背景:尽管是与直肠癌患者预后显著相关的关键指标,全直肠系膜切除术(TME)的最佳手术方式尚未确定.这项研究的目的是评估手术方法对TME质量和手术切缘的关联,并描述接受机器人手术的患者的手术和长期肿瘤学结果。腹腔镜,并为直肠癌开放TME。
方法:通过机器人(Rob)进行下段前切除术或腹部手术切除的非转移性直肠腺癌,腹腔镜(lap),或从美国直肠癌协会数据库(2007-2017)中选择开放方法.使用反向选择的准泊松回归分析来研究手术入路与目标结局之间的关系。
结果:在纳入研究的664名患者中,手术入路分布如下:351例(52.9%)经开放入路TME,159(23.9%)通过机器人方法,和154(23.2%)通过腹腔镜入路。在三个队列中,基线人口统计学没有显着差异。腹腔镜队列的低位直肠癌患者(距肛门边缘<6厘米)少于机器人和开放队列(Lap28.6%对Rob59.1%对Open45.6%,P=0.015)。与开放方法相比,接受Rob和LapTME的患者术中失血更少(Rob200mL[Q1,Q3:100.0,300.0]与Lap150mL[Q1,Q3:75.0,250.0]与开放300mL[Q1,Q3:150.0,600.0],P<0.001)。手术时间没有差异(Rob243分钟[Q1,Q3:203.8,300.2]与Lap241分钟[Q1,Q3:186,336]与Open226分钟[Q1,Q3:178,315.8],三种方法之间的P=0.309)。与开放方法相比,机器人和腹腔镜方法的术后住院时间更短(Rob5.0d[Q1,Q3:4,8.2]vsLap5d[Q1,Q3:4,8]vs.Open7.0d[Q1,Q3:5,9],P<0.001)。机器人之间的TME质量没有统计学上的显着差异,腹腔镜,和开放式方法(79.2%,64.9%,和64.7%,分别为;P=0.46)。边际阳性率,圆周边缘和远端边缘的复合材料,机器人和开放入路比腹腔镜入路高(Rob8.2%对开放6.6%对重叠1.9%,P=0.17),Rob与Lap(赔率比0.21;95%置信区间0.05,0.83)和Rob与Open(赔率比0.5;95%置信区间0.22,1.12)。长期生存率没有差异,包括总生存率和无复发生存率,在接受机器人治疗的患者之间,腹腔镜,或打开TME(图1)。
结论:在接受直肠癌手术治疗的患者中,我们没有观察到机器人之间的TME质量差异,腹腔镜,或开放式方法。在我们的研究中,与腹腔镜TME相比,机器人和开放式TME与更高的边缘阳性率相关。这可能是由于机器人和开放队列中低直肠癌的比例较高。我们还报道了上述手术技术之间的总生存率和无复发生存率没有显着差异。
BACKGROUND: Despite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer.
METHODS: Patients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest.
RESULTS: Among the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1).
CONCLUSIONS: In patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques.