崔 勇,程樹杰,張燕北,王 乾,霍 然
腹腔鏡輔助與開腹全結(jié)腸系膜切除術(shù)治療老年人右半結(jié)腸癌療效和安全性的比較
崔 勇1,程樹杰2,張燕北3,王 乾4,霍 然5
目的分析比較腹腔鏡輔助全結(jié)腸系膜切除(laparoscopy-assisted complete mesocolic excision, LCME)與開腹全結(jié)腸系膜切除(open complete mesocolic excision, OCME)治療老年人右半結(jié)腸癌的可行性、安全性及臨床療效觀察。方法回顧性分析河北大學附屬醫(yī)院2011-04至2015-09收治的老年右半結(jié)腸癌170例的臨床資料,其中LCME組和OCME組各85例,比較兩組患者的術(shù)中、術(shù)后臨床資料及隨訪資料。結(jié)果兩組患者的術(shù)中出血量、初次排氣時間、初次進流食時間、平均住院時間,LCME組患者明顯少于OCME組,差異有統(tǒng)計學意義(均P<0.05)。兩組患者手術(shù)質(zhì)量分級、手術(shù)時間、清掃淋巴結(jié)數(shù)目、術(shù)后心腦血管意外發(fā)生率及未見統(tǒng)計學差異(均P>0.05)。術(shù)后隨訪時間為48個月,兩組患者的復發(fā)率和轉(zhuǎn)移率差異無統(tǒng)計學意義。結(jié)論腹腔鏡輔助全結(jié)腸系膜切除術(shù)(LCME)治療老年患者右半結(jié)腸癌的安全性、可行性、根治性,以及短期生存均不遜于傳統(tǒng)開腹手術(shù)。
結(jié)腸腫瘤;全結(jié)腸系膜切除術(shù);腹腔鏡手術(shù);右半結(jié)腸切除術(shù);手術(shù)質(zhì)量分級;老年患者
在我國,結(jié)腸癌是老年人最常見的消化道惡性腫瘤之一。近來研究發(fā)現(xiàn),腫瘤發(fā)生于結(jié)腸近端的患者比例逐漸增多,因此右半結(jié)腸癌根治術(shù)的比例亦隨之增加[1]。腹腔鏡結(jié)腸癌根治術(shù)在圍術(shù)期康復和術(shù)后生活質(zhì)量方面均優(yōu)于傳統(tǒng)開腹手術(shù),且根治效果相似[2-4]。全結(jié)腸系膜切除(complete mesocolic excision,CME)的概念由德國學者Hohenberger最先提出,即在完整的結(jié)腸筋膜層內(nèi)徹底清掃淋巴結(jié)[5]。老年結(jié)腸癌患者各器官生理儲備功能相對降低,常合并心腦血管疾病,加上右半結(jié)腸血管解剖變異較多見,故腹腔鏡全結(jié)腸系膜切除(LCME)對老年患者并不簡單,且老年患者能否從中真正獲益仍不明確。本研究通過比較LCME和開腹全結(jié)腸系膜切除(OCME)治療老年患者右半結(jié)腸癌的臨床療效,探討LCME手術(shù)的安全性、可行性。
1.1 對象 入組標準:年齡≥65歲,術(shù)前檢查明確診斷為右半結(jié)腸癌(術(shù)前影像學檢查病灶位于升結(jié)腸、結(jié)腸肝曲、橫結(jié)腸右半段或盲腸,病理活檢證實腺癌),且影像學檢查評估為可切除,無遠處轉(zhuǎn)移;無明顯手術(shù)禁忌。兩組患者均有手術(shù)適應(yīng)證,且均同意接受手術(shù)。排除標準:既往行腹部手術(shù)、急診手術(shù)患者;行術(shù)前放化療患者。
按照上述標準,本研究入組河北大學附屬醫(yī)院自2011-04至2015-09行右半結(jié)腸根治術(shù)的170例老年右半結(jié)腸癌患者,其中LCME組和OCME組各85例。對比兩組患者術(shù)前臨床資料,差異無統(tǒng)計學意義(均P>0.05,表1)。
表1 LCME與OCME患者臨床資料比較 (n=85;
1.2 手術(shù)方法 兩組患者手術(shù)均在我院由同一團隊醫(yī)師施行,主刀醫(yī)師具有豐富的腹腔鏡及開腹結(jié)腸癌CME手術(shù)經(jīng)驗。兩組均采用中間入路法。
1.3 手術(shù)質(zhì)量的分級評估 根據(jù)術(shù)中腔鏡以及術(shù)后大體標本影像資料,采用West[6]的手術(shù)切除平面分級系統(tǒng):A級固有肌層平面(腸系膜不完整,破損達腸壁固有肌層);B級結(jié)腸系膜內(nèi)平面(腸系膜基本完整,但在遠離腸管方向上有破損);C級結(jié)腸系膜平面(標本腸系膜完整,光滑)。
1.4 觀察指標 (1)術(shù)中相關(guān)指標:手術(shù)時間、出血量;(2)術(shù)后恢復指標:初次排氣時間、初次進流食時間、平均住院時間、術(shù)后30 d內(nèi)并發(fā)癥;(3)手術(shù)質(zhì)量分級指標;(4)術(shù)后病理指標:腫瘤直徑、腫瘤病理分期、淋巴結(jié)清掃數(shù)目;(5)隨訪指標:術(shù)后48個月復發(fā)率和轉(zhuǎn)移率。
2.1 術(shù)中及術(shù)后情況比較 兩組患者手術(shù)均順利完成,無醫(yī)源性副損傷病例出現(xiàn),LCME組無中轉(zhuǎn)開腹病例。兩組手術(shù)時間、肺部感染及術(shù)后心腦血管疾病并發(fā)癥差異無統(tǒng)計學意義。LCME組術(shù)中出血量、初次排氣時間、初次進流食時間、平均住院時間顯著少于OCME組,差異有統(tǒng)計學意義(均P<0.05)。LCME組術(shù)后30 d內(nèi)并發(fā)癥發(fā)生率相比OCME組有降低趨勢(12.9%和24.7%,P=0.05),乳糜漏的發(fā)生率LCME組明顯低于OCME組(P<0.05)。兩組患者均無住院死亡病例(表2)。
表2 LCME與OCME患者手術(shù)情況比較 (n=85;
2.2 手術(shù)質(zhì)量分級指標比較 LCME組中West C級79例(92.9%),West B級6例(7.0%)。OCME組中West C級81例(95.2%),West B級4例(4.7%),差異無統(tǒng)計學意義。兩組中無West A級病例。
2.3 術(shù)后病理結(jié)果比較 兩組在腫瘤直徑、淋巴結(jié)清掃數(shù)目、腫瘤TNM分期、組織學分型方面差異無統(tǒng)計學意義(均P>0.05,表3)。
2.4 隨訪結(jié)果比較 術(shù)后隨訪48個月,每3個月隨訪1次,隨訪內(nèi)容包括腫瘤標志物、胸部、腹盆腔影像學檢查(B超、CT)及腸鏡等。LCME組隨訪67例,OCME組隨訪61例,兩組腫瘤局部復發(fā)率和遠處轉(zhuǎn)移率差異無統(tǒng)計學意義(表3)。
表3 LCME與OCME組患者術(shù)后病理及隨訪結(jié)果比較 (n=85;
自1990年,Jacobs等[7]實施第一例腹腔鏡右半結(jié)腸切除術(shù)以來,腹腔鏡技術(shù)發(fā)展迅速,目前幾乎所有類型的結(jié)直腸手術(shù)均可由腹腔鏡完成。CME手術(shù)的核心要點為:保證臟層筋膜完整,銳性分離筋膜;中央?yún)^(qū)血管高位結(jié)扎;規(guī)范的區(qū)域淋巴結(jié)清掃。我中心的腹腔鏡手術(shù)也始終是按CME原則的要求實施。
在手術(shù)操作方面,右半結(jié)腸LCME手術(shù)的難點在于尋找正確的層面,即準確進入Toldt間隙。通常采用中間入路,以回結(jié)腸血管內(nèi)側(cè)的系膜為切入點[8],此處無重要結(jié)構(gòu),損傷輸尿管和重要血管的機會較小。
在手術(shù)質(zhì)量控制方面,手術(shù)切除平面分級最初被應(yīng)用在腹腔鏡輔助手術(shù)對比開腹手術(shù)治療直腸癌的CLASICC[9]研究中。目前已經(jīng)有大量研究證實,直腸癌手術(shù)質(zhì)量會影響患者的局部復發(fā)和遠期生存,且可以通過手術(shù)切除平面來作出預(yù)測[10,11]。West等[6]首先將手術(shù)切除平面的病理分級系統(tǒng)應(yīng)用于結(jié)腸癌手術(shù)的質(zhì)量評價,并發(fā)現(xiàn),手術(shù)切除平面分級與腫瘤局部復發(fā)率無明顯相關(guān),但單因素分析時West C級患者的5年總生存率比West A級患者提高15%,患者總生存率與手術(shù)質(zhì)量明顯相關(guān),說明手術(shù)切除平面病理分級系統(tǒng)可以很好的反應(yīng)手術(shù)的質(zhì)量和療效。本研究中,兩組手術(shù)平面分級均達WestB級、C級,無WestA級病例,差異無統(tǒng)計學意義,進一步證實,LCME同OCME相比在手術(shù)質(zhì)量上無差異,手術(shù)治療效果相當。
在腫瘤根治性方面,研究已證實手術(shù)清掃淋巴結(jié)數(shù)目的增加與Ⅱ/Ⅲ期結(jié)腸癌術(shù)后生存率的提高相關(guān)[12,13]。本研究所有病例的淋巴結(jié)清掃數(shù)目均符合NCCN診治指南要求(≥12枚),且LCME與OCME組淋巴結(jié)檢出數(shù)分別為28枚和27枚,差異無統(tǒng)計學意義,既往文獻[14-16]也有類似報道。同時,兩組標本環(huán)周切緣及遠近端切緣均為陰性。本研究初步證實LCME與OCME的腫瘤根治性效果相當,亦可作為可供選擇的手術(shù)方式。
在術(shù)后并發(fā)癥方面,腹腔鏡結(jié)直腸癌手術(shù)相對于開腹手術(shù)外科具有創(chuàng)傷小,應(yīng)激水平低的優(yōu)勢,老年患者行腹腔鏡手術(shù)時獲益較多[17,18]。本研究中LCME組相比OCME組術(shù)后30 d內(nèi)并發(fā)癥發(fā)生率有降低趨勢(P=0.05未達統(tǒng)計學意義),可能與本研究入組樣本量較小有關(guān)。術(shù)后心腦血管疾病,肺部感染發(fā)生率差異無統(tǒng)計學意義。乳糜漏是CME術(shù)后一種常見并發(fā)癥,發(fā)生率高達13.5%[19]。本研究中LCME組乳糜漏發(fā)生率明顯低于OCME組,這可能與超聲刀等設(shè)備的使用以及腹腔鏡的放大效應(yīng)帶來的操作細致性有關(guān)。因此,我們認為LCME手術(shù)的安全性不劣于OCME。
在患者預(yù)后方面,兩組患者術(shù)后隨訪48個月,局部復發(fā)率和遠處轉(zhuǎn)移率的差異無統(tǒng)計學意義。但我們認為,由于本研究樣本量較少、隨訪時間仍較短,術(shù)后患者遠期生存情況仍需進一步觀察。Kitano等[20]發(fā)現(xiàn),結(jié)直腸癌腹腔鏡手術(shù)與傳統(tǒng)開腹手術(shù)相比,Ⅱ/Ⅲ期患者有更高的5年生存率。
老年患者的心、腦、肺重要臟器的生理儲備功能較差、代償能力不足,同時其免疫功能較低,手術(shù)創(chuàng)傷可能使機體相關(guān)情況進一步惡化,存在一定的手術(shù)風險。有研究發(fā)現(xiàn),腹腔鏡手術(shù)在對老年人免疫功能的影響及術(shù)后炎性反應(yīng)方面均優(yōu)于開腹手術(shù)[21]。本研究也發(fā)現(xiàn).腹腔鏡手術(shù)對老年患者生理功能影響小、切口創(chuàng)傷小、術(shù)后疼痛輕,對于老年患者機體狀態(tài)的穩(wěn)定更加有優(yōu)勢。
LCME相較于OCME手術(shù)在老年患者中行右半結(jié)腸癌切除的手術(shù)質(zhì)量、根治程度、實用性、安全性方面均無明顯差異,故LCME具有廣闊的發(fā)展空間。目前,對老年患者LCME的研究多為單中心回顧性研究,仍需多中心RCT研究進一步證實其遠期療效。
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Comparisonofefficacyandsafetybetweenlaparoscopicassistedandopentotalmesorectalexcisioninthetreatmentofrightcoloncancerintheelderly
CUI Yong1,CHENG Shujie2,ZHANG Yanbei3,WANG Qian4,and HUO Ran5.
1.Surgical Oncology,2.Department of General Surgery,5.Medical Oncology,Affiliated Hospital of Hebei University,Baoding 071000,China;3.Petvic Sursery,4.Department of Pcediatrics,Baoding No.1 Hospital, BaoDing 071000,China
ObjectiveTo evaluate the safety and feasibility of laparoscopic-assisted CME (laparoscopic complete mesocolic excision, LCME) and open CME (open complete mesocolic excision, OCME) in the treatment of elderly patients with right colon cancer.MethodsData was collected retrospectively by reviewing the medical records of 170 patients of right-sided colon cancer who had undergone right colectomy in the Affiliated Hospital of Hebei University between April 2011 and September 2015. The elderly patients were equally divided into LCME group and OCME group based on the approach to colectomy. Demographic variables including age, gender, information on surgery,pathological findings and follow-up were collected and analyzed.ResultsThe median blood loss, median time to anal exhaust, post-operative liquid food, and hospital stay were significantly shorter or lower in LCME group than those in OCME group (P<0.05). The difference of durations of surgery, operation quality grading、cardiac-cerebrovascular accidents,tumor diameter and the number of harvested lymph nodes were not statistically significant between the two groups (P>0.05). After follow-up of 48 months, the rate of local recurrence and distant metastasis showed no significant difference between the two groups (P>0.05).ConclusionsLCME is a safe and feasible treatment for elderly patients with right colon cancer. It can facilitate the recovery of postoperative patients.
colon cancer; complete mesocolic excision; laparoscopic surgery; right hemicolectomy,operation quality grading;senile patients
R735.35
河北省政府資助臨床醫(yī)學優(yōu)秀人才培養(yǎng)項目 (361007)
崔 勇,碩士,主治醫(yī)師。
071000 保定,河北大學附屬醫(yī)院:1.腫瘤外科,2.普外科,5.腫瘤內(nèi)科;071000 保定市第一醫(yī)院:3.直腸外科,4.兒科
霍 然,E-mail:mycymail@163..com
(2017-06-21收稿 2017-10-02修回)
(責任編輯 張 楠)