新輔助放化療對(duì)腹腔鏡直腸癌手術(shù)病人近期臨床結(jié)局影響

盧琦，趙萍，周巖冰，王東升

(青島大學(xué)附屬醫(yī)院普外科，山東 青島 266003)

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新輔助放化療對(duì)腹腔鏡直腸癌手術(shù)病人近期臨床結(jié)局影響

盧琦，趙萍，周巖冰，王東升

(青島大學(xué)附屬醫(yī)院普外科，山東 青島 266003)

目的 探討新輔助放化療對(duì)腹腔鏡直腸癌手術(shù)病人近期臨床結(jié)局的影響。方法 回顧性分析47例新輔助放化療后行腹腔鏡手術(shù)的直腸癌病人(新輔助組)與同期58例僅行腹腔鏡手術(shù)的直腸癌病人(對(duì)照組)的臨床資料。比較兩組病人的手術(shù)相關(guān)指標(biāo)、并發(fā)癥發(fā)生率及病理學(xué)指標(biāo)。結(jié)果 兩組病人術(shù)前臨床資料比較差異無(wú)顯著統(tǒng)計(jì)學(xué)意義(P>0.05)。新輔助組回腸末端造口率高于對(duì)照組；淋巴結(jié)清掃數(shù)目明顯低于對(duì)照組，差異均有顯著統(tǒng)計(jì)學(xué)意義(χ2=25.694,t=4.818,P<0.05)。其余手術(shù)相關(guān)指標(biāo)、并發(fā)癥發(fā)生率兩組間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 新輔助放化療后行腹腔鏡直腸癌手術(shù)是安全、可行的，并不增加術(shù)后并發(fā)癥。

直腸腫瘤；放化療,輔助；腹腔鏡

近年來(lái)，直腸癌治療水平的提高得益于臨床對(duì)新輔助放化療理念的接受、腹腔鏡直腸癌根治手術(shù)的開展及直腸全系膜切除術(shù)(TME)治療原則的廣泛應(yīng)用[1-3]。越來(lái)越多的進(jìn)展期直腸癌病人在手術(shù)前接受新輔助放化療,以降低臨床分期、縮小原發(fā)病灶。美國(guó)國(guó)立綜合癌癥網(wǎng)絡(luò)(NCCN)臨床實(shí)踐指南指出，T3期或存在局部淋巴結(jié)轉(zhuǎn)移的直腸癌是新輔助放化療的指征。已有研究結(jié)果表明，新輔助放化療可以降低進(jìn)展期直腸癌病人局部復(fù)發(fā)率，提高生存率[4]。2012年1月—2014年7月，我科對(duì)47例直腸癌病人術(shù)前行放化療，本文對(duì)其臨床資料進(jìn)行分析，探討新輔助放化療對(duì)腹腔鏡直腸癌手術(shù)病人近期臨床結(jié)局的影響。

1 資料與方法

1.1 一般資料

選取2012年1月—2014年7月我科直腸癌數(shù)據(jù)庫(kù)中術(shù)前行放化療的直腸癌病人(新輔助組)47例，同時(shí)選取術(shù)前未行放化療的直腸癌病人(對(duì)照組)58例，兩組病人均由同一手術(shù)者行腹腔鏡直腸癌手術(shù)。所有病人均經(jīng)結(jié)腸鏡檢查、活檢病理證實(shí)為直腸癌，術(shù)前影像學(xué)分期為Ⅱ～Ⅲ期，腫瘤距肛緣≤12 cm。兩組病人的年齡、性別、體質(zhì)量指數(shù)(BMI)、NRS 2002營(yíng)養(yǎng)評(píng)分、美國(guó)麻醉師協(xié)會(huì)評(píng)分(ASA)分級(jí)等差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。

1.2 新輔助放化療方案

新輔助組病人均在術(shù)前接受放化療治療，放化療方案根據(jù)NCCN指南及病人經(jīng)濟(jì)情況由腫瘤科醫(yī)生制定。放療設(shè)備為直線加速器23EX，應(yīng)用多野照射技術(shù)(一般2～4個(gè)照射野)，放射野包括腫瘤、直腸周圍淋巴結(jié)、骶前及髂內(nèi)淋巴結(jié)，盆腔放射劑量40～50 Gy,每周4～5次。化療方案：XELOX(奧沙利鉑+希羅達(dá))23例，F(xiàn)OLFOX(奧沙利鉑+亞葉酸鈣+氟尿嘧啶)18例，單用希羅達(dá)6例。

1.3 手術(shù)方法

新輔助組在結(jié)束放化療后6～8周內(nèi)接受腹腔鏡手術(shù)，手術(shù)遵循TME原則，按常規(guī)方法進(jìn)行。

1.4 觀察指標(biāo)

收集兩組病人的臨床資料，包括手術(shù)相關(guān)指標(biāo)：中轉(zhuǎn)開腹率、手術(shù)方式、保肛率、根治度、手術(shù)時(shí)間、術(shù)中出血量、末端回腸造口；術(shù)后恢復(fù)指標(biāo)：術(shù)后排氣時(shí)間、術(shù)后進(jìn)食時(shí)間、術(shù)后住院天數(shù)；術(shù)后并發(fā)癥：吻合口漏、腸梗阻、切口感染、骶前出血、盆腔出血、肺部感染、尿潴留、菌群失調(diào)、死亡；病理學(xué)指標(biāo)：淋巴結(jié)清掃數(shù)目、遠(yuǎn)端切緣陽(yáng)性率、病理完全緩解率。

2 結(jié) 果

2.1 兩組手術(shù)情況比較

新輔助組3例中轉(zhuǎn)開腹,對(duì)照組4例中轉(zhuǎn)開腹,兩組中轉(zhuǎn)開腹率比較差異無(wú)顯著性(P>0.05)。中轉(zhuǎn)開腹原因:腹腔嚴(yán)重粘連、手術(shù)視野及解剖層次辨別不清4例，腫瘤侵透腸管與周圍組織浸潤(rùn)固定2例，術(shù)中出血1例。新輔助組與對(duì)照組手術(shù)方式比較，差異無(wú)顯著性(P>0.05)。新輔助組的保肛率為78.72%，對(duì)照組為74.14%，兩組間比較差異無(wú)顯著性(P>0.05)。新輔助組達(dá)到根治效果的比例為93.62%，對(duì)照組為93.10%，兩組間差異無(wú)顯著性(P>0.05)。新輔助組與對(duì)照組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后排氣時(shí)間、術(shù)后進(jìn)食時(shí)間、術(shù)后住院天數(shù)比較，差異均無(wú)顯著性(P>0.05)。新輔助組行回腸末端造口術(shù)32例，對(duì)照組11例，差異有顯著性(χ2=25.694，P<0.05)。新輔助組淋巴結(jié)清掃數(shù)目少于對(duì)照組，差異有顯著性(t=4.818,P<0.05)。兩組腫瘤遠(yuǎn)端切緣均為陰性。見表2。

2.2 兩組術(shù)后并發(fā)癥比較

新輔助組1例死亡，原因?yàn)槟[瘤短期復(fù)發(fā)。新輔助組并發(fā)癥發(fā)生率29.79%，對(duì)照組24.14%，兩組比較差異無(wú)顯著性(P>0.05)。見表3。

表1 兩組病人術(shù)前臨床資料比較

表2 兩組病人的手術(shù)相關(guān)情況比較

表3 兩組病人術(shù)后并發(fā)癥比較(例)

3 討 論

臨床上進(jìn)展期直腸癌病人手術(shù)前行新輔助放化療已經(jīng)逐漸被認(rèn)可，相關(guān)研究表明術(shù)前放化療能使腫瘤縮小達(dá)到降期的效果[5]，同時(shí)也降低局部復(fù)發(fā)率[6-7]。但MARIJNEN等[8]研究表明，新輔助放化療可能會(huì)增加出血傾向和延遲切口愈合，會(huì)使解剖標(biāo)志和手術(shù)視野模糊，增加腹腔鏡手術(shù)的難度[9]。因此，有必要對(duì)新輔助放化療后行腹腔鏡直腸癌手術(shù)的安全性及可行性進(jìn)行研究。

中轉(zhuǎn)開腹率是評(píng)價(jià)腹腔鏡手術(shù)可行性的重要指標(biāo)之一。Logistic回歸分析結(jié)果顯示，中轉(zhuǎn)開腹率與年齡、BMI、手術(shù)例數(shù)、有腹部手術(shù)史、腫瘤大小有關(guān)[10]。本研究結(jié)果顯示，新輔助組中轉(zhuǎn)開腹率為6.38%，對(duì)照組為6.90%，兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義。提示新輔助放化療并不增加中轉(zhuǎn)開腹率。

保留肛門括約肌功能是影響直腸癌病人術(shù)后生活質(zhì)量的關(guān)鍵[11]。本研究結(jié)果顯示，新輔助組的保肛率高于對(duì)照組,但差異無(wú)統(tǒng)計(jì)學(xué)意義，不足以證明新輔助放化療對(duì)直腸癌病人的保肛效果更佳。但有研究表明，在腫瘤距肛緣3～5 cm的病人中，新輔助放化療后手術(shù)的保肛率明顯高于直接手術(shù)[12]。

本文新輔助組的回腸末端造口率高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義，主要是因?yàn)樾螺o助放化療后病人腸壁水腫明顯，組織愈合能力相對(duì)較差，同時(shí)吻合口位置較低，存在吻合口漏的風(fēng)險(xiǎn)，因此手術(shù)醫(yī)生通常會(huì)選擇行回腸末端造口術(shù)(通常3～6個(gè)月后回納)。本文兩組術(shù)后并發(fā)癥發(fā)生率差異無(wú)統(tǒng)計(jì)學(xué)意義,新輔助放化療并不增加吻合口漏發(fā)生率，這得益于外科醫(yī)生腹腔鏡技術(shù)和低位吻合技術(shù)的提高，得益于新輔助治療對(duì)手術(shù)時(shí)機(jī)的把握[13]。同時(shí)，回腸末端造口也是對(duì)吻合口的一種保護(hù)。

本文術(shù)后病理結(jié)果顯示，新輔助組淋巴結(jié)清掃數(shù)目明顯少于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義，可能因?yàn)榻?jīng)過(guò)放化療后淋巴結(jié)達(dá)到了降期，淋巴結(jié)大不明顯，增加了獲取難度[14]。另外，本文新輔助組9例獲得了病理完全緩解，獲得病理完全緩解的病人具有較低的復(fù)發(fā)率和良好的預(yù)后[15]。

綜上所述，進(jìn)展期直腸癌病人術(shù)前行新輔助放化療，近期臨床結(jié)局較好，并不增加術(shù)后并發(fā)癥。獲得病理完全緩解的病人局部復(fù)發(fā)率及預(yù)后可能會(huì)更可觀[16]，但長(zhǎng)期的腫瘤學(xué)結(jié)局還需要進(jìn)一步隨訪研究。另外，本研究只是一個(gè)單中心回顧性研究，還需要多中心隨訪對(duì)照研究加以驗(yàn)證。

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(本文編輯 黃建鄉(xiāng))

EFFECTS OF NEOADJUVANT CHEMORADIOTHERAPY ON SHORT-TERM CLINICAL OUTCOMES IN PATIENTS UNDERGOING LAPAROSCOPIC SURGERY FOR RECTAL CANCER

LUQi,ZHAOPing,ZHOUYanbing,WANGDongsheng

(Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, China)

ObjectiveTo investigate the effects of neoadjuvant chemoradiotherapy on short-term clinical outcomes in patients received laparoscopic surgery for rectal cancer.MethodsA retrospective analysis of clinical data was done in 47 patients with rectal cancer underwent laparoscopic surgery following neoadjuvant chemoradiotherapy (neoadjuvant therapy group), and 58 patients with the same condition received laparoscopic surgery alone (control group) during the same period. The surgical parameters, postoperative complications and pathological indicators between the two groups were compared.ResultsThe preoperative conditions between the two groups were not significantly different (P>0.05). The rates of terminal-ileum fistulation in the neoadjuvant therapy group were higher than that in the control group, the number of lymph nodes resected was less, the differences were significant between the two groups (χ2=25.694,t=4.818,P<0.05). The rest operation-related parameters and complications between the two groups were not statistically significant (P>0.05).ConclusionPreoperative chemoradiation followed by laparoscopic surgery for rectal cancer is safe and feasible, which does not increase postoperative complications.

rectal neoplasms; chemoradiotherapy, adjuvant; laparoscopes

2015-01-26;

2015-05-19

盧琦(1987-)，男，碩士研究生。

王東升(1976-)，男，博士，副主任醫(yī)師，碩士生導(dǎo)師。

R735.37

A

1008-0341(2015)04-0445-03