背景:全括约肌间切除术(ISR)是超低位直肠癌(ULRC)患者的最终保肛术,这可能导致不同程度的肛门直肠功能障碍。被称为低位前切除综合征(LARS),严重影响患者术后生活质量。这项研究的目的是讨论带蒂大网膜移植(PGOT)的直肠系膜重建对减轻ULRC患者全ISR后LARS的价值,希望为LARS的预防和改善提供新的思路和策略。
方法:我们回顾性分析26例ULRC患者的住院资料和术后肛门直肠功能,2015年1月至2022年2月在我们中心符合纳入和排除标准的患者.并结合部分患者的肛门直肠测压和直肠磁共振成像(MRI)排粪造影结果,综合评价患者术后肛肠生理和形态学变化,以及它们与LARS的相关性。
结果:在这项研究中,纳入26例ULRC患者,根据是否行PGOT分为观察组(n=15)和对照组(n=11)。手术时间等手术效果差异无统计学意义,术中出血量和术后并发症比较差异无统计学意义(P>0.05)。术后随访显示两组患者术后3个月内均出现严重LARS,但手术后的第三个月,两组的LARS逐渐开始减少,特别是在观察组中,显示出更快的恢复和更好的恢复,差异具有统计学意义(P<0.001)。通过肛门直肠测压,观察组的平均直肠静息压显著低于对照组(P=0.010)。此外,观察组术后直肠后肠系膜厚度明显高于对照组(P=0.001),也高于术前水平(P=0.018)。此外,直肠MRI排粪造影显示,新直肠在大网膜垫下具有良好的顺应性,它的肠蠕动是协调的。
结论:ULRC患者,在大网膜的帮助下,在全ISR和LARS恢复后协调他们的新直肠蠕动更快更好。PGOT有望成为ULRC术后患者LARS防治的有效策略,值得临床推广。
BACKGROUND: Total intersphincteric resection (ISR) is the ultimate anus-preserving surgery for patients with ultra-low rectal cancer (ULRC), which can result in various degrees of anorectal dysfunction. Known as low anterior resection syndrome (LARS), it seriously affects the postoperative quality of life of patients. The aim of this study was to discuss the value of mesorectal reconstruction with pedicled greater omental transplantation (PGOT) to relieve LARS following total ISR in patients with ULRC, hoping to provide new ideas and strategies for the prevention and improvement of LARS.
METHODS: We retrospectively analyzed hospitalization data and postoperative anorectal function of 26 ULRC patients, who were met inclusion and exclusion criteria in our center from January 2015 to February 2022. And combined with the results of anorectal manometry and rectal magnetic resonance imaging (MRI) defecography of some patients, we assessed comprehensively anorectal physiological and morphological changes of the patients after surgery, and their correlation with LARS.
RESULTS: In this study, 26 patients with ULRC were enrolled and divided into observation group (n = 15) and control group (n = 11) according to whether PGOT was performed. There were no significant differences in surgical results such as operative time, intraoperative blood loss and postoperative complications between the two groups (P > 0.05). Postoperative follow-up showed that patients in both groups showed severe LARS within 3 months after surgery, but from the 3rd month after surgery, LARS in both groups gradually began to decrease, especially in the observation group, which showed faster recovery and better recovery, with statistically significant difference (P < 0.001). Through anorectal manometry, the mean rectal resting pressure in the observation group was significantly lower than that in the control group (P = 0.010). In addition, the postoperative thickness of the posterior rectal mesenterium in the observation group was significantly higher than that in the control group (P = 0.001), and also higher than the preoperative level (P = 0.018). Moreover, rectal MRI defecography showed that the neo-rectum had good compliance under the matting of greater omentum, and its intestinal peristalsis was coordinated.
CONCLUSIONS: ULRC patients, with the help of greater omentum, coordinated their neo-rectum peristalsis after total ISR and recovery of LARS was faster and better. PGOT is expected to be an effective strategy for LARS prevention and treatment of ULRC patients after surgery and is worthy of clinical promotion.