目的 对比经肛内镜入路经括约肌间切除术(transanal endoscopic intersphincteric resection,TaE-ISR)与完全经腹入路经括约肌间切除术(completely transabdominal approach for intersphincteric resection,CTA-ISR)治疗超低位直肠癌的围手术期安全性和肿瘤学疗效.方法 回顾性分析2022年6月至2023年6月期间在上海交通大学医学院附属瑞金医院接受TaE-ISR或CTA-ISR患者的临床资料,其中38例行TaE-ISR,16例行CTA-ISR.比较2组患者的手术相关指标(包括手术时间、毗邻脏器损伤、保护性造口、留置肛管)、术后恢复及并发症、肿瘤学结果(包括环周切缘阳性率、远端切缘长度、淋巴结获取数目等).结果 TaE-ISR组患者的肿瘤下缘距肛缘距离比CTA-ISR组更低[4.0(3.4,4.5)cm vs 4.9(4.1,5.9)cm)],差异具有统计学意义(P＜0.001).TaE-ISR组的手术时间更长[(177.18±37.24)minvs(146.25±38.86)min]、留置肛管率更高[97.4％(37/38)vs 56.3％(7/16)]、保护性造口率更高[94.7％(36/38)vs 12.5％(2/16)],经肛取标本率更高[92.1％(35/38)vs0％(0/16)],术后首次半流质饮食时间更快[4(3,5)dvs6(5,6)d],差异均有统计学意义(P＜0.05).TaE-ISR组未发生毗邻脏器损伤,而CTA-ISR组有2例患者出现术中毗邻脏器损伤(0％vs12.5％),差异有统计学意义(P=0.026).2组患者的术后住院时间、术后首次排气时间、术后并发症Clavien-Dindo分级、吻合口漏和吻合口狭窄发生率、远切缘长度、淋巴结清扫总数及阳性淋巴结数目比较差异均无统计学意义(P＞0.05).所有病例术后标本远端切缘均充足、环周切缘均为阴性.结论 TaE-ISR与CTA-ISR均可应用于超低位直肠癌的保肛手术,两者相比TaE-ISR在肿瘤下缘距肛缘距离较近时可能是一种较CTA-ISR更为合理的入路方式.
A comparative study of transanal endoscopic approach and completely transabdominal approach in intersphincteric resection
Objective To compare the perioperative safety and oncologic efficacy of transanal endoscopic intersphincteric resection(TaE-ISR)and the completely transabdominal approach intersphincteric resection(CTA-ISR)for the treatment of ultra-low rectal cancer.Methods Clinical data of patients who underwent TaE-ISR or CTA-ISR at Ruijin Hospital,Shanghai Jiao Tong University School of Medicine,from June 2022 to June 2023,were retrospectively analyzed.A total of 38 cases of TaE-ISR and 16 cases of CTA-ISR were included.Comparison of surgery-related indexes(including operation time,injury of adjacent organs,protective stoma,and placement of anal tube),postoperative recovery and complications,and oncological results(including positive rate of circumferential resection margin,positive rate of distal resection margin,and number of lymph nodes)were compared between the 2 groups.Results The distance of the lower edge of the tumor from the anal verge was lower in the TaE-ISR group than that in the CTA-ISR group[4.0(3.4,4.5)cm vs.4.9(4.1,5.9)cm,P＜0.001].A longer duration of the surgery[(177.18±37.24)min vs(146.25±38.86)min],a higher rate of the anal tube[97.4％(37/38)vs 56.3％(7/16)],a higher rate of protective stoma[94.7％(36/38)vs 12.5％(2/16)],and a higher rate of transanal specimen extraction[92.1％(35/38)vs 0％(0/16)],faster time to first postoperative semi-liquid diet[4(3,5)d vs 6(5,6)d]were observed in the TaE-ISR group(P＜0.05).No adjacent organ injuries occurred in the TaE-ISR group,whereas 2 patients in the CTA-ISR group had intraoperative adjacent organ injuries(0％vs 12.5％),the difference was statistically significant(P=0.026).There was no statistically significant difference between the 2 groups in terms of postoperative hospitalization,postoperative time to first flatus,Clavien-Dindo grading of postoperative complications,the incidence of anastomotic leakage and anastomotic stenosis,distal margin distance,the total number of lymph nodes cleared,and the number of positive lymph nodes(P＞0.05).Postoperative specimens in all cases were adequate for distal margins and negative for circumferential margins.Conclusion TaE-ISR and CTA-ISR can both be applied to anus-preserving surgery for ultra-low rectal cancer,but TaE-ISR may be a more reasonable approach than CTA-ISR when the lower edge of the tumor is closer to the anal verge.
ultra-low rectal cancerintersphincteric resectioncompletely transabdominal approachtransanal endoscopic surgery
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