低位直肠癌腹腔镜辅助下腹会阴联合切除术

1、    低位直肠癌腹腔镜辅助下腹会阴联合切除术        摘要目的评估低位直肠癌的腹腔镜辅助下手术是否优 于传统的腹会阴联合切除术。方法研究组在59例连续入院的患者 中选择24例进行腹腔镜辅助下腹会阴联合切除术，研究组与其他34例用传统方法手术的患者 (对照组)进行比较。结果研究组和对照组分别随访30.1个月和28 . 3个月。研究组较对照组手术时间明显延长(P0.001)，而术中出血量(P0.02) 和术后镇痛剂的需要量(P0.02)明显少于对照组，恢复正常饮食的时间(

2、P0.04)和总住院时间(P0.02)明显短于对照组。两组的肿 瘤清除情况、并发症发生率、无瘤间期和生存率无明显差别。结论腹腔镜辅助下腹会阴联合切除术与传统手术比较术后恢复较快，而肿瘤清除情况、并发症 、病死率、无瘤间期以及生存率无明显差别。关键词结直肠肿瘤外科手术腹腔镜Laparoscopic assisted abdomino-perineal resection for low rectal adenocarcinomaK.L.Leung，S.P.Y.Kwok*，W.Y.Lu，W.C.S Meng，C.C.Chung，P.B.S. Lai，K.H.Kwong*From the Depar

3、tment of Surgery, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong and the Department of Surgery , United Christian Hospital, Hong Kong*All correspondence to: Professor W.Y.Lau, Department of Surgery, The Chinese University of Hong Kong, Prince of Wal

4、es Hospital Shatin, New Territories, Ho ng KongFAX NO:(852)26377974Telephone NO:(852)26322623AbstractObjectiveTo find out whether laparoscopic assisted was better than open abdomino-perinea l resection for low rectal adenocarcinoma.Method Twenty-five (stu dy group) out of 59 consecutive patients who

5、 were considered su itable were selected for laparoscopic assisted abdomino-perineal resection. The y were compared with the other 34 patients operated by open method (control grou p).Results The median follow up time for the study and control groups were 30.1 and 28.3 months respectively. The opera

6、tion time was significa ntly longer (t-test, P0.001),while the operative blood loss (Mann-Whitn ey U test, P=0.02),the postoperative analgesic requirement (Mann Whitney U test,P=0.02),the time to r esume normal diet (Mann-Whitney U test, P=0.04) and the total hospital stay (Mann-Whitney U test,P=0.0

7、2) were significanty less in the study than in t he control group. The oncological clearance, the complication rate, the disease free interval and survival were comparable in the two groups. Conclusion Laparoscopic assisted abdomino-perineal resection allowed earlier postoperative recovery, with com

8、parable oncological clearance, morbidity, mortality, disease free interval and survival.Key wordsColorectal neoplasms Surgical procedureLaparoscopicIntroductionSince the successful introduction of laparoscopic cholecystectomy, laparoscopic a ssisted colorectal surgery has been widely attempted by en

9、thusiastic surgeons. P romising early results were reported1-4. However, most of the series i nclud ed a heterogeneous group of benign and malignant diseases, as well as procedures of different magnitudes. The efficacy of a right hemicolectomy may not be the s a me as that of a left hemicolectomy, a

10、nd most likely different from that of a col ostomy. Abdomino-perineal resection for cancer attracts separate consideration because of the concern of sacrificing the anal sphincter unnecessarily and the i ntrinsically high urogenital and perineal wound complication rates5-7. Fu rthermore,few studies

11、have compared statistically the outcome of laparoscopic a n d conventional surgery in a cohort of patients. With increasing number of cases and the length of follow up time, interpretation of recurrence and survival data becomes more meaningful. This study aimed to find out whether laparoscopic assi

12、 sted resection was better than open abdomino-perineal resection for low rectal adenocarci noma. The data was prospectively collected in a time period when both approaches were used.Patients and methodFrom January 1993 to January 1996,69 abdomino-perineal resections were performe d for patients with

13、 adenocarcinoma of low rectum. Ten patients were excluded fro m this study because they were considered not suitable for the laparoscopic assis ted resection, of which four patients had very bulky disease on investigations, three patients presented with recurrent or metachronous tumours, and three p

14、atie nts were planned for low anterior resection but failed to preserve the anal sphi ncter at operation.In the remaining 59 patients, laparoscopic approach was considered possible and it was attempted in 25 patients. All procedures were performed or supervised by surgeons experienced in colorectal

15、surgery. The selection of patients for the la paroscopic assisted resection depended on the availability of informed consent, laparoscopic instruments as well as surgeons experienced in laparoscopic surgery . We have not performed any emergency abdomino-perineal resection in this perio d.All patient

16、s underwent pre-operative colonoscopy and biopsy of the tumour. Tran sabdominal ultrasonography was used to assess the size of the tumour, to look fo r evidence of local infiltration and/or distant metastasis. Computerized tomogra phy was performed when the patients had bulky disease. Bowel preparat

17、ion was wit h four liters of polyethylene glycol electrolyte solution the day before operati on. Systemic prophylactic antibiotics consisting of cefuroxime 750 mg and metron i dazole 500 mg were administered intravenously at induction of anaesthesia. Urina ry catheter and nasogastric tube were routi

18、nely used.Our laparoscopic approach has been reported previously4. In short, the pat ient was put in a Lloyd Davies position. Pneumoperitoneum was created by open te chnique. Three 12mm working ports were inserted under direct vision:at right med clavicular line at level of umbilicus, at right mid-c

19、lavicular line at level of anterior superior iliac spine, and at left mid-clavicular line at level of ant erior superior iliac spine. In the later cases we inserted the left lower quadra nt port at the intented site of colostomy. The sigmoid colon and rectum were mob ilized down to the pelvic floor.

20、 The ureters, the hypogastric nerve and pelvic p arasympathetic plexus were safeguarded. The lymphovascular pedicle, the sigmoid mesentery and sigmoid colon were transected with endo GIA (US Surgical Corp. Aut o Suture). With the help of the perineal surgeon, the rectum together with the w hole meso

21、rectum was fully mobilized and the specimen was retrieved through the p erineal wound. If the pelvic peritoneum could be conveniently approximated in th e midline, it was closed with EndoHernia (US Surgical Corp. AutoSuture) before t h e specimen was removed and the pneumoperitoneum lost. In some pa

22、tients, the pelv ic peritoneum was not closed. The perineal wound was closed primarily with a dra in put in the pelvic cavity via a separate stab wound or the posterior wall of v agina where appropriate (In open surgery, the pelvic peritoneum was routinely cl osed. The perineal drain was connected t

23、o low suction).A terminal colostomy was fashioned at the left lower quadrant port site after a 2cm disc of skin was exci sed. Post-operatively diet was resumed as soon as bowel function returned clini cally. Pethidine 1 mg/kg was given intramuscularly every four-hourly on demand. The patients were d

24、ischarged home when fully ambulatory. If necessary, patients were sent to convalescence hospital for wound care and/or colostomy training. Th e patients were then discharged when the perineal wound became manageable on an out patient basis. All patients were followed up regularly after discharge fro

25、m hospital.The following data were collected prospectively:sex, age, distance of tumour fro manal verge, operation time, post-operative analgesic requirement, time to res ume normal diet, duration of stay in the tertiary center and in the convalescenc e hospital, morbidity and mortality. The specime

26、ns were fixed unpinned and exami ned for tumour length, margin clearance and Dukes' staging. Adjuvant chemotherap y and radiotherapy were offered to patients whose tumour extended beyond the bow el wall or with lymph node metastasis. We have not offered pre-operative radio therapy to these patie

27、nts. Chi square test, Student t test, and Mann Whitney U t est were used to compare categorical, parametric and non-parametric data respec tively. Survival and disease free intervals were calculated with Kaplan-Meier m ethod, differences between groups were compared with log rank test.ResultsThe dem

28、ographic data are shown in Table 1. The two groups were comparable in sex , age, tumour length, tumour site as well as length of follow up. Patients in t he control group had more advanced Dukes' staging than the study group, but the difference is not significant.Table 1Demographic dataStudy gro

29、up(Converted cases included)Control groupNumber of patients2534Sex ratio (MF)15102113Age(years, mean & S.D.)62.2(13.3)63.5(15.2)Dukes' staging1/13/5/60/12/12/10(A/B/C/D)Length of tumour4.3(1.7)4.4(1.4)(cm,mean & S.D)Level of tumour from anal verge4.0(1.5)4.3(2.2)(cm, mean & S.D.)Surg

30、eons' experience6-11(9)3-22(9)(years, range & median)Follow up time6.0-52.3(30.1)1.9-55.1(28.3)(months,range & median)Complications of the two groups are shown in Table 2. There was no operative mor tality. In the study group, one patient passed 1200 mL of heavily blood-stained fluid fro

31、m the perineal drain in the recovery room, he did not show any signs of circulatory decompensation but remained stable on close observation.Another pat ient had prolonged fever after operation. Abdominal sonographic examination show ed a pelvic collection, which drained spontaneously via the perinea

32、l wound. Two patients needed conversion to open surgery because of unexpectedly bulky tumour which was not apparent on pre-operative investigation. One patient sustained ri ght ureteric injury after conversion and it was repaired immediately. There was one urinary fistula in each group, both resolve

33、d on conservative treatment. Prima ry healing failure of the perineal wound and urinary tract problems were common in both groups. Twenty-four patients(96%) in the study group and 26(76.5%) in t he control group had their perineal wounds completely healed on first follow up, the median of which were

34、 45 and 53.5 days from operation respectively. (P=0 .08 by fisher exact test). Table 2ComplicationsStudy group(Converted cases included)Control groupIntra-abdominal bleeding10Pelvic abscess10Pneumonia03Wound infection22Burst abdomen02Failed primary healing714of perineal woundUrinary retention59Urina

35、ry tract infection48Ureteric injury10Urinary fistula11Total22(12 patients)39(21 patients)The operation time was significantly shorter in the control group. The operative blood loss, the post-operative analgesic requirement, the time to resume nor mal diet and the total hospital stay were significant

36、ly less in the study group than in the control group(Table 3). Table 3Operation time, blood loss, analgesic require ment, time to resume normal diet, hospital stay and oncological clearanceStudy group(Converted cases included)Control groupp valuesOperation time215.6(47.9)166.3(36.3)0.001*(minutes,me

37、an & S.D.)Blood loss100-3000(500)400-3125(1000)0.02+(ml, range & median)Post-operative analgesic requirement0-36(5)0-35(11)0.02+(No. of injections,range & median)Time to resume normal diet2-15(4)3-22(4)0.04+(days, range & median)Stay in tertiary center5-27(8)6-39(10)0.12+(days, range

38、 & median)Total hospital stay7-66(16)10-66(25.5)0.02+(days, range & median)Lymph nodes removed2-31(10)1-41(12)0.34+(No. range & median)Resection margins involed21n.s.#+Mann Whitney Utest,*Student t test, #Chi square test. The oncological clearance in terms of number of lymph nodes remove

39、d was comparab le in both groups. In the study group, two patients had microscopical anal margi n involvement. The first patient was a converted case who had a bulky tumour and ureteric injury. The other patient had a linitis plastica type of tumour with a microscopic spread of more than 4cm. In the

40、 control group, one patient had late ral margin involvement.The survival rates at 4 years were 68.0%(standard error 9.3%) for the study grou p and 45.9% (standard error 9.3%) for the control group. This may reflect a diff erence in disease staging. However, stage by stage comparison for the two grou

41、ps showed no significant difference. The respective disease free rates at 4 years (Dukes' D diseases excluded) were 84.2% (standard error 8.4%) and 77.8%(standard error 8.8%). There were 3 recurrences in the study group (1 in bone, 1 in liver and 1 in pelvis) and 5 recurrences in the control gro

42、up (1 in bone, 2 in liver a nd 2 in pelvis). There was no port site recurrence in this study.DiscussionAlthough laparoscopic cholecystectomy has been shown to result in earlier recove ry when compared with open cholecystectomy, such benefit may not be conf errable to other procedures. Theoretically,

43、 laparoscopic surgery is more benefic ial to procedures in which the “access trauma” is significant and outweighs th e “dissection/resection trauma”. In this study, we were able to show that lap aroscopic assisted abdomino-perineal resection was less painful, allowed patien ts to resume diet and be

44、discharged home earlier. Long hospital stay in patients who underwent abdominoperineal resection is not uncommon because of the presenc e of a perineal wound8.Open abdomino-perineal resection is known to have a high complication rate whic h ranges from 23% to 76%. The commonest are urogenital and pe

45、rineal wound proble ms5-7. Bladder dysfunction occurs in 7% to 68% while failed primary he ali ng of the perineal wound occurs in 8% to 56% of cases. The wide variation in com plication rates probably reflects differences in the pick up rate and in the def ination of complications. In our series, th

46、e overall complication rate (56%) was comparable to those reported in conventional open surgery. There was no signifi cant difference between the study group(48%) and control group (62%) with a favo urable trend towards laparoscopic approach. We closed the perineal wound sometim es by closing the pe

47、lvic peritoneum and sometimes not because of technical reaso n and because the two alternatives were acceptable8. Dissecting with t he slim laparoscopic instruments has the advantage of having less squeeze on the re ctum, with less soiling in the perineum around the anal opening.In laparoscopic surg

48、ery for malignant disease, the adequacy of tumour clearance and the possible increased risk of disease dissemination are more important than an earlier post-operative recovery. Patients with early port site recurrenes h ave been reported with laparoscopic assisted colectomy for malignancy9-10 . In o

49、ur series, we were unable to find any port site recurrence or other uncomm on tumour recurrence with laparoscopic surgery. The oncological clearance in ter ms of the number of lymph nodes removed and the margin clearance was comparable in the two groups. There was also no difference in survival and

50、in disease free interval between the two groups on a stage by stage comparison.In surgery for carcinoma of rectum, concern was also raised as whether the anal sphincter could be preserved in some patients. For conventional open surgery, th e reported rate of abdomino-perineal resection varies betwee

51、n 11% to 55% of rec tal carcinoma7，11-14. The variation reflects the attitude and experie nce of the surgeons, and probably also a difference in referral pattern. For rectal cancer within 5 cm from the anal verge, abdomino-perineal resection is the onl y surgical option for most patients. As a polic

52、y, we do not attempt laparoscopic assisted resection if there is any possibility of preserving the anal sphincter. In our center, the estimated abdominoperineal resection rate in the study perio d was 27.6%(69 out of 250 rectal cancer) while the rate in the pre-study period was 31.3% (141 out of 451

53、 rectal cancer, from 1986 to 1992).There may be a selection bias in this study as the patients' allocation was not random. The significance of the end point parameters may also be interpreted as marginal because the number of patients is small. However, our results at this p reliminary stage sug

54、gest that laparoscopic assisted abdomino-perineal resection for low rectal carcinoma does not jeopardize our patients of adequate tumour cl earance. It offers the benefits of minimally invasive surgery. A randomized tria l, with larger sample size and longer follow up, is justified and has been star

55、t ed in our centre. The results will be available about 5 years later.作者单位：梁家骝刘允怡蒙家兴钟志超赖宝山：香港中文大学外科系郭宝贤邝国雄：香港联合医院外科References1Monson JRT, Darzi A, Carey PD, Guillou PJ. Prospective evaluati on of laparoscopic-assisted colectomy in an unselected group of patients. Lancet 199 2;340:831-833.2Tate JJT, Kwok S, Dawson JW, Lau WY, Li AKC. Prospective comparison of laparoscopic and c