿瘤切缘均清晰。在LAP组中位随访1.5年和CON组中位随访1.7年后，LAP组未发生端口部位复发。发生了7例与癌症相关的死亡（LAP组3例，CON组4例）。
在这项前瞻性随机试验中，对于因癌症或息肉接受大肠切除手术的特定患者，腹腔镜技术与传统手术技术一样安全，并且与传统手术相比，肺和胃肠功能恢复更快。没有明显的短期肿瘤学劣势。需要更长时间的随访来全面评估肿瘤学结果。
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