不同取标本途径在直肠癌微创手术中的疗效对比

目的对常规直肠癌经辅助切口取标本与经自然腔道取标本手术（NOSES）进行比较，探讨NOSES的近远期疗效。 方法回顾性分析2018年1月至2020年12月大连医科大学附属第二医院胃肠外科行直肠癌微创手术的217例患者的临床资料，根据标本取出方式不同分为NOSES组（研究组）和传统经腹部辅助切口组（对照组）。采用PSM平衡两组患者术前基本资料，研究组和对照组各纳入患者63例，比较两组患者的围手术期资料、术后病理资料及远期随访资料。 结果研究组患者腹壁切口更短（t=-19.791，P＜0.001），术后离床时间更早（t=-5.978，P＜0.001），胃肠道功能恢复更快（t=-7.656，P＜0.001），疼痛评分更低（术后12 h：t=-4.372，P＜0.001；术后24 h：t=-5.835，P＜0.001），两组对比差异均存在统计学意义。研究组患者切口并发症发生率明显低于对照组，差异存在统计学意义［（0）vs.（9.5%），χ²=4.375；P=0.028］。采用Clavien-Dindo分级标准对术后并发症进行分类，研究组共8例术后并发症（12.7%），其中CD Ⅰ级并发症3例（4.8%），CD Ⅱ级并发症2例（3.2%），CD Ⅲ级并发症3例（4.8%）；研究组术后并发症发生率较对照组低，但差异无统计学意义［（12.7%）vs.（22.2%），χ²=1.983；P=0.159］。对比两组患者的术后病理资料及远期随访资料，在淋巴结检出总数（t=0.603，P=0.548）、近切缘（t=-0.110，P=0.912）及远切缘长度（t=-0.126，P=0.900）、总生存率（χ²=0.002，P=0.962）及无病生存率（χ²=0.625，P=0.429）上，差异均无统计学意义。 结论NOSES安全可行，具有术后疼痛轻、损伤小、胃肠道功能恢复较快等优点，具有与传统经辅助切口取标本手术相似的长期肿瘤学结果。

Comparison of different methods of specimen collection in minimally invasive surgery for rectal cancer

ObjectiveDemonstrated the short- and long-term efficacy of NOSES by comparing abdominal incision for specimen extraction and natural orifice specimen extraction surgery (NOSES) in the treatment of rectal cancer. MethodsWe retrospectively analyzed the clinical data of 217 patients who underwent NOSES or conventional minimally invasive surgery in the department of gastrointestinal surgery of the Second Affiliated Hospital of Dalian Medical University from January 2018 to December 2020. According to the different methods of the removal of surgical specimen, all patients were divided into the following groups: NOSES group (experimental group) and the auxiliary incision group (control group). PSM was used to balance the baseline data, there were 63 patients in the NOSES group and 63 patients in the auxiliary incision group, respectively; perioperative data, pathological data and the long-term efficacy were analyzed among two groups. ResultsCompared to the auxiliary incision group, patients in the NOSES group had shorter incision lengths (t=-19.791, P＜0.001), earlier out-of-bed time (t=-5.978, P＜0.001), shorter postoperative gastrointestinal recovery time (t=-7.656, P＜0.001) and lower VAS score of the incision pain (postoperative 12 h: t=-4.372, P＜0.001; postoperative 24 h: t=-5.835, P＜0.001), these differences were statistically significant. The incidence of incision complications in the NOSES group was significantly lower than that in the auxiliary incision group(0 vs. 9.5%, χ²=4.375; P=0.028). Postoperative complications were graded by Clavien-Dindo classification, postoperative complications occurred in 8 patients in the NOSES group (12.7%), the amounts of Clavien-Dindo grade Ⅰ, Ⅱ and Ⅲ complications were 3 (4.8%), 2 (3.2%) and 3 (4.8%); compared to the auxiliary incision group, the NOSES group had lower rate of postoperative complications, but no difference was statistically significant (12.7% vs. 22.2%, χ²=1.983; P=0.159). Compared the pathological data and the long-term efficacy of two groups, there were all no significant differences in the number of dissected lymph nodes (t=0.603, P=0.548), the length of proximal margin (t=-0.110, P=0.912) and distal resection margin (t=-0.126, P=0.900), overall survival (χ²=0.002, P=0.962) and disease-free survival (χ²=0.625, P=0.429). ConclusionNOSES has obviously advantages of less postoperative pain, smaller damage and earlier postoperative recovery, provides satisfactory efficacy and acceptable safety, and similar long-term oncologic outcomes compared with conventional minimally invasive surgery.