| Objective:To compare the clinical efficacies of the laparoscopic transanal total mesorectal excision(TaTME)and transabdominal intersphincteric resection(ISR)for low rectal cancer,and discuss the feasibility,effectiveness,safety,economic significance,advantages and disadvantages of those two surgical method.Methods :According to inclusion and exclusion criteria,80 patients with low rectal cancer in our hospital from January 2015 to January-2017 were randomly divided into TaTME group and ISR group according to the number random table method.Inclusion criteria were:(1)preoperative colonoscopy pathology biopsy proven rectal cancer;(2)aged18-85 years;(3)to exclude local recurrence and distant metastasis;(4)tumor from the dentate line less than 5cm;(5)the primary tumor diameter less than5cm;(6)no intestinal obstruction or intestinal perforation;(7)by MRI or EUS(endoscopic ultrasonography)in the diagnosis of clinical stage T1-3Nx M0 tumors,and the tumor did not invade the levator ani or external sphincter;(8)the preoperative anal function and sphincter systolic function are normal;(9)whether or not they have received neoadjuvant therapy;(10)agreed by medical ethics the committee,patients and their families to provide written informed consent.Exclusion criteria:(1)dottiness,not normal communication or mental disabilities;(2)complicated with intestinal obstruction or perforation in patients with intestinal;(3)combined colorectal multiple source cancer;(4)do not agreewere included in the study or the patients with poor compliance;(5)preoperative assessment of coagulation function abnormal,pulmonary infection,severe pulmonary dysfunction and other surgical contraindications;(6)patients with anal stenosis;(7)sphincter dysfunction patients;(8)less than 18 years of age or older than 85 years;(9)The differentiation degree of tumor is low differentiation.After careful assessment,the patients included history collection,physical examination,anal function evaluation,blood analysis,blood biochemistry,tumor markers,blood coagulation routine,double lower extremity arteriovenous ultrasound,colonoscopy,chest X-ray,abdominal enhanced CT and pelvic enhanced MRI.After completing preoperative examination and preoperative preparation,laparoscopy assisted transanal total mesorectal excision was performed in the TaTME group,while laparoscopy assisted transabdominal sphincterectomy in the ISR group.The data acquisition were: gender,age,past history,anesthesia,operation,duration of operation time,incision length,blood loss,blood transfusion,the distance between the lower margin of the tumor and the dentate line,the distance between the anastomosis and the dentate line,the tumor size,pathological type and clinical staging,lymph node metastasis,the surgery whether detection of distant metastases,surgical complications,postoperative recovery,postoperative pain,anal exhaust time,hospitalization time,hospitalization expenses and postoperative complications were analyzed.Results: There was no significant difference between the two groups in age,sex,body mass index,The distance between thelower margin of the tumor and the dentate line,ASA classification and preoperative T staging(P>0.05).The two groups were all successfully completed,and no transfer to open the abdomen.The operation time of the TaTME group was 267.98±46.2 minutes,the ISR group was 250.03±37.19 minutes,and there was no statistical difference(P>0.05).The amount of bleeding in the TaTME group was 55.38 ± 15.54 ml and the ISR group was 16.5±13.02 ml,There was no significant difference between the two groups(P=0.07).There were one case of ureteral injury and vaginal injury in the TaTME group.There was no ureteral injury or vaginal injury in the ISR group.There was no significant difference between the two groups(P=0.31).In the TaTME group,35 patients underwent prophylactic ileostomy,while 38 patients in the ISR group underwent prophylactic ileostomy.There was no significant difference between the two groups(P = 0.23).In the TaTME group,one patients received intraoperative blood transfusion,and two cases in the ISR group had blood transfusion,there was no statistical difference between the two groups(P=0.56).After the operation,the eating time of TaTME group was 1.65 ± 0.66 days,and the ISR group was 2.5 ± 1.13 days.The difference between the two groups was statistically significant(P<0.05).The TaTME group for the first time postoperative activities was 2.8 ± 0.88 days,and the ISR group was 3.6 ± 1.3days.The difference between the two groups was statistically significant(P =0.02).The hospitalization time in the TaTME group was 10.63 ± 1.73 days,and the ISR group was 13.2 ± 1.42 days.The difference between the two groupswas statistically significant(P < 0.05).The total cost of the TaTME group was3.47 ± 0.89(ten thousand yuan),and the ISR group was 4.48 ± 0.64(ten thousand yuan),and the difference between the two groups was statistically significant(P < 0.05).There was no significant difference in the anastomotic complications between the two groups(P = 0.64).There was no significant difference in the postoperative complications of pelvic abscess,urinary retention,incision infection and deep venous thrombosis in the two groups.There was no intestinal obstruction in the TaTME group,and there were four cases in the ISR group,the difference was statistically significant(P = 0.04).There were one cases of anal pain in the TaTME group and six cases in the ISR group.The number of cases in the ISR group was significantly lower than that in the ISR group,which was statistically significant compared with the ISR group(P = 0.04).The two groups of patients all met the criteria of TME radical operation for rectal cancer.The mean diameter of tumor,the distance between distal tumor and distal margin,Number of lymph nodes and positive number,circumferential margin were not statistically significant.There was no significant difference in postoperative TNM pathological stage between the two groups(P = 0.53).There was no significant difference in the degree of tissue differentiation between the two groups(P = 0.36).Two groups of patients with preoperative Wexner score was zero points,The score of the TaTME group was8.31 ± 3.32 in six months after surgery,and 5.48 ± 1.85 in twelve months after surgery,The score of the ISR group was 10.97 ± 2.56 in six months aftersurgery,and 5.97 ± 1.99 in twelve months after surgery,TaTME group six months after surgery,Wexner score was significantly lower than that of group ISR,The differences between the two groups were statistically significant(P<0.05),and suggesting that twelve months after surgery,TaTME group anal function is better than that of ISR group.There was no significant difference in the Wexner score between the two groups in the twelve months after the operation(P=0.29).The Wexner score of the same group of patients decreased in twelve and six months after operation,indicating that the anal function is gradually restored.Two groups of patients six months after operation,Kirwan grading indicated that anal function decreased to varying degrees,but TaTME group was better than ISR group,the difference was statistically significant(P= 0.02).There was no significant difference between the two groups of patients with distant metastasis,the number of local recurrence,and the survival rate of one and two years.conclusions:(1)TaTME is a safe and viable surgical method for low rectal cancer.compared with ISR,time of postoperative food intake earlier,early ambulation time faster,shorter hospital stay,lower total cost,not increase the intraoperative and postoperative complications,the postoperative recovery has an advantage,Save the cost,,reduce the economic burden of patients;(2)There are fewer anal pain patients after TaTME,and the early anal function is better,the surgery can make patients with low rectal cancer,not only to keep the anus,but also ensure the function of the anus,and the quality of life is better.(3)TaTME operation can achieve the curative effect of radicalresection of tumor,and its short-term effect is equal to that of traditional ISR operation. |
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