Comparison Of Short-term Clinical Efficacy Of Laparoscopic Assisted ISR Via Pelvic And Mixed Approaches

Objective: To compare the technical points,safety,postoperative complications and anal function of laparoscopic assisted intersphincteric resection(ISR)via pelvic and mixed approachesMethods: 90 patients with ISR from January 2016 to November 2020 in the Hospital were retrospectively collected and divided into pelvic approach group(60cases),mixed approach group(30 cases)according to whether the ISR approach was anal or not.The data of the two groups were collected,including general information,intraoperative conditions,postoperative pathology,postoperative complications and postoperative anal function.The statistical software was SPSS 25.0.The mean ±standard deviation((?)± s)was used to describe the measurement data in accordance with normal distribution and t test was used for inter group comparison of it.The median(range)was used to describe the measurement data that did not conform to normal distribution and Mann Whitney U test of nonparametric test was used for inter group comparison.Chi square test or Fisher test were used to compare the count data between groups.Kaplan Meier method was used to calculate the survival time,and log rank method was used to test the survival difference between groups and the difference was statistically significant with P < 0.05.Results:(1)Comparison of general information:There were no significant differences in gender,age,height,weight,body mass index,neoadjuvant therapy,preoperative tumor markers(CEA,CA199)and ASA classification between the two groups(P >0.05).The distance between the tumor and the anal margin in the pelvic approach group(4.49±0.54cm)was higher than that in the mixed approach group(3.52±0.47cm).The difference between the two groups was statistically significant(P < 0.001).(2)Comparison of intraoperative conditions and postoperative pathology: Compared with pelvic approach group,the operation time of the mixed approach group was longer,the median intraoperative blood loss was more,and the postoperative anastomotic stoma was lower than that of the pelvic approach group(P < 0.05).There was no significant difference in postoperative hospital stay,total hospital stay,distance of distal resection margin,depth of postoperative pathological invasion,lymph node metastasis and TNM stage between mixed approach group and pelvic approach group(P > 0.05).(3)Comparison of postoperative complications:The incidence of total complications in the pelvic approach group and the mixed approach group was 26.7% and 30%respectively,and there was no significant difference between the two groups(P >0.05).There was no significant difference in incidence of complications such as anastomotic leakage,anastomotic bleeding,anastomotic stenosis,intestinal obstruction,wound infection,urinary retention,pelvic infection,pulmonary infection,incisional hernia,chylous fistula,abdominal and pelvic abscess between the two groups(P >0.05).(4)Comparison of postoperative anal function: The total stomal return rate was 92.0%in the two groups,93.3% in the pelvic approach group and 90.0% in the mixed approach group.In the pelvic approach group,3 cases were not returned due to anastomotic complications,and 1 case was not returned due to insufficient time;in the mixed approach group,2 cases were not returned due to anastomotic complications,and 1 case was not returned due to insufficient time.The Wexner scores at 1 month and3 months after ostomy closure were 15.0(12.0-17.0)and 12.0(10.0-14.0)in the pelvic approach group,and 16.0(14.0-18.0)and 14.0(12.0-16.0)in the mixed approach group.The difference between the two groups was statistically significant.The Wexner scores of the pelvic approach group and the mixed approach group were 10.0(9.0-12.0)and11.0(8.0-12.0)respectively at 6 months after the ostomy closure,and there was no significant difference between the two groups.(5)Postoperative follow-up: a total of 90 patients were included in the study.The follow-up time was 6-62 months,the median follow-up time was 27 months,and the deadline of follow-up was March 2021.All 90 patients were followed up.The median follow-up time was 27 months.There were 3 cases of local recurrence,4 cases of liver metastasis and 3 cases of lung metastasis.In the mixed approach group,the follow-up time was 6-53 months,and the median follow-up time was 28 months.There were 1case of local recurrence,2 cases of liver metastasis and 1 case of lung metastasis.The3-year DFS(disease-free survival)of the pelvic approach group and the mixed approach group were 84.7% and 87.9% respectively,and the difference was not statistically significant(P > 0.05).There was no death in all follow-up patients.Conclusion: The two approaches in this study are safe and feasible.Compared with the pelvic approach group,the incidence of anastomotic leakage in the mixed approach group was relatively higher,and the anal function was relatively poor in the short term after operation.However,for male,obese,pelvic stenosis,and lower tumor location,the mixed approach group could perform perfect anastomosis under the condition of ensuring safe DRM.According to the gender,BMI,tumor location and surrounding infiltration,ISR can be selected for patients with low rectal cancer with appropriate approach.ISR can not only ensure the radical resection of tumor,but also make patients obtain satisfactory anal function.It is a worthy surgical technique.However,the number of samples in this study is small and the follow-up time is short.It is necessary to further expand the sample size and extend the follow-up time for further study.