乙状结肠及直肠癌NOSES手术困难的影响因素分析

目的分析乙状结肠及直肠癌NOSES手术困难的影响因素。 方法回顾性分析了2017年1月至2021年3月期间郑州大学第一附属医院和河南大学淮河医院结直肠外科收治的315例乙状结肠和直肠癌试行NOSES患者的临床病例资料，包括术前检查、手术过程以及手术结果。采用单因素分析和多因素Logistic回归模型分析对导致手术困难的影响因素进行分析。 结果纳入的315例患者中，男性200例，女性115例。年龄（61±13）岁，肿瘤最大径中位数为3.6（P25，P75：2.8，4.8）cm。其中223例（70.8%）经直肠残端取出标本困难。单因素分析显示，BMI＞25.0 kg/m²（χ²=5.987，P=0.014）、肿瘤并肠腔狭窄（χ²=9.170，P=0.002）、肿瘤距肛缘距离＞5.0 cm（χ²=5.275，P=0.022）、肿瘤最大径＞5.0 cm（χ²=5.735，P=0.017）、直肠系膜前后径＞6.0 cm（χ²=7.708，P=0.005）以及手术医师学习曲线≤50例（χ²=5.013，P=0.025）与标本经直肠残端取出困难有关（均P＜0.05）。而年龄、性别、腹部手术史等与标本经直肠残端取出困难无关（均P＞0.05）。多因素分析显示，BMI＞25.0 kg/m²、肿瘤并肠腔狭窄、肿瘤距肛缘距离＞5.0 cm、肿瘤最大径＞5.0 cm、直肠系膜前后径＞6.0 cm以及手术医师学习曲线≤50例是造成NOSES手术困难的独立影响因素（均P＜0.05）。 结论手术前评估BMI、肿瘤距肛缘距离、是否肿瘤并肠腔狭窄、肿瘤最大径、直肠系膜前后径及手术医师的经验等临床因素，有利于筛选比较合适的乙状结肠及直肠癌患者进行经直肠残端取标本手术。

Analysis of the influencing factors of the failure of NOSES for colorectal cancer

ObjectiveTo analyze the influencing factors of the failure of NOSES for sigmoid cancer and rectal cancer. MethodsA retrospective case-control study was conducted. Clinical data of 315 cases of sigmoid and rectal cancer patients undergoing trial NOSES in the colorectal surgery department of the First Affiliated Hospital of Zhengzhou University and Huaihe Hospital of He'nan University from January 2017 to March 2021, including preoperative examination, surgical process and surgical results. Univariate analysis and multivariate Logistic regression model were used to analyze the influencing factors leading to surgical difficulty. ResultsAmong the 315 patients included, 200 were males and 115 were females. The age was (61±13) years old, and the median size of the largest tumor was 3.6 (P25, P75: 2.8, 4.8) cm. Among them, 223 cases (70.8%) had difficulty in removing specimens by NOSES. Univariate analysis showed that BMI＞25.0 kg/m² (χ²=5.987, P=0.014), tumor obstruction (χ²=9.170, P=0.002), tumor distance from anal edge＞5.0 cm (χ²=5.275, P=0.022), tumor maximum diameter＞5.0 cm (χ²=5.735, P=0.017), the anterior and posterior diameter of the mesorectal＞6.0 cm (χ²=7.708, P=0.005), and the learning curve of the surgeon ≤50 cases (χ²=5.013, P=0.025) were associated with the difficulty of NOSES (all P＜0.05). Age, sex and history of abdominal surgery were not associated with the difficulty of NOSES (all P＞0.05). Multivariate analysis revealed that BMI＞25.0 kg/m², tumor obstruction, tumor distance from the anus to＞5.0 cm, tumor maximum diameter＞5.0 cm, mesorectal diameter＞6.0cm, and learning curve ≤50 cases were independent influencing factors for NOSES difficulty (all P＜0.05). ConclusionsPreoperative evaluation of BMI, tumor distance from anal margin, tumor obstruction, tumor maximum diameter and mesorectal anteroposterior diameter is helpful for selecting suitable sigmoid colon and rectal cancer patients for NOSES.