直肠癌NOSES术与传统腹腔镜直肠癌根治术术后疗效对比研究

于杰  

青岛大学附属青岛市立医院普外科

【摘要】  目的：比较腹腔镜直肠癌肿物经自然腔道取出术Natural orifice specimen extraction surgery（Noses）与传统腹腔镜直肠癌根治术术后疗效，包括患者的近期临床结局及应激水平。方法：选取2016年9月至2018年10月至青岛市立医院就诊的直肠癌患者共46例，根据手术方式分为noses组（n=16组）和腹腔镜（LAP）组（n=30组）。记录两组患者的术后排气时间、术后15天感染率、术后第一天疼痛评分（vas评分）及住院时间来比较患者的近期临床结局；记录患者术前1天及术后第1、3、7天CRP、TNF-ɑ、IL-6以期比较应激水平。结果：noses组术后排气时间早于LAP组，差异具有统计学意义（p<0.05）。两组患者术后15天感染率无统计学意义（P>0.05）。Noses组术后疼痛程度低于LAP组（vas评分），差异具有统计学意义（p<0.05）。Noses组患者术后住院时间短于LAP组，差异具有统计学意义（p<0.05）。两组患者术前1天及术后第1天CRP、TNF-ɑ、IL-6无明显统计学差异（p>0.05），术后第3天及第7天noses组CRP、TNF-ɑ、IL-6低于LAP组，差异具有统计学意义（p<0.05）。

结论：直肠癌noses术相比于传统腹腔镜直肠癌根治术，微创优势突出，显著降低患者疼痛，术后应激水平低，利于患者术后早期康复。

【关键词】直肠癌  经自然腔道肿物取出术  腹腔镜  应激水平  近期临床结局

Comparative study of postoperative outcomes of conventional laparoscopic radical resection for rectal cancer with NOSES.  Yu Jie，Department of General Surgery,Qingdao Municipal Hospital, Qingdao University

Corresponding author: Zhou Shaofei,【Abstract】 Objective: To compare the efficacy of laparoscopic rectal cancer with natural orifice specimen extraction surgery (Noses) and conventional laparoscopic radical resection, including recent clinical outcomes and stress levels. METHODS: A total of 46 patients with low rectal cancer who were admitted to Qingdao Municipal Hospital from September 2016 to October 2018 were enrolled. The patients were divided into the noses group (n=16 group) and the traditional laparoscopy (LAP) group according to the surgical procedure (n= 30 groups). The postoperative venting time, postoperative infection rate, postoperative first day pain score, and length of hospital stay were recorded to compare the patient's recent clinical outcomes; the patients were recorded 1 day before surgery and 1, 3, and 7 days after surgery. CRP, TNF-ɑ, IL-6 in order to compare the patient's stress level. RESULTS: The postoperative venting time of the noses group was earlier than that of the LAP group, and the difference was statistically significant (p<0.05). There was no significant difference in postoperative infection rate between the two groups (P>0.05). The degree of postoperative pain in the Noses group was significantly lower than that in the LAP group (vas score), and the difference was statistically significant (p<0.05). The postoperative hospital stay was shorter in the Noses group than in the LAP group, and the difference was statistically significant (p<0.05). There was no significant difference in CRP, TNF-ɑ, IL-6 between the two groups before surgery and on the first day after surgery (p>0.05). The pre-CRP and TNF- in the nose group were on the 3rd and 7th day after operation. The sputum and IL-6 were lower than the LAP group, and the difference was statistically significant (p<0.05).

Conclusion: Compared with traditional laparoscopic rectal cancer radical resection, rectal cancer noses has a more prominent advantage, which significantly reduces the pain of patients, and the postoperative stress level is low, which is beneficial to the early rehabilitation of patients.

第一台腹腔镜直肠癌手术开展距今已经20多年[1]，技术日趋完善，但直肠肿物扔需额外的腹部取出口，不仅增加腹部创伤，更加剧患者痛苦，这就促进微创外科的发展。经自然腔道直肠肿物取出术应运而生。本文共收集46例于2016.06-2018.10期间至我院诊治的直肠癌患者信息资料，以期比较直肠癌NOSES术与传统腹腔镜直肠癌根治术术后疗效。

资料与方法

一、一般资料

    收集2016.06-2018.10期间至我院诊治的直肠癌患者资料，共46例，根据手术方式分为noses组16例，LAP组30例。所有入组患者均经直肠镜活检，病理报告证实为直肠癌，术前完善影像学检查，包括全腹部ct、胸部ct、锁骨上淋巴结b超，排除肿瘤的远处转移。

二、统计学分析

所有数据使用 SPSS 22.0 统计软件分析。计量资料采用均数 ± 标准差(x±s)，使用 t 检验分析两组患者应激水平、术后排气时间和住院时间等差异;计数资料使用 χ2 检验，分析两组患者术后15天感染率等差异。P <0.05 则认为差异有统计学意义。

结果

一、近期临床结局

  Noses组与Lap组术后排气时间分别为2.7±0.8d和3.5±0.9d，差距具有统计学意义（t=4.337，p<0.001）。Noses组与Lap组术后15天感染率分别为12.5%和16.7%，差距具无统计学意义（ χ2=0.122，P >0.05）。 Noses组与Lap组术后第一天疼痛评分（vas评分）分别为2.7±0.8分和3.9±1.4分，差距具有统计学意义（t=3.235，p<0.005）。 Noses组与Lap组住院时间分别为6.9±4.8天和11.5±5.3天，差距具有统计学意义（t=2.223，p<0.005）。见表1。

表1  Noses组与Lap组近期临床结局

二、应激水平

   两组患者术前1天及术后第1天CRP、TNF-ɑ无明显统计学差异（p>0.05），术后第3天及第7天noses组的前CRP、TNF-ɑ低于LAP组，差异具有统计学意义（p<0.05）。见表2。

表2  Noses组与Lap组应激水平

讨论

   直肠癌的发病率处于癌症前三名，严重危害患者生存。腹腔镜直肠癌根治术的疗效已得到广泛认可，但为进一步减轻患者痛苦，缩短患者住院时间，经自然腔道肿物取出术应运而生[2]。Noses术无额外腹部切口，患者疼痛减轻，符合加速康复外科的理念[3]。此外，结合上表，Noses术相比于Lap术，患者术后炎症反应轻，对机体免疫系统影响小。但Noses术患者花费较高，对手术者和设备要求较高，对患者的选择要求较多，技术开展存在一定难度。

综上，noses术作为一种新技术，手术效果安全，患者术后恢复良好，获益较大。

References:

[1]. 蒋晖, 费伯健与史俊峰, 经自然腔道肿物取出的腹腔镜直肠癌根治术与开腹直肠癌根治术的疗效比较. 中国临床医学, 2012(06): 第628-629页.

[2]. 林恒军, 邱学科与袁航, 经肛拖出式全腹腔镜直肠癌前切除在直肠癌患者中的临床价值. 中国内镜杂志, 2017(01): 第1-5页.

[3]. Sylla, P., Current experience and future directions of completely NOTES colorectal resection. 世界胃肠外科杂志：英文版（电子版）, 2010. 2(6

): p. 193

-198

.