改良的腹腔镜辅助下ELAPE手术临床效果观察

目的比较一种改良的腹腔镜辅助下的肛提肌外肌腹会阴联合切除术（ELAPE）和常规腹腔镜辅助的腹会阴联合切除术（APR）两种手术方法治疗需切除肛门的低位直肠癌的临床效果差异。 方法选取2015年12月至2021年6月68位低位直肠癌患者的病例资料，随机分为APR组和改良ELAPE组，每组34例。APR组患者给予常规APR术，改良ELAPE组患者给予改良的ELAPE术，比较分析两组患者治疗效果。临床参数包括手术时间、术中出血量、淋巴结阳性率、术中穿孔、环周切缘阳性率、排气时间、排便时间、进食时间、腹腔引流量、会阴切口拆线时间、盆腔引流管拔除时间、住院时间；术后并发症包括术后盆腔出血、肠梗阻、会阴切口感染、会阴切口周围血肿以及其他少见并发症，随访结果项目包括局部复发率、远处转移率和死亡率。 结果改良ELAPE组手术时间长于APR组，差异具有统计学意义（t=5.490，P=0.000）；术中出血量（t=-0.775，P=0.441）、淋巴结阳性率（χ²=0.553，P=0.457）、环周切缘阳性率（χ²=0.863，P=0.353）、穿孔率差异无统计学意义；改良ELAPE组排气时间（t=-4.403，P=0.000）、排便时间（t=-2.934，P=0.005）、会阴切口拆线时间（t=-2.490，P=0.015）均早于APR组，腹腔引流量少于APR组（t=3.524，P=0.001），差异具有统计学意义；两组进食流质食物时间（t=0.593，P=0.555）、盆腔引流管拔除时间（t=1.581，P=0.122）、住院时间（t=-1.465，P=0.148）无明显差别，差异均无统计学意义；两组患者术后盆腔出血（t=4.24，P=0.94）、肠梗阻（t=5.55，P=0.58）、会阴切口感染（t=7.74，P=0.54）、会阴切口周围血肿（t=8.55，P=0.14）以及其他少见并发症（t=3.11，P=0.41）比较差异均无统计学意义；术后随访6~60个月，改良ELAPE组局部复发率（χ²=5.639，P=0.018）、远处转移率（χ²=4.178，P=0.041）均低于APR组，差异具有统计学意义，两组死亡率差异无统计学意义（χ²=2.601，P=0.107）。 结论改良的腹腔镜辅助的ELAPE手术较传统腹腔镜辅助的APR手术来说是一个安全有效的手术方式，能有效减少局部复发和远处转移，加快患者术后康复，值得临床推广。

Evaluation of clinical efficacy of modified laparoscopic assisted ELAPE surgery

ObjectiveTo observe and evaluate the different clinical effects between laparoscopic assisted modified extralevator abdominoperineal excision (ELAPE) and abdominoperineal resection (APR) on low rectal cancer with resection of anus. MethodsProspective studies were conducted between December 2015 and June 2021. Sixty-eight patients with low rectal cancer were randomly assigned to modified laparoscopic assisted ELAPE surgery group and traditional laparoscopic APR surgery group, thirty-four patients for each. Then the clinical efficacy of different groups would be evaluated . The clinical and pathological parameters including operation time, blood loss, lymph nodes positive rate, perforation rate, positive rate of circumferential, exhaust time, defecation time, eating time, abdominal drainage flow, perineal incision suture-out time, pelvic drainage tube removal time and hospital stay; Postoperative complications included postoperative pelvic hemorrhage, intestinal obstruction, perineal incision infection, perineal incision hematoma and other rare complications. The follow-up results included local recurrence rate, distant metastasis rate and mortality. ResultsThe operation time in ELAPE group was significantly longer than that in APR group (t=5.490, P=0.000); There was no significant difference in intraoperative bleeding (t=-0.775, P=0.441), lymph node positive rate (χ²=0.553, P=0.457), positive rate of circumferential margin (χ²=0.863, P=0.353) and perforation rate; exhaust time (t=-4.403, P=0.000). The defecation time (t=-2.934, P=0.005) and perineal incision suture-out time (t=-2.490, P=0.015) in ELAPE group were earlier than those in APR group, the abdominal drainage flow less than APR group (t=3.524, P=0.001), the difference was statistically significant. There was no significant difference in the time of eating liquid food (t=0.593, P=0.555), pelvic drainage tube removal (t=1.581, P=0.122) and hospital stay (t=-1.465, P=0.148) between the two groups; There was no significant difference in postoperative pelvic hemorrhage (t=4.24, P=0.94), intestinal obstruction (t=5.55, P=0.58), perineal incision infection (t=7.74, P=0.54), perineal incision hematoma (t=8.55, P=0.14) and other rare complications (t=3.11, P=0.41) between the two groups. After follow-up for 6~66 months, the local recurrence rate (χ²=5.639, P=0.018) and distant metastasis rate (χ²=4.178, P=0.041) in ELAPE group were lower than those in APR group, the difference was statistically significant, and there was no significant difference in mortality between the two groups (χ²=2.601, P=0.107). ConclusionCompared with the traditional APR, the modified laparoscopic assisted ELAPE is a safer surgery, which can effectively reduce the local recurrence rate and distant metastasis rate, as well as accelerate the postoperative rehabilitation of patients. In our opinion, this surgical procedure is worth of recommendation.