目的:比较经尾侧入路联合中间翻页式与传统腹腔镜下右半结肠癌根治术临床治疗效果,为临床提供理论依据。方法:选择2018年01月至2021年11月大理大学第一附属医院普外科行腹腔镜下右半结肠癌根治术的56例患者的临床资料,根据不同的手术入路,分为实验组(经尾侧入路联合中间翻页式入路)和对照组(传统入路),其中,尾侧入路联合中间翻页式组27例,传统中间入路组29例,观察两组的基本资料(年龄、BMI、性别)、CEA值、术前血红蛋白及白蛋白量、术后血红蛋白及白蛋白量、手术时长、术中出血量、术中淋巴结清扫数、术后排便时间、术后排气时间、术后进食时间、术后住院天数、术后并发症、住院费用等情况。比较两组手术入路的临床效果。结果:尾侧入路联合中间翻页式组的手术时长、术中出血量、术后排便时间、住院费用均少于传统中间入路组,差异具有统计学意义(P < 0.05)。两组术中淋巴结清扫数、术后排气时间、术后进食时间、术后住院天数、术后并发症差异无统计学意义(P > 0.05)。结论:与传统入路相比,尾侧入路联合中间翻页式具有手术时长短、术中出血量少、术后排便时间短、住院费用少等优势,值得临床应用与推广。 Objective: To compare the clinical therapeutic effects of caudal approach combined with middle page turning and traditional laparoscopic radical resection of right colon cancer, so as to provide theoretical basis for clinic. Methods: The clinical data of 56 patients who underwent laparoscopic radical resection of right colon cancer in the department of general surgery of the First Affiliated Hospital of Dali University from January 2018 to November 2021 were selected. According to dif-ferent surgical approaches, they were divided into experimental group (caudal approach combined with middle flipping approach) and control group (traditional approach). Among them, there were 27 cases in caudal approach combined with middle flipping approach and 29 cases in traditional middle approach. The basic data (age, BMI, gender), CEA value, preoperative hemoglobin and al-bumin, postoperative hemoglobin and albumin, operation time, intraoperative bleeding, in-traoperative lymph node dissection, postoperative defecation time, postoperative exhaust time, postoperative eating time, postoperative hospital stay, postoperative complications and hospitali-zation expenses of the two groups were observed. The clinical effects of the two groups were com-pared. Results: The operation time, intraoperative bleeding, postoperative defecation time and hospitalization expenses of the caudal approach combined with the middle page turning group were significantly lower than those of the traditional middle approach group (P < 0.05). There was no significant difference in the number of lymph node dissection, postoperative exhaust time, postoperative eating time, postoperative hospital stay and postoperative complications between the two groups (P > 0.05). Conclusion: Compared with the traditional approach, the caudal approach combined with the middle page turning approach has the advantages of long operation time, less intraoperative bleeding, short postoperative defecation time and less hospitalization cost. It is worthy of clinical application and promotion.
目的:比较经尾侧入路联合中间翻页式与传统腹腔镜下右半结肠癌根治术临床治疗效果,为临床提供理论依据。方法:选择2018年01月至2021年11月大理大学第一附属医院普外科行腹腔镜下右半结肠癌根治术的56例患者的临床资料,根据不同的手术入路,分为实验组(经尾侧入路联合中间翻页式入路)和对照组(传统入路),其中,尾侧入路联合中间翻页式组27例,传统中间入路组29例,观察两组的基本资料(年龄、BMI、性别)、CEA值、术前血红蛋白及白蛋白量、术后血红蛋白及白蛋白量、手术时长、术中出血量、术中淋巴结清扫数、术后排便时间、术后排气时间、术后进食时间、术后住院天数、术后并发症、住院费用等情况。比较两组手术入路的临床效果。结果:尾侧入路联合中间翻页式组的手术时长、术中出血量、术后排便时间、住院费用均少于传统中间入路组,差异具有统计学意义(P < 0.05)。两组术中淋巴结清扫数、术后排气时间、术后进食时间、术后住院天数、术后并发症差异无统计学意义(P > 0.05)。结论:与传统入路相比,尾侧入路联合中间翻页式具有手术时长短、术中出血量少、术后排便时间短、住院费用少等优势,值得临床应用与推广。
右半结肠癌根治术,腹腔镜,尾侧入路联合中间翻页式入路,传统中间入路
Zhe Li1, Yunbo Tan2, Liquan Jin2*
1School of Clinical Medicine, Dali University, Dali Yunnan
2Department of General Surgery, The First Affiliated Hospital of Dali University, Dali Yunnan
Received: Sep. 8th, 2022; accepted: Sep. 30th, 2022; published: Oct. 8th, 2022
Objective: To compare the clinical therapeutic effects of caudal approach combined with middle page turning and traditional laparoscopic radical resection of right colon cancer, so as to provide theoretical basis for clinic. Methods: The clinical data of 56 patients who underwent laparoscopic radical resection of right colon cancer in the department of general surgery of the First Affiliated Hospital of Dali University from January 2018 to November 2021 were selected. According to different surgical approaches, they were divided into experimental group (caudal approach combined with middle flipping approach) and control group (traditional approach). Among them, there were 27 cases in caudal approach combined with middle flipping approach and 29 cases in traditional middle approach. The basic data (age, BMI, gender), CEA value, preoperative hemoglobin and albumin, postoperative hemoglobin and albumin, operation time, intraoperative bleeding, intraoperative lymph node dissection, postoperative defecation time, postoperative exhaust time, postoperative eating time, postoperative hospital stay, postoperative complications and hospitalization expenses of the two groups were observed. The clinical effects of the two groups were compared. Results: The operation time, intraoperative bleeding, postoperative defecation time and hospitalization expenses of the caudal approach combined with the middle page turning group were significantly lower than those of the traditional middle approach group (P < 0.05). There was no significant difference in the number of lymph node dissection, postoperative exhaust time, postoperative eating time, postoperative hospital stay and postoperative complications between the two groups (P > 0.05). Conclusion: Compared with the traditional approach, the caudal approach combined with the middle page turning approach has the advantages of long operation time, less intraoperative bleeding, short postoperative defecation time and less hospitalization cost. It is worthy of clinical application and promotion.
Keywords:Radical Resection of Right Colon Cancer, Laparoscopic, Caudal Approach Combined with Middle, Traditional Laparoscopic Approach
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结肠癌是消化道恶性肿瘤中最常见的恶性肿瘤之一,其发病率及致死率均较高 [
选择2018年01月至2021年11月大理大学第一附属医院普外科行腹腔镜下右半结肠癌根治术的56例患者作为研究对象,收集患者的临床资料,其中男性34例,女性22例,采用回顾性随机对照研究的方法,根据手术入路分为尾侧入路联合中间翻页式(实验组)和传统中间入路(对照组)。实验组27例,男性14例,女性13例,年龄45~79岁,平均年龄(61.85 ± 10.10)岁,对照组29例,男性20例,女性9例,年龄31~78岁,平均年龄(57.38 ± 11.36)岁。两组患者年龄、性别、BMI、CEA值、术前血红蛋白及白蛋白量、术后血红蛋白及白蛋白量等一般资料经比较差异无统计学意义(均P > 0.05) (表1)。患者及其家属均知悉研究内容,并自愿配合参与。
尾侧入路联合中间翻页式入路 | 传统中间入路 | |||
---|---|---|---|---|
n | 27(48.2%) | 29(51.8%) | ||
年龄(岁) | 61.85±10.10 | 57.38±11.36 | T=1.553 | P=0.126 |
BMI (kg/m2) | 21.72±2.91 | 21.77±2.65 | T=-0.070 | P=0.94 |
性别 | ||||
男 | 14 | 20 | ||
女 | 13 | 9 | ||
术前HGB (g/L) | 117.00±30.99 | 122.62±38.43 | T=-0.600 | P=0.551 |
术前ALB (g/L) | 39.67±6.04 | 39.73±5.40 | T=-0.042 | P=0.967 |
CEA (ng/ml) | 2.93(2.12-6.84) | 4.87(1.53-8.90) | Z=-0.851 | P=0.395 |
术后HGB (g/L) | 104.74±19.83 | 115.66±26.57 | T=-1.732 | P=0.089 |
术后ALB (g/L) | 29.23±4.11 | 31.44±5.47 | T=-1.695 | P=0.096 |
表1. 两组患者临床资料对比
纳入标准:符合CSCO2020结直肠癌诊疗指南;年龄19~85岁;男性或非孕期女性;定位诊断:肿瘤位于盲肠、升结肠及结肠肝区;定性诊断:术前肠镜检查及病理学活检均明确为结肠癌;手术方式为腹腔镜右半结肠癌根治术;术前进行评估无转移者;首次确诊且既往无其他相关病史 [
排除标准:肿瘤无法完全切除;存在肠梗阻;存在广泛的腹腔转移或远处器官的转移;剖腹探查者或腔镜手术中转开腹;患者或家属不同意入组者;以往存在腹部手术者 [
本研究经大理大学第一附属医院伦理委员会批准。
实验组:气管插管全身麻醉,患者取改良截石位,双上肢内收,消毒铺巾完毕后将患者体位调整为头低脚高,与水平面呈30˚角,左倾15˚,充分暴露术区。主刀站于患者两腿之间,助手和扶镜手站于患者左侧。使用五孔法,先在脐上缘1 cm处切1 cm切口,将其作为观察孔。脐与耻骨联合中点取1 cm切口为右手操作孔,于麦氏点为左手操作孔。左锁骨中线与肋下缘4 cm交点处及反麦氏点作为助手操作孔。穿刺气腹针,建立气腹,气腹压控制在10~13 mmHg之间。建立手术操作孔,探查腹腔,明确肿瘤位置、大小,明确要切除的范围。提起右半结肠,由结肠与骨盆交界处切开后腹膜,显露出腹主动脉,分离并离断肠系膜下动脉。在右侧髂血管上2 cm的位置沿“黄白交界线”走形打开腹膜,进入右侧的Todlt间隙,继续拓展Todlt间隙,上侧暴露出十二指肠与胰腺,右至生殖血管,内侧至肠系膜上静脉。再将体位改为头高较低30˚,在胃大弯血管弓处将胃结肠韧带离断,进入横结肠系膜后间隙,暴露出肠系膜上静脉、胃网膜右静脉、右结肠静脉、胰十二指肠上静脉,游离并离断右结肠静脉,继续向下向右分离结肠系膜,打开肝结肠韧带。在胰腺下缘分离并离断结肠中静脉,在肠系膜上动脉处分离并离断结肠中动脉右侧分支。在此与尾侧入路汇合。由尾侧向头侧分离并离断肠系膜上静脉,反转至右结肠系膜前方 [
对照组:与实验组不同的是助手站于患者右侧,扶镜手站于患者两腿之间。探查腹腔,明确切除肿瘤的范围。充分暴露要切除的升结肠范围。首先采取头低脚高的改良截石位,将小肠推向头侧。找出回结肠血管在系膜上的投影点,找出肠系膜上静脉的走向,根据其走行找到回结肠血管,沿着肠系膜上静脉的走行分离并离断回结肠动、静脉与右半结肠动、静脉。由回结肠血管蒂下缘打开肠系膜,由此进入Todlt间隙,进入Todlt间隙后继续拓展,向头侧拓展至十二指肠水平部 [
1) 比较两组患者的手术开展情况,包括手术时间、术中出血量、手术时长、术中淋巴结清扫数目。
2) 比较两组患者的术后情况,术后排便时间、术后排气时间、术后进食时间、术后住院天数、住院费用。
3) 比较两组患者的术后并发症发生情况。术后至出院当天,记录患者术后并发症发生情况,包括术口感染、肺部感染、不完全性肠梗阻。
采用SPSS 25.0软件进行统计学分析,计量资料采用均数±标准差进行统计,组间对比较采用t检验进行数据分析。计数资料采用相对数进行统计,运用Fishers精确检验进行数据分析。P < 0.05有统计学意义。
尾侧入路联合中间翻页式组的手术时长、术中出血量均少于传统中间入路组,差异具有统计学意义(P < 0.05)。但两组在术中淋巴结清扫数方面差异无统计学意义(P > 0.05) (表2)。
尾侧入路联合中间翻页式入路 | 传统中间入路 | T值 | P值 | |
---|---|---|---|---|
手术时长(min) | 228.78 ± 63.66 | 263.62 ± 78.55 | −1.815 | 0.045 |
术中出血量(ml) | 152.59 ± 107.15 | 178.28 ± 98.42 | −0.935 | 0.048 |
术中淋巴结清扫数(个) | 19.19 ± 6.73 | 19.93 ± 7.35 | 0.395 | 0.694 |
表2. 两组患者手术指标的对比
尾侧入路联合中间翻页式组的术后排便时间、住院费用均少于传统中间入路组,差异具有统计学意义(P < 0.05)。两组术后排气时间、术后进食时间、术后住院天数差异无统计学意义(P > 0.05) (表3)。
尾侧入路联合中间翻页式入路 | 传统中间入路 | Z值 | P值 | |
---|---|---|---|---|
术后排便时间(天) | 3.00 (1.00~4.00) | 3.00 (1.00~4.00) | −0.639 | 0.049 |
术后排气时间(天) | 2.00 (1.00~2.00) | 1.00 (1.00~2.00) | −0.817 | 0.414 |
术后进食时间(天) | 4.00 (2.00~5.00) | 4.00 (2.00~5.00) | −0.092 | 0.927 |
术后住院天数(天) | 10.00 (8.00~12.00) | 10.00 (8.50~13.50) | −0.066 | 0.947 |
住院费用(元) | 32101.49 (28291.89~39540.61) | 37116.34 (32770.76~42114.18) | −2.091 | 0.037 |
表3. 两组患者术后恢复指标的对比
两组术后并发症的比较,差异无统计学意义(P大于0.05) (表4)。
尾侧入路联合中间翻页式入路 | 传统中间入路 | Z值 | P值 | |
---|---|---|---|---|
术口感染 | 8/25.0 | 12/40 | - | - |
肺部感染 | 12/37.5 | 10/33.3 | - | - |
不完全性肠梗阻 | 7/21.9 | 3/10.0 | - | - |
总发生率 | 84.4 | 83.3 | −1.545 | 0.122 |
表4. 两组患者的术后并发症发生情况的对比
结肠癌作为临床上发病率最高的癌症之一,指肠黏膜上皮细胞恶性肿瘤,随着疾病进展患者会逐渐出现不同的症状,如下腹部疼痛、贫血、腹泻、大便性状改变等。而结肠癌发病因素有可能与环境因素、饮食习惯、生活习惯有关 [
结肠癌一旦确诊,均需要手术切除肿瘤,术后常规放化疗,以提高患者的预后与生活质量 [
随着医学的不断发展,医生与患者对于手术风险的不断降低及对手术安全性需求的提升,开展手术治疗过程中,不仅需降低手术中各种风险的发生,更需提升术中、术后的安全性,可有效提高患者对手术治疗的满意度。尽管由于各种手术入路存在巨大争议 [
综上所述,尾侧入路联合中间翻页式入路右半结肠癌根治术的效果优于传统的中间入路,可降低手术时长、术中出血量,术后排便时间缩短、住院费用少的优势。可促进术后康复,值得临床推广和应用。
李 哲,谭云波,金礼权. 经尾侧入路联合中间翻页式与传统腹腔镜下右半结肠癌根治术临床对比研究分析Clinical Comparative Study of Caudal Approach Combined with Middle Page Turn-ing and Traditional Laparoscopic Radical Resection of Right Colon Cancer[J]. 临床医学进展, 2022, 12(10): 8864-8870. https://doi.org/10.12677/ACM.2022.12101279