| Objective:To analyze the clinical effection of laparoscopic intersphincteric resection(Lap-ISR)in anus-preserving treatment of low rectal cancer and evaluate the feasibility and safety between completely abdominal approach Lap-ISR and Lap-ISR combined with modified Bacon as well as postoperative anal function recovery and risk factors affecting stool control function.Methods:Collecting the clinical and follow-up data of patients with low rectal cancer treated by laparoscopic intersphincteric resection in gastrointestinal surgery of Northern Jiangsu People’s Hospital from February 2016 to December 2018.After screening according to the corresponding inclusion and exclusion criteria,a total of 62patients were included in the study and completed follow-up.Applying perioperative Clavien-Dindo complication grading to assess surgical safety.Postoperative anal function was evaluated by Wexner incontinence score,Williams criteria,GIFO gastrointestinal function questionnaire.Dividing the patients into two groups according to the condition of anal function(Wexner score>10)and good anal function(Wexner score≤10).Analyzing the general clinical characteristics,surgical related data,postoperative pathological results,postoperative complications,and anal function indexes of the two groups were performed.Screening out significant influencing factors with Single factor screening analysis and including logistic regression multivariate analysis of the independent risk factors affecting the prognosis of anal function.Results:A total of 62 patients were included in the study,36 males(58.1%),26females(41.9%),median age 62(40-71)years old,BMI 23.48±2.98kg/m~2,tumor inferior margin distance from anal margin 4.36±0.76 cm,and neoadjuvant chemoradiotherapy was performed in 7 cases(11.3%).Among them,53 patients underwent completely abdominal approach Lap-ISR,Lap-ISR combined with modified Bacon was performed in 9 patients who were unable to secure a safe margin cut or were unable to use instrument anastomosis under endoscopy.The average operation time was184.87±31.25min,the median bleeding volume was 50(20-350)ml,the distance from the anastomosis to the anal margin was 2.21±0.45cm,the length of the incision margin was 1.62±0.47cm,and the maximum tumor diameter was 3.22±1.28cm.Postoperative pathological TNM staging included 34 cases in stage I(54.8%),12 cases in stage II(19.4%),16 cases in stage III(25.8%),a total of 13(6-30)median lymph nodes,and a median positive lymph node of 0(0-6)pieces.None of the patients died during the perioperative period.During the period,a total of 11 patients experienced 16complications.There were 9 cases of Clavien-Dindo complications gradeⅠ-Ⅱ,and only2 cases of gradeⅢ-Ⅳ.Difficulty urination/urinary retention(8.1%),pelvic infection(6.5%),anastomotic leakage(6.5%),and anastomotic stenosis(6.5%)are common complications after surgery.The Wexner score was 1.16±0.94 before surgery,14.61±2.58 at 4 months after surgery,10.15±3.07 at 8 months after surgery,and 8.03±3.42 at 12 months after surgery.Twenty-one patients with Wexner scores of more than 10 after 12 months(33.9%),41cases(66.1%)with Wexner score≤10.Williams standard classification:14 cases(22.6%)and 26 cases(41.3%)of A and B grades with good anal function;12 cases(19.4%)of C grades with average anal function and occasional liquid fecal incontinence;Poor function,9 cases(14.5%)and 1 case(1.6%)of grades D and E often showing incontinence.Patients were divided into two groups with good anal function and poor anal function according to Wexner score.Univariate analysis showed that the distance between the anastomotic opening and the anal margin was≤2cm(P=0.021),radiotherapy(P=0.004),and anastomotic leakage(P=0.011)And pelvic infection(P=0.011)were statistically significant.Logistic regression multivariate analysis results showed that radiotherapy(P=0.021;OR 4.627;95%CI 1.255-17.061)was an independent risk factor affecting postoperative anal function.Patients were 4.627 times more likely to have anal dysfunction than those who did not receive radiation therapy.Conclusion:Completely abdominal approach Lap-ISR is safe and feasible for low rectal cancer,which is more convenient and accurate than transanal approach.When it is impossible to guarantee a safe resection margin or anastomosis with laparoscopic instruments,Lap-ISR combined with modified Bacon is a safe and effective operation for Lap-ISR.Patients with completely abdominal approach Lap-ISR combined with conventional preventive stoma,which can reduce the severity of anastomotic leakage,and relieve the symptoms of anal incontinence in the short term after surgery.Most patients can obtain satisfactory anal function after Lap-ISR.Radiotherapy is an independent risk factor affecting the recovery of anal function. |
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