直肠癌保留肛门括约肌手术适应证的选择及预后分析

目的探讨直肠癌保留肛门括约肌(sphincterpreservationoperation,SPO)手术选择标准,分析影响直肠癌保肛术适应证选择的因素。方法回顾性分析1994年4月至2004年4月间,手术治疗708例直肠癌患者的临床资料,对SPO术与经腹会阴切除手术(abdominoperinealresection,APR)两组患者的临床病理指标和生存率进行统计学比较。结果本组直肠乙状结肠交界段癌66例;直肠上段癌138例;直肠中段癌195例;直肠下段癌309例。APR术227例;SPO手术481例,其中Dixon手术449例,拖出保肛手术12例,“J”Poch20例。SPO和APR术两组患者在性别、年龄、肝脏转移、肿瘤长径、浸润深度、Dukes分期等方面比较,差异无统计学意义(P>0.05);但在有无合并低位肠梗阻、癌肿部位、组织学分化程度、侵犯周径、淋巴结转移及根治程度方面比较,差异有统计学意义(P<0.05,P<0.01)。全组根治性切除660例(93.2%)。SPO术保肛率66.7%(311/481),其中低位直肠癌43.7%(135/309)。手术死亡率0.4%(3/708);术后局部复发率5.5%(39/708)。SPO组中位生存时间(65.0±6.9)个月,5年生存率59.3%;APR组中位生存时间(42.2±5.6)个月,5年生存率42.3%;两组比较P<0.01。结论直肠癌患者在确保根治前提下应首选SPO术,低位直肠癌患者根据肿瘤部位、分化程度、淋巴结转移状况及手术者经验选择SPO适应证应是可行的。

Indications and prognostic analysis of sphincter preservation operation for rectal cancer

OBJECTIVE: To explore the indications of sphincter preservation operation (SPO) for rectal cancer, and factors influencing selective indications of SPO. METHODS: From April 1994 to April 2004, clinical data of 708 cases with rectal cancer were analyzed retrospectively. The patients received either SPO (SPO group, n=481) or abdominoperineal resection (APR group, n=227). Clinicalpathologic parameters and survival rate were compared between the two groups. RESULTS: There were 66 patients with tumor located in sigmoid-rectum borderline, 138 in upper rectum, 195 in middle rectum, 309 in lower rectum. Dixon operation was performed in 449 patients, Bacon operation in 12, and "J" Poch anastomesis in 20 and Hartman operation in 13. There was no differences in sex, ages, liver metastasis, size, depth of invasion and Dukes stages between APR and SPO groups, but there was significant difference in lower bowel obstruction, tumor location, differentiation degree, infiltrated circumference of intestine, lymph node metastasis and radical approaches between the two groups. Radical excision was performed in 660 rectal cancer cases with radical excision rate of 91.5% . SPO was performed in 481 cases with preservation rate of 66.7%, including 135 lower rectal cancer with preservation rate of 43.7%. The operative mortality was 0.4% (3/708), regional recurrence rate was 5.51% (39/708) after operation. The median survival time was (65.0+/- 6.9) months in SPO group and (42.2+/- 5.6) months in APR group (P< 0.01), the 5-year survival rate was 59.3% and 42.3% in SPO and APR group (P< 0.001). CONCLUSIONS: SPO should be considered as primary choice for rectal cancer patients, but it must be ensured that complete radical resection be performed. Indications for SPO in lower rectal cancer depend on tumor location,differentiation degree,and infiltrated circumference of intestine,lymph node metastasis.