腹腔镜中低位直肠癌根治术中盆腔自主神经监测(IMPAN)的价值

目的 通过应用术中盆腔自主神经监测（intraoperative monitoring of pelvic autonomic nerves，IMPAN）对中低位直肠癌腹腔镜手术中盆腔自主神经丛（pelvic autonomic nerve plexus，PANP）进行探查和保护，探讨术中盆腔神经保护的方法及神经监测的临床疗效。方法 回顾性分析2012年1月至2018年12月在复旦大学附属华山医院开展的腹腔镜中低位直肠癌根治术患者的临床资料，筛选其中79例术前肛门功能正常、性生活相对活跃的资料完整患者进入本研究，其中盆腔神经丛监测组包括双侧监测和单侧监测共43例，常规直肠全系膜切除术（total mesorectal excision，TME）肉眼判断者36例为对照组。比较两组手术时间、术中出血量、淋巴结阳性人数比例、术后平均住院时间及留置导尿管时间，通过标准化问卷随访比较两组患者术后生活质量、术后排尿功能、排便功能及性功能变化。结果 监测组与对照组平均手术时间、术中出血量、淋巴结阳性人数比例、术后平均住院时间及留置导尿管时间差异无统计学意义（P>0.05）。在79例患者中，双侧监测成功组（n=33）患者术后泌尿功能、生活质量相对较高，造口回纳后性功能障碍发生率较低。术后1年双侧监测组与对照组（n=36）相比，国际前列腺症状评分（international prostate symptom score，IPSS）分别为2.94±2.49 vs.5.19±3.30，生活质量（quality of life，QoL）评分为1.73±0.67 vs.2.56±0.84，差异有统计学意义（P<0.05），其中男性患者双侧监测组（n=21）与对照组（n=23）国际勃起功能问卷-5（international index of erectile function-5，IIEF-5）评分分别为20.23±3.86 vs.16.30±3.98，差异有统计学意义（P<0.05）。双侧监测组患者Wexner评分（4.21±1.47）低于单侧监测组（4.90±0.88）及对照组（6.00±1.70）（P<0.05）。单侧监测组（n=10）患者术后5~6月泌尿功能有轻度障碍，随着术后康复时间延长有所改善，术后1年泌尿、排便及性功能障碍发生率也相对较低，与对照组相比差异有统计学意义（P<0.05）。结论 腹腔镜中低位直肠癌根治术中采用IMPAN技术有助于定位盆腔植物神经的走向、变异以及确认其功能完整性，降低医源性损伤的发生率，提高患者的生活质量，改善预后。

The value of intraoperative monitoring of pelvic autonomic nerves （IMPAN） during laparoscopic surgery for middle and low resection cancer

Objective To discuss the method of pelvic autonomic nerve plexus (PANP) protection and the clinical efficacy of the nerve monitoring through the application of intraoperative monitoring of pelvic autonomic nerves (IMPAN) for exploring and protecting PANP during laparoscopic surgery of middle and low rectal caner. Methods We retrospectively investigated a series of patients undergoing laparoscopic radical resection of low and middle rectal cancer from Jan 2012 to Dec 2018 in Huashan Hospital,Fudan University.Seventy-nine cases with normal anus function and relatively active sexual life before the operation were enrolled in this study,among which IMPAN group included a total of 43 patients who were performed of bilateral and unilateral monitoring,the conventional total mesorectal excision (TME) judging by naked eye as control group included 36 patients.We then compared the two groups of operation time,intraoperative blood loss,percentage of lymph node positive,the average length of hospital stay and postoperative urethral catheter time.Meanwhile,we compared the two groups of patients with postoperative quality of life,urinary function,anorectal function,sexual function through a standardized questionnaire. Results The average operation time,intraoperative blood loss,percentage of lymph node positive,the average length of hospital stay and postoperative urethral catheter time did not show significant difference between the two groups(P>0.05).In the 79 cases,the patients in the bilateral monitoring group (n=33) had relatively fine postoperative urinary function,quality of life,and a low incidence of sexual dysfunction after recovering the stoma.Compared bilateral monitoring patients with the control group (n=36),IPSS (international prostate symptom score) at 1 year after operation was 2.94±2.49 vs.5.19±3.30,and QoL (the quality of life)score was 1.73±0.67 vs.2.56±0.84,the difference was statistically significant (P<0.05).Among these,IIEF-5 (international index of erectile function-5)score was 20.23±3.86 vs.16.30±3.98 between male patients in bilateral monitoring (n=21) and control group (n=23) respectively (P<0.05).Wexner score in the bilateral monitoring group (4.21±1.47) was lower than that in the unilateral monitoring group (4.90±0.88)and the control group (6.00±1.70) (P<0.05).The urination function in the unilateral monitoring group (n=10) was mildly impaired through 5 to 6 months after the operation.But with the extension of postoperative recovery time,the incidences of urination,defecation and sexual dysfunction were also relatively lower at 1 year after the operation compared with the control group (P<0.05). Conclusion The application of IMPAN could help to locate the trend and variation of pelvic plexus and confirm its functional integrity,reduce the incidence of iatrogenic injury,improve the quality of life of patients and improve prognosis.