【作者】 李军；

【导师】 张苏展；

【作者基本信息】 浙江大学 ， 肿瘤学， 2007， 博士

【摘要】 结直肠癌是危害人类健康的主要恶性肿瘤之一。手术切除仍然是目前结直肠癌治疗的核心手段。在不损害恶性肿瘤患者长期预后的前提下尽量减少创伤并最大程度的保留功能是目前肿瘤外科治疗的发展趋势之一。腹腔镜技术的应用使很多外科手术趋向微创化。但是，结直肠癌患者是否适合接受腹腔镜手术存在较大争议。早期阶段，高戳口复发风险的相关报道使结直肠癌腹腔镜手术的安全性受到质疑。随着研究的进展，结直肠癌腹腔镜手术呈现出差异化的发展趋势。多项前瞻性随机对照试验（Randomized Controlled Trials，RCT）验证了结肠癌腹腔镜手术的长期疗效。结肠癌腹腔镜手术已逐渐被接受。相对而言，直肠癌腹腔镜手术的研究较少，其可行性仍存在普遍争议。表现为：（1）腹腔镜是否能够克服狭小盆腔的限制，实现根治性切除?是否增加并发症发生率?（2）腹腔镜辅助直肠癌手术是否具有微创伤价值?（3）腹腔镜辅助直肠癌手术是否改变肿瘤细胞转移的规律?部分研究认为，腹腔镜手术后吻合口瘘发生率和环周切缘（Circumferential Resection Margin，CRM）阳性率高，因此不推荐腹腔镜辅助直肠癌前切除术。对于腹腔镜手术微创伤价值的评价多来自医生的观察指标，如疼痛、胃肠道功能恢复时间和住院时间。针对腹腔镜手术后患者生活质量的评价的研究非常少。一项研究发现，腹腔镜术后男性直肠癌患者性功能易受损。国内尚无类似研究报道。目前，针对腹腔镜手术对结直肠癌肿瘤细胞转移影响的研究多来自细胞和动物实验，相应的临床研究较少。中国大肠癌患者中直肠癌构成比高于欧美，其中约2/3为中低位直肠癌。目前，我国腹腔镜辅助结直肠癌手术也以直肠癌为主。但是，多数RCT未纳入中低位直肠癌患者。腹腔镜辅助直肠癌根治术的临床应用尚缺乏足够的证据支持。为了评价腹腔镜辅助直肠癌根治术的研究现状和临床可行性，本课题研究了以下四部分内容：第一部分结直肠癌腹腔镜手术短期疗效和安全性的荟萃分析目的：评价结直肠癌腹腔镜手术的短期疗效和安全性。方法：检索2005年12月前已公开发表的比较结直肠癌腹腔镜手术与开腹手术短期临床效应差异的RCT。按纳入和排除标准筛选后进行质量评分，提取短期临床效应指标，进行荟萃分析。结果：9项RCT纳入荟萃分析，平均质量评分7.6±0.6分。仅有2项RCT针对中低位直肠癌，质量评分均为5分。腹腔镜手术组与开腹手术组患者基本特征均衡。较之开腹手术组，腹腔镜手术组切口长度减少12cm（95％CI[-13.51，-10.49]，P＜0.01），出血量较开腹手术组减少约75ml（95％CI[-86.06，-62.99]，P＜0.01），但是手术时间延长42min（95％CI[32.18，52.50]，P＜0.01）。标本长度、切缘阳性率及淋巴结检出数量等，两组均无差异。两组患者术中并发症、术后总体并发症和具体并发症发生率无差异。腹腔镜手术组患者术后第一天疼痛更轻（加权均数差WMD=-0.80，95％CI[-1.26，-0.34]，P＜0.01），肠外镇痛药使用量更少（标准化均数差SMD=-0.31，95％CI[-0.42，-0.21]，P＜0.01），同时其术后排气时间、肠蠕动恢复时间、饮食恢复时间及出院时间均早于开腹手术组患者（P＜0.05）。结论：腹腔镜手术可安全地根治结直肠癌，对患者的创伤亦明显减少。基于目前可获得的最佳证据，本研究认为腹腔镜手术可常规应用于治疗结肠癌。但是，针对腹腔镜辅助直肠癌手术应用的RCT少且质量不高。对腹腔镜辅助直肠癌手术应用价值的最终判断有待于更多RCT的结果。第二部分腹腔镜辅助直肠癌根治术短期疗效的3中心对照研究目的：探讨腹腔镜辅助直肠癌根治术的短期疗效和安全性。方法：本研究是回顾性对照研究。研究对象是2004年1月到2005年12月间在3家大学附属医院接受腹腔镜根治术的直肠癌患者，对照是同期接受开腹手术的直肠癌患者。收集患者的一般资料、手术、术后恢复、并发症、病理诊断和辅助治疗数据进行比较。随访至2006年12月。遵循处理意向原则（Intention To Treat，ITT）进行统计分析。结果：3中心共完成非急症直肠癌手术335例。其中，腹腔镜辅助手术115例，开腹手术220例。两手术组患者各项临床病理参数均无显著性差异（P＞0.05）。99.4％（333/335）的患者未接受过术前放化疗。保肛的235例患者中有201例（85.59％）接受了全直肠系膜切除（Total Mesorectal Excision，TME）。与开腹手术比较，腹腔镜手术切口短、出血少、术中和术后输血率低，但是手术时间延长（P＜0.05）。腹腔镜手术组中13例（11.3％）患者需中转开腹。2手术组远切缘距离、纵向切缘阳性率、肿瘤最大径和检出淋巴结数量均无显著性差异（P＞0.05）。3中心均未报告环周切缘状况。2手术组患者术中并发症发生率、术后3个月内并发症发生率、住院期间二次手术发生率和围手术期死亡率均无显著性差异（P＞0.05）。腹腔镜手术组患者自控镇痛（Patient Controlled Analgesia，PCA）使用率低于开腹手术组（13.0％vs34.5％，P=0.000），但是术后患者肠外镇痛药和口服镇痛药使用量均无显著性差异（P＞0.05）。与开腹手术组比较，腹腔镜手术组患者排气时间、流质恢复时间、半流质恢复时间、排便时间、排尿时间、下床活动时间和术后住院时间均更短，差异均有统计学意义（P＜0.05）。中位随访20个月（四分位数间距11个月），随访率93.1％。2手术组患者辅助化疗率、化疗方案构成及辅助化疗完成率均无显著性差异（P＞0.05）。2手术组患者（Ⅰ～Ⅲ期）局部复发率、远处转移率和总生存率均无显著性差异（P＞0.05）。结论：腹腔镜辅助直肠癌手术符合根治手术的要求，同时具有创伤小和恢复快的优势，不增加并发症发生率。短期结果提示腹腔镜辅助直肠癌根治术安全有效。腹腔镜辅助直肠癌根治术的长期疗效有赖于前瞻性随机对照试验结果。第三部分腹腔镜辅助根治术对直肠癌患者短期生活质量影响的研究目的：评价腹腔镜辅助根治术对直肠癌患者短期生活质量的影响。方法：本研究是前瞻性非随机观察研究。2005年6月至2006年9月间共95例直肠癌患者加入研究并接受了根治手术，其中腹腔镜手术组42人，开腹手术组53人。记录两组患者手术数据和术后恢复数据进行比较。以欧洲癌症研究治疗组织（European Organization for Research and Treatment，EORTC）开发的QLQ-C30和QLQ-CR38量表测定两组患者术前、术后1周和术后3个月时的生活质量评分进行比较。遵循处理意向原则进行了统计学分析。结果：两手术组患者的临床病理特征均衡。腹腔镜手术组中转率为23.8％（10/42）。与开腹手术比较，腹腔镜手术时间延长40min，但是切口长度短16cm且出血更少，术后患者恢复排气时间、流质时间、半流质时间和排便时间均更早（P＜0.05）。两组患者术后并发症发生率相似（P＞0.05）。EORTC QLQ-C30量表分析表明，围手术期腹腔镜手术组患者经济困难领域评分始终低于开腹手术组患者，差异有统计学意义（P＜0.05）和临床意义。除此以外，只有术后1周时总体健康领域评分差异（腹腔镜手术组中位评分33.3vs开腹手术组中位评分25.0，P=0.003）以及疼痛领域评分差异（腹腔镜手术组中位评分33.3vs开腹手术组中位评分50.0，P=0.006）有统计学意义，仅后者具有临床意义。围手术期，两组患者的大部分领域评分均无显著性差异（P＞0.05）。EORTC QLQ-CR38量表分析发现，术后3个月时58.3％的患者（49/84）有排尿症状，61.1％的男性患者（11/18）有勃起或射精困难，4例女性患者（4/5）有阴道干涩或性交痛。但是，围手术期两组患者各领域评分均无显著性差异（P＞0.05）。结论：相对开腹手术而言，腹腔镜辅助直肠癌根治术减少了创伤，但是其生活质量优势微弱。腹腔镜辅助直肠癌根治术对患者膀胱功能和性功能的影响与开腹手术相当。第四部分腹腔镜手术对直肠癌患者外周血中鸟苷酸环化酶C浓度的影响目的：探讨腹腔镜手术对直肠癌肿瘤细胞血行播散的影响。方法：研究对象是接受根治手术的74例直肠癌患者，其中腹腔镜手术30例，开腹手术44例。以荧光定量RT-PCR（Real-time quantitative reverse transcriptase-polymerase chain reaction，Real time RT-PCR）技术检测术前、术中和术后1周患者外周静脉血中鸟苷酸环化酶C（Guanylyl Cyclase C，GCC）mRNA的拷贝数。以15例健康人为对照。分别以流式细胞术和免疫散射比浊法检测术前、术后第3日和术后1周患者外周静脉血中淋巴细胞亚群比例和血清C-反应蛋白（C-Reactive Protein，CRP）水平。结果：52.7％（39/74）的直肠癌患者术前外周血中检测到GCC mRNA（中位拷贝数为485.0copy/ml血），健康对照组阳性率为13.3％（2/15，中位拷贝数为0.0copy/ml血），差异有统计学意义（P＜0.05）。术前、术中和术后1周，腹腔镜组和开腹组患者间外周血中GCC mRNA拷贝数差异均无统计学意义（P＞0.05）。亚组分析显示，接受腹腔镜手术的Ⅰ期患者术中和术后1周时外周血中GCC mRNA拷贝数均低于术前（P=0.022），接受开腹手术的Ⅰ期患者外周血中GCC mRNA拷贝数有相似变化趋势，但是差异无统计学意义（P=0.097）；接受腹腔镜手术的N₁患者术中外周血中GCC mRNA拷贝数高于术前（P=0.044），但是术后1周时回落至术前水平，而接受开腹手术的N₁患者围手术期外周血中GCC mRNA拷贝数差异无统计学意义（P＞0.05）。对临床病理参数匹配的腹腔镜组和开腹组各13例患者进行配对，分析2组患者围手术期淋巴细胞亚群比例和血清CRP变化差异。术后直肠癌患者出现细胞免疫抑制，表现为术后T淋巴细胞比例、CD4/CD8比率和NK细胞比例降低。相同时间点两手术组患者间淋巴细胞亚群比例均无显著性差异（P＞0.05）。术后第3日患者血清CRP表达量均高于术前（P=0.000），但是腹腔镜手术组患者CRP表达量低于开腹组（P=0.026）。中位随访9个月（全距4～16个月），腹腔镜手术组无复发和死亡事件。结论：遵循无瘤操作原则的腹腔镜辅助直肠癌根治术不增加肿瘤细胞血行播散的机率。腹腔镜辅助直肠癌根治术的创伤小于开腹手术，但是对患者细胞免疫抑制程度相似。更多还原

【Abstract】 Colorectal cancer represents a major public health problem. So far, operation is the capital method to treat the colorectal cancer. One of trends in oncological surgery is that less trauma and best function reserved without hurt to the outcome of patients with malignant neoplasms.The application of laparoscopy made it true that more operations trended to minimal trauma. However, the application of laparoscopic operation for the colorectal cancer patients was questioned. The abnormal high port site recurrence rate in early time cast doubt on the safety of laparoscopic operation. With the progress in researches, the different tendency appeared in the application of laparoscopic resection for colorectal cancers. The long-term efficacy of laparoscopic colectomy for colon cancer was authenticated by several prospective randomized controlled trials （RCT）. As a result, the laparoscopic operation for colon cancer has been accepted gradually.However, the feasibility of laparoscopic resection for rectal cancer was of general controversies with limited number researches. The questions included: （1） Could laparoscopic operation resect the rectal cancer radically regardless the limitation of narrow pelvic? Would laparoscopic resection increase the complication rate? （2） Did laparoscopic operation for rectal cancer mean minimal trauma? （3） Would laparoscopic operation alter the metastasis pattern of rectal cancer cells? The high rates of anastomotic leakage and circumferential resection margin （CRM） were reported by some researches. As a result, the laparoscopic assisted anterior resection for rectal cancer was not recommended. Most researches evaluating the minimaltrauma value focused the parameters, such as pain, time resuming bowel function and hospital stay, which were the most concerned by the surgeons. The number of research focusing the quality of life was small. The phenomena of more male sexual functional impairments after laparoscopic operation for rectal cancer was reported by a research form UK. There wasn’t similar research reported in China. The most of researches focusing the impact of laparoscopic operation on the cancer cell metastasis were in vitro not in vivo. The constituent ratio of rectal cancer of China in colorectal cancer was higher than that of Europe and America. Moreover, 2/3 of rectal cancer lies in the middle and low fragment of rectum. Accordingly, laparoscopic rectal resection made up the major of laparoscopic assisted colorectal cancer operation in China. However, patients with middle-low rectal cancer weren’t included in most RCT. Therefore, there weren’t enough evidences to support the feasibility of laparoscopic assisted rectal cancer resection. To assess the current situation and feasibility of laparoscopic resection for rectal cancer, four parts researches were designed:Part oneMeta-analysis of short-term efficacy and safety after laparoscopic resectionfor colorectal cancerObjective: To assess the short-term efficacy and safety of laparoscopic resection （LR） for colorectal cancer.Methods: A literature search was performed for the randomized controlled trials （RCT） comparing the difference of laparoscopic and open resection （OR） for colorectal cancer by the end of December 2005. After inclusion and exclusion standard was performed, RCT were appraised by two reviewers independently. The short-term outcomes were extracted and analyzed in Meta analysis.Results: 9RCTs were included in the Meta analysis, which mean quality score was 7.6 ± 0.6. Only 2RCTs aimed the middle-low rectal cancer both with quality score5. The patients’ baseline characteristics were similar in two treatment groups. Comparing OR, the incision length in LR deceased 12cm （95%CI[-13.51,-10.49], P<0.01）, blood loss deceased 75ml （95%CI[-86.06,-62.99], P<0.01）, but the operation time was prolonged 42min （95%CI[32.18,52.50], P<0.01）. The length of resected specimens, positive rates of resection margins and number of retrieved lymph nodes didn’t show significant differences. There were no significant differences in morbidity rates in operation and post operation between two treatment groups. In patients undergoing LR, the intensity of pain in the first day after operation was shorter （WMD—0.80, 95%CI[-1.26,-0.34], P<0.01）, the parenteral narcotics requirement was reduced （SMD=-0.31, 95%CI[-0.42,-0.21], P<0.01）, the average time to first flatus, first bowel movement, resuming diet and discharge were reduced （P<0.05）.Conclusions: Laparoscopic resection for colorectal cancer is safe and effective, with less pain and faster recovery than open resection. The routine use of laparoscopic assisted resection for colon cancer was supported by enough evidences. However, there was less RCT aimed rectal cancer with low quality score. The role of laparoscopic assisted surgery for rectal cancer will be demonstrated by more RCT.Part two Laparoscopic assisted operation for the cure of rectal cancer: short-term results of three-center case control studyObjective: To assess the short-term efficacy and safety of laparoscopic assisted resection （LR） for rectal cancer.Methods: This is a case control study. The rectal cancer patients’ undergone laparoscopic assisted resection came from 3 affiliated hospitals of university between January 2004 and December 2005. The rectal cancer patients adopted open resection （OR） simultaneously were the control. A data collection and comparison was performed which included baseline characteristics of patients, operation, recovery post operation, complication, pathological diagnosis and adjuvant therapy. Follow-upwas ceased by December 2006. Analysis was by intention to treat （ITT）.Results: 335 rectal cancer procedures without emergency were performed in 3 centers, which included 115 LR and 220 OR. The patients’ baseline characteristics were similar in two treatment groups（P>0.05）. 99.4% （333/335） patients didn’t receive adjuvant chemoradiotherapy. 85.59% （201/235） patients with anal sphincter preservation received total mesorectal excision. Comparing OR, LR was of shorter incision length, less blood loss, need for transfuse during and post operation and prolonged operation time （P<0.05）. 13 （11.3%） patients underwent conversion from laparoscopic to open surgery. There were no differences between 2 operation groups in distance of tumor from the distal section edge, positive rate of length wise section edge, the largest diameter and the number of harvested lymph nodes （P>0.05）. The status of circumferential resection margin wasn’t reported by any center. There were no differences between 2 operation groups in complication rate during operation, complication rate operation 3months later, reoperation rate in hospital and morbidity rate perioperative （P>0.05）. In patients undergoing LR, patient controlled analgesia was less used than OR （13.0%vs34.5%, P=0.000）. The parenteral narcotics and oral narcotics requirements didn’t show significant differences （P>0.05）. Comparing OR, the average time to first flatus, resuming fluid and semifluid diet, defecation, micturition, ground activity and discharge were reduced in LR （P<0.05）. The follow-up rate was 93.1% with median 20months （IQR 11months）. There were no significant differences between 2 operation groups in rate of adjuvant chemotherapy, regimen composition and complete rate （P>0.05）. No statistical differences were found between 2 operation groups in recurrence rate, metastasis rate and overall survival rate （P>0.05）.Conclusions: Laparoscopic radical resection for rectal cancer meets the principle of radical operation with fewer traumas, faster recovery and reasonable complication rate. Due to the short-term results, laparoscopic radical resection for rectal cancer was safe and effective. The long-term efficacy will be demonstrated by RCT.Part three Impact of laparoscopic radical resection on quality of life in rectal cancer patientsObjective: To investigate the impact of laparoscopic radical resection on quality of life in rectal cancer patients.Methods: This is a prospective non-randomized observational study. From June 2005 to September 2006, 95 rectal cancer patients joined in the study and accepted radical operation. 42 patients accepted laparoscopic resection （LR）, in the same time 53 patients accepted open resection （OR） who was the control. The data of operation and recovery of 2 groups’ patients were collected and analyzed. EORTC （European Organization for Research and Treatment） QLQ-C30 and QLQ-CR38 questionnaire were applied to evaluate the scores of quality of life of patients before operation, 1 week later and 3 months later separately. Analysis was by intention to treat.Results: The patients’ baseline characteristics were similar in two operation groups（P>0.05）. The conversion rate was 23.8% （10/42） in LR. Comparing OR, the operation time was prolonged 40min with shorter incision to 16cm in LR （P<0.05）. The time to fist flatus, resuming fluid and semifluid diet and defecation were reduced in LR also（P<0.05）. Analysis of QLQ-C30 questionnaire showed that the financial difficulties were always lower in LR than in OR with statistical significance （P<0.05） and clinical significance. Except financial difficulties, only the difference of global health status 1 week later （LR median33.3vsOR median 25.0, P=0.003） and the difference of pain 1 week later （LR median33.3vsOR median 50.0, .P=0.006） were of statistical significance. However, only the latter was of clinical significance. There were no significant differences in most scales between perioperation （P>0.05）. Analysis of QLQ-CR38 scores showed that 58.3% （49/84） patients were of micturition problems, 61.1% （11/18） male patients had erection or ejaculation difficulties 3 months later and 4 （4/5） female patients had symptom of dry vagina or pain during intercourse. However, no significant difference was found in any scale ofQLQ-CR38 between LR and OR （P>0.05）.Conclusions: Comparing open operation, laparoscopic assisted radical resection for rectal cancer was of fewer traumas and minimal benefit of quality of life. Laparoscopic resection was of no harmful impact on bladder and sexual function of rectal cancer patients.Part four Impact of laparoscopic resection on the copy number of guanylyl cyclase C mRNA in the peripheral blood of rectal cancer patientsObjective: To investigate the impact of laparoscopic resection on circulating free tumor cells in the peripheral blood of rectal cancer patients.Methods: 74 rectal cancer patients without metastasis were recruited. Laparoscopic resection was adopted by 30 patients. Open operation were given to the other 44 patients. Quantitation of peripheral circulating free tumor cells was performed preoperatively, during operation and 1 week later by means of real-time quantitative reverse transcriptase-polymerase chain reaction （Real time RT-PCR） targeting guanylyl cyclase C （GCC） mRNA. 15 healthy volunteer was the control. Moreover quantitation of the subgroup proportion of peripheral blood lymph cell and level of serum C-reactive protein （CRP） were performed preoperatively, 3 day later and 1 week later by means of flow cytometry and nephelometry respectively in rectal cancer patients.Results: GCC mRNA was detected in 52.7%（39/74） preoperative rectal cancer patients with median 485.0copy/ml blood and 13.3%（2/15） healthy control with median 0.0copy/ml blood （P<0.05）. There were no significant difference of the GCC mRNA value between 2 operation group at any time（P>0.05）. Subgroup analysis showed that the GCC mRNA value during operation and 1 week later were lower than preoperative value in TNM I stage patients undergoing laparoscopic operation（P=0.022）. The same trend was found in open operation group without statistical significance（P=0.097）. The GCC mRNA during operation was higher thanpreoperative value in N₁ patients undergoing laparoscopic operation（P=0.044）, but descend to the preoperative level 1week later. There was not the similar trend in open group（P>0.05）. Matching analysis was performed between 13 pairs coming from 2 operation groups targeting the subgroup proportion of peripheral blood lymph cell and serum CRP. Cell immune suppression appeared after operation including the decrease of proportion of T cell, CD4/CD8 ratio and proportion of NK cell. There was no significant difference between 2 operation groups at 3 time points（P>0.05）. The CRP degree of 3 day later was higher than that preoperative（P=0.000）. The CRP degree of 3 day later was lower in laparoscopic operation group than the value of open operation（P=0.026）. With a median follow-up of 9 months（4～16 months）, there was no recurrence and death in laparoscopic operation group.Conclusions: Laparoscopic radical resection for rectal cancer had no significantly deleterious effect on circulating free tumor cells with the precondition of no-touch principle. There was less trauma followed laparoscopic operation than open operation. There was no difference in cell immune suppression between the patients having laparoscopic radical resection and those undergone open surgery for rectal cancer.更多还原