| Objective: Comparing the clinical efficacy of open? laparoscopic and Da Vinci robotic transabdominal extralevator abdominoperineal excision.Methods: A retrospective cohort study.We collected the clinical data of 137 patients with low rectal cancer who underwent transabdominal ELAPE were enrolled in our ward from January 2012 to September 2018.Among them,21 cases were open ELAPE,98 cases were assisted by laparoscopy and 18 cases were assisted by Da Vinci robot.According to the preoperative imaging data and digital rectal examination,the location and upper boundary of the tumor were determined,and the levator anal muscle was excised individually.Using SPSS22.0 statistical software,the measurement data of normal distribution is expressed as(?) ±s,and the comparison between groups is analyzed by one-way variance analysis;the measurement data of skewed distribution is expressed as M(range),and the comparison between groups is measured by non-parametric test.Count data were expressed as frequency and percentage.Chi-square test or Fisher's exact probability method was used to compare between groups.The survival rate was calculated by Kaplan-Meier method,and the difference between groups was tested by Log-rank test.Results:(1)comparison of basic clinical features before operation: There was no significant difference in the body mass index(body mass index,BMI),ASA,tumor marker level(CEA,CA199),preoperative clinical stages,pathological types,tumor location,preoperative neoadjuvant radiotherapy and chemotherapy in three groups of patients(P > 0.05).Compared with open group,the distance of tumor to anal margin was lower in robot group and laparoscopy group(P < 0.05).(2)intraoperative and postoperative condition:intestinal perforation occurred in 1 case,the positive rate of circumferential resection margin was 8.0%(11/137),no intraoperative death occurred,1 case was converted to open method,biological mesh were used to reconstruct pelvic floor in 7 cases.There were no significant differences in intestinal perforation,positive circumferential resection margin,intraoperative blood transfusion,postoperative hospital stay,time of perineal drainage tube placement and postoperative pathology among the three groups(P > 0.05).The open group had more intraoperative bleeding than the laparoscopy group(P < 0.009),the robot group had a longer operative time than the open group and the laparoscopy group(180~450min,P < 0.001,P = 0.013),and a more expensive total cost(87130 ±20337 yuan,P < 0.001).(3)postoperative complications: pulmonary infection occurred in 11 cases,abdominal incision infection in 2 cases,intestinal obstruction in 15 cases.The total complication rate of perineal incision was 33.6%(46/137),and the infection rate of perineal incision was 30.7%(42/137),among which 38 cases had a history of preoperative radiotherapy and chemotherapy,and 3 cases had been treated with biology mesh to repair the pelvic floor.The average postoperative hospital stay of patients with perineal incision infection was 23.36(7~56)days,and that without perineal incision infection was 10.75(5~58)days,There was significant difference between the two groups(P < 0.001).Only one case of perineal hernia appeared in the laparoscopy group.37 patients with chronic sinus tract formation after operation,32 of them with postoperative perineal incision infection.10 patients need to be hospitalized for complications within one month after discharge,1 was intestinal obstruction,1 was postoperative urinary retention,and the others were treated with incision infection.There was no significant difference in postoperative pulmonary infection,abdominal incision infection,intestinal obstruction and perineal incision complications among the three groups(P > 0.05).(4)prognosis: The median follow-up time was 28 months(18.5-41 months),120 cases were followed-up,the follow-up rate was 87.6%.A total of 17 patients died during follow-up,of which 2 died of local recurrence,6 died of distant metastasis,and 9 died of unknown cause of death.There was no significant difference in the 3-year overall survival rate(OS)(83.2% vs 81.9% vs 100%,P=0.557)?the 3-year local recurrence-free survival rate(LRFS)(83.2% vs 81.9% vs 100%,p=0.574)and the 3-year distant metastasis-free survival rate(DMFS)(84.2% vs 80.6% vs 80.8%,P = 0.739)between the open group,laparoscopy group and robot group.There were 7 patients(5.1%)with voiding dysfunction and 17 men(32.1%)with different degrees of erectile or ejaculatory dysfunction.There was no significant difference in urinary and reproductive dysfunction among the three groups(P > 0.05).Inconclusion:1.Open?laparoscopic and robotic transabdominal ELAPE are safe and feasible surgical methods.2.The open transabdominal ELAPE had more intraoperative bleeding compared with laparoscopy group;robotic transabdominal ELAPE had longer operative times,higher total hospitalization costs.laparoscopy group and robot group have greater bias to choose the lower tumor location in rectal cancer patients.There were no significant differences in the basic clinical features,pathological data,intraoperative conditions,postoperative complication and prognosis among the three different surgical modes of transabdominal ELAPE.Robot-assisted transabdominal ELAPE in protecting urogenital function may have a certain advantage.4.Perineal incision infection is a major complication after transabdominal ELAPE.It is an important factor in prolonging postoperative hospital stay and returning to hospital due to complications. |
PDF Full Text Request