腹腔镜直肠癌保肛手术的学习曲线研究

doi:10.3877/cma.j.issn.1674-6899.2021.06.005

目的

探讨腹腔镜直肠癌保肛手术学习曲线及其对术后并发症及肿瘤根治效果的影响。

方法

回顾性分析2009年9月至2014年12月火箭军特色医学中心肛肠外科由同一组具有丰富开腹手术经验医师完成的208例腹腔镜直肠癌保肛手术的临床资料。采用移动平均法绘制手术时间曲线，并定义曲线达到稳定状态所对应的手术例数为学习曲线。根据学习曲线，将患者分为A组(学习曲线阶段组)和B组(熟练阶段组)；分别比较两组患者的一般临床资料、术后并发症及切除标本的病理结果。

结果

手术时间的移动平均曲线在手术例数达到80例时，进入稳定状态，将患者分为A组(第1~80例)和B组(第81~208例)。B组的肿瘤距肛门平均距离低于A组(P<0.05)；B组合并呼吸系统疾病和接受直肠癌经括约肌间切除术的比例高于A组(P<0.05)。B组的手术时间、术中出血量较A组减少(P<0.05)。两组总的术后并发症发生率差异无统计学意义(P>0.05)，但B组的术后尿潴留发生率显著低于A组(P<0.05)。两组术后标本病理检查结果中远端切缘均为阴性；两组淋巴结检出数目和环周切缘阳性比例比较，差异均无统计学意义(P>0.05)。

结论

具有丰富开腹经验的外科医师在其腹腔镜直肠癌保肛手术学习曲线阶段，可以保证良好的肿瘤根治效果；但应关注可能发生的术后排尿功能障碍。

关键词: 腹腔镜手术, 直肠癌, 保肛术, 学习曲线

Objective

To investigate the learning curve of laparscopic sphincter-saving resection for rectal cancer and its influence on postoperative complications and oncological safety.

Methods

Between Sep. 2009 and Dec. 2014, 208 consecutive patients who were scheduled to undergo laparoscopic sphincter-saving resection for rectal cancer were enrolled in the present study. The learning curve was analyzed based on operative time using the moving average method. The cut-off point at which the mean operative time stabilized was defined as learning curve. The patients were divided into A (learning period) and B (experienced period) group. Data including the patients′ demographic characteristics, surgical characteristics, pathological results, postoperative complications were compared between the two groups.

Results

The learning curve analysis for operative time using the moving average method showed stabilization at 80 cases, and the patients were divided into A (1-80 cases) and B group (81-208 cases). Patients had lower tumor distance from anal verge in group B than in group A (P<0.05). A significantly higher proportion of combined respiratory disease and inter sphincteric resection (ISR)were observed for patients in group B than they in group A (P<0.05). Both the operating time and blood loss were significantly lower in group B than they in group A. The rate of overall postoperative complications in group A had no significant difference compared with it in group B (P>0.05), but the rate of urinary retention was significantly lower in group B (P<0.05). There was no significant difference in the pathological results between the 2 groups, including number of harvested lymph nodes, ratio of positive circumferential margin, and ratio of affected distal margin.

Conclusions

Surgeons in the learning curve period of laparoscopic sphincter-saving resection for rectal cancer, could allow oncological safety, but they should pay attention to possibly high rate of postoperative urinary dysfunction.

Key words: Laparoscopic surgery, Sphincter-saving resection, Rectal cancer, Learning curve

图1 直肠癌经括约肌间切除术手术步骤注：A.保留左结肠动脉，清扫第253组淋巴结；B.显露左侧输尿管及生殖血管；C.分离直肠后间隙，保护双侧腹下神经；D.切断后方Hiatal韧带，进入括约肌间间隙；E.LONE-STAR拉钩牵拉显露肛门及肿瘤，标记下切缘；F.脱出并离断肠管，拟行结肛吻合；G.结肛手工吻合；H.术后常规行回肠袢式造口

图2 腹腔镜直肠癌保肛手术的手术时间曲线

表1 腹腔镜直肠癌保肛手术的两组临床一般资料比较

临床参数		学习曲线阶段组(第1~80例)	熟练阶段组(第81~208例)	t(χ²，Z)值	P值
年龄[岁，中位数(范围)]		62.5(23~83)	62.0(25~85)	0.181	0.856^a
性别[例(%)]
	男	44(55.0)	79(61.7)	0.920	0.338^b
	女	36(45.0)	49(38.3)
体质量指数[kg/m²，中位数(范围)]		24.0(15.2~32.0)	24.5(17.9~39.1)	1.707	0.089^a
术前放射治疗[例(%)]		3(3.8)	8(6.3)	0.614	0.536^c
合并其他疾病[例(%)]
	糖尿病	18(22.5)	24(18.8)	0.430	0.512^b
	高血压	30(37.5)	38(29.7)	1.366	0.243^b
	呼吸系统疾病	1(1.3)	12(9.4)	5.547	0.019^b
肿瘤下缘距肛门距离[cm，中位数(范围)]		7(2~15)	5(1~15)	2.290	0.023^a
手术方式[例(%)]
	直肠癌前切除术	61(76.3)	77(60.2)	5.711	0.017^b
	直肠癌经括约肌间切除术	19(23.8)	51(39.8)
预防性末端回肠造口[例(%)]		37(46.3)	73(57.0)	2.297	0.130^b
中转开腹[例(%)]		4(5.0)	2(1.6)	2.077	0.207^c
手术时间[min，中位数(范围)]		240(125~475)	165(60~345)	7.715	<0.001^d
术中出血量[ml，中位数(范围)]		100(20~800)	50(10~800)	5.832	<0.001^d
TNM分期[例(%)]
	0、Ⅰ、Ⅱ期	47(58.8)	70(54.7)	0.330	0.566^b
	Ⅲ、Ⅳ期	33(41.3)	58(45.3)

表1 腹腔镜直肠癌保肛手术的两组临床一般资料比较

临床参数		学习曲线阶段组(第1~80例)	熟练阶段组(第81~208例)	t(χ²，Z)值	P值
年龄[岁，中位数(范围)]		62.5(23~83)	62.0(25~85)	0.181	0.856^a
性别[例(%)]
	男	44(55.0)	79(61.7)	0.920	0.338^b
	女	36(45.0)	49(38.3)
体质量指数[kg/m²，中位数(范围)]		24.0(15.2~32.0)	24.5(17.9~39.1)	1.707	0.089^a
术前放射治疗[例(%)]		3(3.8)	8(6.3)	0.614	0.536^c
合并其他疾病[例(%)]
	糖尿病	18(22.5)	24(18.8)	0.430	0.512^b
	高血压	30(37.5)	38(29.7)	1.366	0.243^b
	呼吸系统疾病	1(1.3)	12(9.4)	5.547	0.019^b
肿瘤下缘距肛门距离[cm，中位数(范围)]		7(2~15)	5(1~15)	2.290	0.023^a
手术方式[例(%)]
	直肠癌前切除术	61(76.3)	77(60.2)	5.711	0.017^b
	直肠癌经括约肌间切除术	19(23.8)	51(39.8)
预防性末端回肠造口[例(%)]		37(46.3)	73(57.0)	2.297	0.130^b
中转开腹[例(%)]		4(5.0)	2(1.6)	2.077	0.207^c
手术时间[min，中位数(范围)]		240(125~475)	165(60~345)	7.715	<0.001^d
术中出血量[ml，中位数(范围)]		100(20~800)	50(10~800)	5.832	<0.001^d
TNM分期[例(%)]
	0、Ⅰ、Ⅱ期	47(58.8)	70(54.7)	0.330	0.566^b
	Ⅲ、Ⅳ期	33(41.3)	58(45.3)

表2 腹腔镜直肠癌保肛手术的两组术后并发症和病理结果比较

临床参数		学习曲线阶段组(第1~80例)	熟练阶段组(第81~208例)	χ²(Z)值	P值
术后并发症[例(%)]		30(37.5)	37(28.9)	1.665	0.197^a
	吻合口出血	0(0.0)	1(0.8)	0.628	1.000^b
	尿潴留	23(28.8)	19(14.8)	5.908	0.015^a
	泌尿系感染	10(12.5)	7(5.5)	3.243	0.072^a
	吻合口瘘	8(10.0)	11(8.6)	0.117	0.732^a
	肠梗阻	4(5.0)	10(7.8)	0.620	0.431^a
	切口感染	2(2.5)	1(0.8)	1.023	0.561^b
	回肠造口缺血	0(0.0)	1(0.8)	0.628	1.000^b
	小肠瘘	1(1.3)	0(0.0)	1.608	0.385^b
术后病理情况
	检出淋巴结数目[枚，中位数(范围)]	13(6~17)	16(3~38)	0.341	0.366^c
	环周切缘阳性[例(%)]	1(1.3)	4(3.1)	0.738	0.651^b
	远端切缘阳性[例(%)]	0(0.0)	0(0.0)	-	-

表2 腹腔镜直肠癌保肛手术的两组术后并发症和病理结果比较

临床参数		学习曲线阶段组(第1~80例)	熟练阶段组(第81~208例)	χ²(Z)值	P值
术后并发症[例(%)]		30(37.5)	37(28.9)	1.665	0.197^a
	吻合口出血	0(0.0)	1(0.8)	0.628	1.000^b
	尿潴留	23(28.8)	19(14.8)	5.908	0.015^a
	泌尿系感染	10(12.5)	7(5.5)	3.243	0.072^a
	吻合口瘘	8(10.0)	11(8.6)	0.117	0.732^a
	肠梗阻	4(5.0)	10(7.8)	0.620	0.431^a
	切口感染	2(2.5)	1(0.8)	1.023	0.561^b
	回肠造口缺血	0(0.0)	1(0.8)	0.628	1.000^b
	小肠瘘	1(1.3)	0(0.0)	1.608	0.385^b
术后病理情况
	检出淋巴结数目[枚，中位数(范围)]	13(6~17)	16(3~38)	0.341	0.366^c
	环周切缘阳性[例(%)]	1(1.3)	4(3.1)	0.738	0.651^b
	远端切缘阳性[例(%)]	0(0.0)	0(0.0)	-	-

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Learning curve of laparscopic sphincter-saving resection for rectal cancer

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Learning curve of laparscopic sphincter-saving resection for rectal cancer