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Article(id=1199337300866987001, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199337298941804946, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2526.2023.0719, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1670169600000, receivedDateStr=2022-12-05, revisedDate=null, revisedDateStr=null, acceptedDate=1678723200000, acceptedDateStr=2023-03-14, onlineDate=1763873895136, onlineDateStr=2025-11-23, pubDate=1706371200000, pubDateStr=2024-01-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763873895136, onlineIssueDateStr=2025-11-23, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763873895136, creator=13701087609, updateTime=1763873895136, updator=13701087609, issue=Issue{id=1199337298941804946, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='1', pageStart='1', pageEnd='120', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763873894677, creator=13701087609, updateTime=1763874094669, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1199338137823572576, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199337298941804946, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1199338137823572577, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199337298941804946, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=31, endPage=36, ext={EN=ArticleExt(id=1199337301303194621, articleId=1199337300866987001, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Comparison of clinical efficacy of NOSES combined with ERAS and conventional laparoscopic surgery in treatment of rectal cancer, columnId=1199337300007158168, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Special Issue on Rectal Cancer Surgery and Perioperative Treatment Strategies, runingTitle=null, highlight=null, articleAbstract=

Objective To compare the clinical efficacy of natural orifice specimen extraction surgery (NOSES) combined with enhanced recovery after surgery (ERAS) and conventional laparoscopic surgery in treatment of rectal cancer patients. Methods A hundred patients with rectal cancer in the Department of Colorectal and Anal Surgery, the 940th Hospital of Joint Logistics Support Force of PLA were selected as the research objects from January 2019 to December 2021, including 49 cases treated with NOSES combined with ERAS were set as the observation group, and 51 cases treated with conventional laparoscopic surgery of rectal cancer were set as the control group. Postoperative C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), white blood cell count (WBC), percentage of neutrophil (NEUT), K+ concentration, postoperative peristalsis recovery time, first time out-of-bed activity, first liquid feeding time, removal time of urinary, and drainage tubes, hospital stay and intraoperative blood loss, number of lymph node detection, positive margin rate, incidence of complications, and pain score were compared between the two groups. Results The observation group showed significant lower postoperative CRP, PCT, IL-6 levels when compared with control group(P<0.05), while no significant difference in K+ concentration between the two groups (P>0.05). The recovery time of intestinal peristalsis, the time of the first out-of-bed activity, the first liquid feeding time, the time of removal of the urinary tube and the drainage tube, and the number of days of hospitalization in observation group were all superior to the control group (P<0.05). The observation group with the duration of surgery was longer than the control group, and the difference was statistically significant (P<0.05). There were no significant differences in intraoperative bleeding, number of lymph nodes detected and positive rate of resection margins between the two groups (P>0.05). There was no significant difference in the incidence of complications between the two groups (4.1% vs. 7.8%, P>0.05). The observation group showed significant lower pain scores than control group on the 1st, 2nd and 3rd day after surgery (P<0.05). Conclusions NOSES combined with ERAS in treatment of rectal cancer patients is safe and feasible, can narrow the surgical incision, alleviate stress response and postoperative pain, improve postoperative efficacy and reduce the occurrence of complications, so is worthy of promotion and application.

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目的 比较经自然腔道取标本手术(NOSES)联合快速康复外科(ERAS)与常规腹腔镜手术治疗直肠癌患者的临床疗效。方法 选取2019年1月-2021年12月于解放军联勤保障部队第940医院结直肠肛门外科确诊的100例直肠癌患者为研究对象，其中49例行NOSES联合ERAS治疗(设为观察组)，51例行常规腹腔镜直肠癌根治术治疗(设为对照组)。比较两组术后C反应蛋白(CRP)、降钙素原(PCT)、白细胞介素-6(IL-6)、白细胞计数(WBC)、中性粒细胞百分比(NEUT)、K+浓度，术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管和引流管时间、住院时间，以及术中出血量、淋巴结检出数目、切缘阳性率、并发症发生率、疼痛评分等临床指标。结果 观察组术后CRP、PCT、IL-6水平均明显低于对照组(P<0.05)；两组K+浓度比较差异无统计学意义(P>0.05)。观察组术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管及引流管时间、住院时间等均短于对照组，手术时间长于对照组，差异有统计学意义(P<0.05)；两组术中出血量、淋巴结检出数目、切缘阳性率比较差异无统计学意义(P>0.05)。两组并发症发生率比较差异无统计学意义(4.1% vs. 7.8%，P>0.05)；观察组术后第1、2、3天的疼痛评分均明显低于对照组(P<0.05)。结论 NOSES联合ERAS治疗直肠癌，可缩小手术切口，减轻应激反应及术后疼痛，安全可行，有利于提高疗效，降低并发症发生率，值得推广应用。

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宋枫，硕士研究生，副教授，主要从事结直肠肛门外科临床与基础研究

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宋枫，硕士研究生，副教授，主要从事结直肠肛门外科临床与基础研究

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NOSES. 经自然腔道取标本手术；TaTME. 经肛全直肠系膜切除；A. 处理肠系膜血管；B. 游离直肠后间隙；C. 经肛门置入抵钉座；D. 经肛门取出标本；E. TaTME手术；F. 外翻经肛门脱出

, figureFileSmall=IlxfBMqO8SFiAR8aQJ8D7w==, figureFileBig=BjfaMWbuEiNb+I+Y/lRfSw==, tableContent=null), ArticleFig(id=1199376215887937843, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Fig.2, caption=Abdominal wounds of rectal cancer in conventional laparoscopy and NOSES surgery, figureFileSmall=IWNSBSZymE2SzcCp9B5LhA==, figureFileBig=a+sZli0uX0WhkAWcvrGJ7Q==, tableContent=null), ArticleFig(id=1199376216034738492, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=图2, caption=直肠癌常规腹腔镜手术与NOSES手术腹部伤口情况

NOSES. 经自然腔道取标本手术；A. 常规腹腔镜手术腹部伤口情况；B. NOSES手术腹部伤口情况

, figureFileSmall=IWNSBSZymE2SzcCp9B5LhA==, figureFileBig=a+sZli0uX0WhkAWcvrGJ7Q==, tableContent=null), ArticleFig(id=1199376216135401793, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Tab.1, caption=

Comparison of general data in the two groups of rectal cancer patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
年龄(岁, $\bar{x}±s$)56.3±6.458.2±4.5-0.4370.351
性别[例(%)]0.3610.295
男30(61.2)32(62.7)
女19(38.8)19(37.3)
BMI(kg/m2, $\bar{x}±s$)23.30±3.2123.27±2.630.6730.736
肿瘤横径(cm, $\bar{x}±s$)3.11±1.343.24±1.410.3520.413
肿瘤距肛缘距离(cm, $\bar{x}±s$)6.58±2.497.21±2.310.6860.788
TNM分期[例(%)]0.5180.531
Ⅰ6(12.2)3(5.9)
Ⅱ7(14.3)13(25.5)
Ⅲ36(73.5)35(68.6)
), ArticleFig(id=1199376216278008138, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=表1, caption=

两组直肠癌患者一般资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
年龄(岁, $\bar{x}±s$)56.3±6.458.2±4.5-0.4370.351
性别[例(%)]0.3610.295
男30(61.2)32(62.7)
女19(38.8)19(37.3)
BMI(kg/m2, $\bar{x}±s$)23.30±3.2123.27±2.630.6730.736
肿瘤横径(cm, $\bar{x}±s$)3.11±1.343.24±1.410.3520.413
肿瘤距肛缘距离(cm, $\bar{x}±s$)6.58±2.497.21±2.310.6860.788
TNM分期[例(%)]0.5180.531
Ⅰ6(12.2)3(5.9)
Ⅱ7(14.3)13(25.5)
Ⅲ36(73.5)35(68.6)
), ArticleFig(id=1199376216382865743, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Tab.2, caption=

Comparison of the inflammatory indexes and electrolytes concentration in the two groups of rectal cancer patients ($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
CRP(mg/L)
术前3.71±1.633.49±1.563.4120.635
术后第3天47.23±26.8179.85±31.961.1830.017
术后第5天17.46±5.1331.35±4.721.3630.031
PCT(ng/ml)
术前0.39±0.220.46±0.184.1760.781
术后第3天5.51±3.789.18±3.231.3920.039
术后第5天1.83±0.665.11±2.361.4780.043
IL-6(pg/ml)
术前4.33±2.184.17±2.673.1120.547
术后第3天72.17±13.64101.31±21.531.2780.023
术后第5天14.16±6.1221.58±7.161.3920.039
WBC(×109/L)
术前4.7±2.44.4±3.25.5650.912
术后第3天11.2±3.315.8±4.61.5170.047
术后第5天8.2±3.68.8±2.63.3480.619
NEUT(%)
术前56.7±11.653.9±14.23.8420.726
术后第3天68.2±10.676.9±12.81.4310.041
术后第5天67.2±10.468.9±11.73.9120.746
K+(mmol/L)
术前4.25±1.303.63±1.705.1180.856
术后第3天3.11±1.593.28±1.163.7170.723
术后第5天3.85±1.243.49±1.523.5270.683
), ArticleFig(id=1199376216500306259, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=表2, caption=

两组直肠癌患者炎性指标及电解质浓度比较($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
CRP(mg/L)
术前3.71±1.633.49±1.563.4120.635
术后第3天47.23±26.8179.85±31.961.1830.017
术后第5天17.46±5.1331.35±4.721.3630.031
PCT(ng/ml)
术前0.39±0.220.46±0.184.1760.781
术后第3天5.51±3.789.18±3.231.3920.039
术后第5天1.83±0.665.11±2.361.4780.043
IL-6(pg/ml)
术前4.33±2.184.17±2.673.1120.547
术后第3天72.17±13.64101.31±21.531.2780.023
术后第5天14.16±6.1221.58±7.161.3920.039
WBC(×109/L)
术前4.7±2.44.4±3.25.5650.912
术后第3天11.2±3.315.8±4.61.5170.047
术后第5天8.2±3.68.8±2.63.3480.619
NEUT(%)
术前56.7±11.653.9±14.23.8420.726
术后第3天68.2±10.676.9±12.81.4310.041
术后第5天67.2±10.468.9±11.73.9120.746
K+(mmol/L)
术前4.25±1.303.63±1.705.1180.856
术后第3天3.11±1.593.28±1.163.7170.723
术后第5天3.85±1.243.49±1.523.5270.683
), ArticleFig(id=1199376216609358172, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Tab.3, caption=

Comparison of indicators related to surgery in the two groups of rectal cancer patients ($\bar{x}±s$)

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指标

观察组
(n=49)

对照组
(n=51)

tP
手术时间(min)162.1±16.6140.0±18.24.1370.036
术中出血量(ml)29.4±10.327.7±6.71.4510.741
术后肠蠕动恢复时间(h)22.6±4.651.2±3.6-1.7250.037
术后首次离床活动时间(h)8.1±2.418.8±5.2-2.3920.028
术后首次进流食时间(h)26.3±7.942.2±4.1-3.3630.020
术后拔除尿管时间(h)24.7±2.763.1±3.8-1.2750.012
术后拔除引流管时间(d)4.8±2.37.6±3.1-1.8260.042
术后住院时间(d)6.3±1.89.4±4.3-1.9140.034
), ArticleFig(id=1199376216739381603, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=表3, caption=

两组直肠癌患者手术相关指标比较($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
指标

观察组
(n=49)

对照组
(n=51)

tP
手术时间(min)162.1±16.6140.0±18.24.1370.036
术中出血量(ml)29.4±10.327.7±6.71.4510.741
术后肠蠕动恢复时间(h)22.6±4.651.2±3.6-1.7250.037
术后首次离床活动时间(h)8.1±2.418.8±5.2-2.3920.028
术后首次进流食时间(h)26.3±7.942.2±4.1-3.3630.020
术后拔除尿管时间(h)24.7±2.763.1±3.8-1.2750.012
术后拔除引流管时间(d)4.8±2.37.6±3.1-1.8260.042
术后住院时间(d)6.3±1.89.4±4.3-1.9140.034
), ArticleFig(id=1199376216848433513, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Tab.4, caption=

Comparison of surgical complications in the two groups of rectal cancer patients [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
并发症观察组(n=49)对照组(n=51)χ2P
总计2(4.1)4(7.8)1.5290.493
吻合口瘘2(4.1)1(2.0)0.1820.391
吻合口出血00--
吻合口狭窄00--
腹腔感染00--
肠梗阻01(2.0)0.8630.214
切口感染01(2.0)0.8630.214
输尿管损伤01(2.0)0.8630.214
肠管损伤00--
血管损伤00--
坠积性肺炎00--
静脉血栓形成00--
), ArticleFig(id=1199376216961679724, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=表4, caption=

两组直肠癌患者手术并发症发生情况比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
并发症观察组(n=49)对照组(n=51)χ2P
总计2(4.1)4(7.8)1.5290.493
吻合口瘘2(4.1)1(2.0)0.1820.391
吻合口出血00--
吻合口狭窄00--
腹腔感染00--
肠梗阻01(2.0)0.8630.214
切口感染01(2.0)0.8630.214
输尿管损伤01(2.0)0.8630.214
肠管损伤00--
血管损伤00--
坠积性肺炎00--
静脉血栓形成00--
), ArticleFig(id=1199376217041371504, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=EN, label=Tab.5, caption=

Comparison of postoperative pathology in the two groups of rectal cancer patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
肿瘤横径(cm, $\bar{x}±s$)3.61±2.273.48±2.630.2580.362
T分期[例(%)]1.7180.519
T14(8.2)3(5.9)
T27(14.3)13(25.5)
T330(61.2)25(49.0)
T48(16.3)10(19.6)
N分期[例(%)]0.1960.281
N08(16.3)4(7.8)
N114(28.6)13(25.5)
N227(55.1)34(66.7)
M分期[例(%)]2.2520.535
M049(100.0)51(100.0)
M100
组织学分化程度[例(%)]
高分化腺癌7(14.3)10(19.6)0.1150.177
中分化腺癌18(36.7)11(21.6)0.1020.165
低分化腺癌23(46.9)28(54.9)2.3830.625
黏液腺癌1(2.1)2(3.9)1.5920.436
淋巴结检出数目(枚, $\bar{x}±s$)17±316±21.6440.518
切缘阳性率(%)00--
), ArticleFig(id=1199376217183977843, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1199337300866987001, language=CN, label=表5, caption=

两组直肠癌患者术后病理检查结果比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标观察组(n=49)对照组(n=51)χ2/tP
肿瘤横径(cm, $\bar{x}±s$)3.61±2.273.48±2.630.2580.362
T分期[例(%)]1.7180.519
T14(8.2)3(5.9)
T27(14.3)13(25.5)
T330(61.2)25(49.0)
T48(16.3)10(19.6)
N分期[例(%)]0.1960.281
N08(16.3)4(7.8)
N114(28.6)13(25.5)
N227(55.1)34(66.7)
M分期[例(%)]2.2520.535
M049(100.0)51(100.0)
M100
组织学分化程度[例(%)]
高分化腺癌7(14.3)10(19.6)0.1150.177
中分化腺癌18(36.7)11(21.6)0.1020.165
低分化腺癌23(46.9)28(54.9)2.3830.625
黏液腺癌1(2.1)2(3.9)1.5920.436
淋巴结检出数目(枚, $\bar{x}±s$)17±316±21.6440.518
切缘阳性率(%)00--
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NOSES联合ERAS与常规腹腔镜手术治疗直肠癌的临床疗效对比
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宋枫 1 , 高峰 1 , 徐明 1 , 高健 2 , 毛增喜 2
解放军医学杂志 | 直肠癌手术及围手术期治疗策略专题 2024,49(1): 31-36
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解放军医学杂志 | 直肠癌手术及围手术期治疗策略专题 2024, 49(1): 31-36
NOSES联合ERAS与常规腹腔镜手术治疗直肠癌的临床疗效对比
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宋枫1, 高峰1, 徐明1, 高健2, 毛增喜2
作者信息
  • 1解放军联勤保障部队第940医院结直肠肛门外科，甘肃兰州 730050
  • 2解放军联勤保障部队第944医院结直肠肛门外科，甘肃酒泉 753000

    • 宋枫，硕士研究生，副教授，主要从事结直肠肛门外科临床与基础研究

Comparison of clinical efficacy of NOSES combined with ERAS and conventional laparoscopic surgery in treatment of rectal cancer
Feng Song1, Feng Gao1, Ming Xu1, Jian Gao2, Zeng-Xi Mao2
Affiliations
  • 1Department of Colorectal and Anal Surgery, the 940th Hospital of Joint Logistics Support Force of PLA, Lanzhou, Gansu 730050, China
  • 2Department of Colorectal and Anal Surgery, the 944th Hospital of Joint Logistics Support Force of PLA, Jiuquan, Gansu 753000, China
出版时间: 2024-01-28 doi: 10.11855/j.issn.0577-7402.2526.2023.0719
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摘要
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目的 比较经自然腔道取标本手术(NOSES)联合快速康复外科(ERAS)与常规腹腔镜手术治疗直肠癌患者的临床疗效。方法 选取2019年1月-2021年12月于解放军联勤保障部队第940医院结直肠肛门外科确诊的100例直肠癌患者为研究对象，其中49例行NOSES联合ERAS治疗(设为观察组)，51例行常规腹腔镜直肠癌根治术治疗(设为对照组)。比较两组术后C反应蛋白(CRP)、降钙素原(PCT)、白细胞介素-6(IL-6)、白细胞计数(WBC)、中性粒细胞百分比(NEUT)、K+浓度，术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管和引流管时间、住院时间，以及术中出血量、淋巴结检出数目、切缘阳性率、并发症发生率、疼痛评分等临床指标。结果 观察组术后CRP、PCT、IL-6水平均明显低于对照组(P<0.05)；两组K+浓度比较差异无统计学意义(P>0.05)。观察组术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管及引流管时间、住院时间等均短于对照组，手术时间长于对照组，差异有统计学意义(P<0.05)；两组术中出血量、淋巴结检出数目、切缘阳性率比较差异无统计学意义(P>0.05)。两组并发症发生率比较差异无统计学意义(4.1% vs. 7.8%，P>0.05)；观察组术后第1、2、3天的疼痛评分均明显低于对照组(P<0.05)。结论 NOSES联合ERAS治疗直肠癌，可缩小手术切口，减轻应激反应及术后疼痛，安全可行，有利于提高疗效，降低并发症发生率，值得推广应用。

直肠癌  /  经自然腔道取标本手术  /  快速康复外科  /  腹腔镜  /  外科手术

Objective To compare the clinical efficacy of natural orifice specimen extraction surgery (NOSES) combined with enhanced recovery after surgery (ERAS) and conventional laparoscopic surgery in treatment of rectal cancer patients. Methods A hundred patients with rectal cancer in the Department of Colorectal and Anal Surgery, the 940th Hospital of Joint Logistics Support Force of PLA were selected as the research objects from January 2019 to December 2021, including 49 cases treated with NOSES combined with ERAS were set as the observation group, and 51 cases treated with conventional laparoscopic surgery of rectal cancer were set as the control group. Postoperative C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), white blood cell count (WBC), percentage of neutrophil (NEUT), K+ concentration, postoperative peristalsis recovery time, first time out-of-bed activity, first liquid feeding time, removal time of urinary, and drainage tubes, hospital stay and intraoperative blood loss, number of lymph node detection, positive margin rate, incidence of complications, and pain score were compared between the two groups. Results The observation group showed significant lower postoperative CRP, PCT, IL-6 levels when compared with control group(P<0.05), while no significant difference in K+ concentration between the two groups (P>0.05). The recovery time of intestinal peristalsis, the time of the first out-of-bed activity, the first liquid feeding time, the time of removal of the urinary tube and the drainage tube, and the number of days of hospitalization in observation group were all superior to the control group (P<0.05). The observation group with the duration of surgery was longer than the control group, and the difference was statistically significant (P<0.05). There were no significant differences in intraoperative bleeding, number of lymph nodes detected and positive rate of resection margins between the two groups (P>0.05). There was no significant difference in the incidence of complications between the two groups (4.1% vs. 7.8%, P>0.05). The observation group showed significant lower pain scores than control group on the 1st, 2nd and 3rd day after surgery (P<0.05). Conclusions NOSES combined with ERAS in treatment of rectal cancer patients is safe and feasible, can narrow the surgical incision, alleviate stress response and postoperative pain, improve postoperative efficacy and reduce the occurrence of complications, so is worthy of promotion and application.

rectal cancer  /  natural orifice specimen extraction surgery  /  enhanced recovery after surgery  /  laparoscopy  /  surgery
宋枫, 高峰, 徐明, 高健, 毛增喜. NOSES联合ERAS与常规腹腔镜手术治疗直肠癌的临床疗效对比. 解放军医学杂志, 2024 , 49 (1) : 31 -36 . DOI: 10.11855/j.issn.0577-7402.2526.2023.0719
Feng Song, Feng Gao, Ming Xu, Jian Gao, Zeng-Xi Mao. Comparison of clinical efficacy of NOSES combined with ERAS and conventional laparoscopic surgery in treatment of rectal cancer[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (1) : 31 -36 . DOI: 10.11855/j.issn.0577-7402.2526.2023.0719
正文
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腹腔镜直肠癌手术是目前治疗直肠癌的主要术式，其操作的安全性及肿瘤的根治彻底性毋庸置疑[1-5]。近年来，随着患者对术后生活质量及美容效果的要求日益提高，经自然腔道取标本手术(natural orifice specimen extraction surgery，NOSES)应用增多，该手术不仅减少了患者由手术创伤带来的痛苦，还有利于腹壁美容及从心理上康复的效果。而加速康复外科(enhanced recovery after surgery，ERAS)通过优化围手术期措施，可提高手术疗效、减少并发症[6]。NOSES与ERAS理念中各种措施相辅相成、互相影响。本研究对比NOSES联合ERAS与常规腹腔镜手术治疗直肠癌患者的临床疗效。
1 资料与方法
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1.1 研究对象
选取2019年1月-2021年12月于解放军联勤保障部队第940医院结直肠肛门外科确诊的100例直肠癌患者为研究对象，其中49例行NOSES手术联合ERAS治疗(设为观察组)，51例行常规腹腔镜直肠癌根治术治疗(设为对照组)。纳入标准：(1)年龄18~80岁；(2)术前确诊为直肠癌；(3)术前检查肿瘤直径≤6.0 cm；(4)无明显手术禁忌证；(5)术前无严重心、肺等器官并发症，能够耐受手术；(6)术中行一期吻合。排除标准：(1)有梗阻、出血、穿孔急诊手术；(2)其他脏器原发或继发恶性肿瘤；(3)术前行放化疗；(4)既往有腹部手术史；(5)术中探査发现肿瘤为局部晚期病变需联合其他器官切除(子宫、小肠、输尿管等)；(6)随访资料不全。本研究经解放军联勤保障部队第940医院伦理委员会审核(202105023)，所有患者均签署知情同意书。
1.2 方法
1.2.1 围手术期处理
观察组按照ERAS理念进行围手术期处理。术前1 d晚20：00口服缓泻剂，不做常规清洁灌肠。术前6 h禁食，2 h禁水，不常规留置胃管。术中麻醉采用全麻，液体适量控制。麻醉后留置尿管，术后24 h拔除，腹腔引流管术后常规48 h拔除。术后患者麻醉苏醒后可咀嚼口香糖，术后6 h可口服糖水200 ml，然后每4 h可再次口服糖水100~300 ml。术后24 h开始口服无渣肠内营养剂并逐渐递增，逐步过渡为流食到半流食。术后麻醉苏醒后可采用半卧位，6 h后可下床活动。
对照组术前1 d晚20：00口服缓泻剂，手术当日行清洁灌肠。术前8 h禁食水，术前留置胃管。麻醉采用全麻。术后肛门排气后拔除胃管，可进流食，逐步过渡为半流食；术后3 d拔除尿管，术后7 d拔除腹腔引流管。术后下床时间依据患者身体恢复情况而定。
1.2.2 手术方法
所有手术均由同一组医师完成。观察组行NOSES直肠癌根治手术，探查肠系膜根部血管有无肿大淋巴结，以及肿瘤部位、大小、浸润程度等。自右侧结肠旁沟处分离乙状结肠，自根部用电钩切开，清扫253组淋巴结，处理肠系膜下血管(图1A)；暴露并保护双侧输尿管，沿盆筋膜脏壁两层之间游离乙状结肠、直肠系膜，按照全直肠系膜切除(total mesorectal excision，TME)原则游离直肠，注意保护盆底神经丛(图1B)；于直肠近端预切除处“裸化”肠管(距肿瘤上缘5.0~10.0 cm处)，然后用切割缝合器切断肠管，向下游离直肠至肿瘤下方3.0~5.0 cm处“裸化”肠管，用结扎带结扎肠管后经肛门部稀碘伏反复冲洗后，于“裸化”肠管处切断肠管；自辅助孔送入保护套，经肛门置入抵钉座，切开近端肠管置入抵钉座，抵钉座中心杆自断端穿出(图1C)；将标本置入保护套内经直肠残端从肛门取出(图1D)；直肠残端用切割缝合器闭合后稀碘伏冲洗盆腔。如肿瘤位置较低可采用经肛全直肠系膜切除(transanal total mesorectal excision，TaTME；图1E)或外翻法将直肠经肛门拖出切除(图1F)。在腹腔镜监视下经肛门置入吻合器机身，中心杆经直肠远端闭合线中点穿出与抵钉座对接完成吻合；放置引流管，缝合穿刺孔。
对照组行常规腹腔镜下直肠癌根治术，腹腔内手术方式与观察组相同，标本取出时取下腹正中切口或右侧切口长约5 cm，逐层入腹，近端肠管离断后置入吻合器钉座，吻合器机身经肛门置入后完成端端吻合，逐层关腹。常规腹腔镜手术与NOSES手术腹部伤口情况如图2所示。
1.2.3 评价指标
(1)收集患者年龄、性别、体重指数(body mass index，BMI)、肿瘤横径、肿瘤距肛缘距离、TNM分期等一般资料。(2)比较两组术前1 d及术后第3、5天炎性指标[如C反应蛋白(C-reactive protein，CRP)、降钙素原(procalcitonin，PCT)、白细胞介素-6(interleukin-6，IL-6)、白细胞计数(white blood cell count，WBC)、中性粒细胞百分比(percentage of neutrophil，NEUT)等]、电解质浓度(K+)；以上数据均于术前1 d及术后第3、5天上午采集静脉血送检验科检测所得。(3)比较两组手术相关指标(如手术时间、术中出血量、术后肠蠕动恢复时间、术后首次离床活动时间、术后首次进流食时间、术后拔除尿管时间、术后拔除引流管时间、术后住院时间等)。(4)比较两组手术并发症发生情况(如吻合口瘘、吻合口出血、吻合口狭窄、腹腔感染、肠梗阻、切口感染、输尿管损伤、肠管损伤、血管损伤、坠积性肺炎、静脉血栓形成等)。(5)比较两组术后病理检查情况(标本切缘情况、淋巴结检出数目等)，以及术后第1、2、3天疼痛评分等。疼痛评分采用10分制视觉模拟量表(visual analog scale，VAS)评估。
1.3 统计学处理
采用SPSS 23.0软件进行统计分析。计量资料以$\bar{x}±s$表示，两组间比较采用t检验；计数资料以例(%)表示，两组间比较采用χ2检验。
P<0.05为差异有统计学意义。
2 结果
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2.1 两组一般资料比较
两组年龄、性别、BMI、肿瘤横径、肿瘤距肛缘距离、TNM分期等比较，差异均无统计学意义(P>0.05，表1)。
2.2 两组炎性指标及电解质浓度比较
两组术前CRP、PCT、IL-6水平，WBC、NEUT，以及K+浓度比较，差异均无统计学意义(P>0.05)。术后第3天，除K+浓度外，观察组其余指标均明显低于对照组(P<0.05)。术后第5天，两组CRP、PCT、IL-6水平比较，观察组均明显低于对照组(P<0.05)；两组WBC、NEUT和K+浓度比较，差异均无统计学意义(P>0.05)(表2)。
2.3 两组手术相关指标比较
所有患者均按计划完成手术操作，观察组与对照组术中出血量比较，差异无统计学意义(P>0.05)；观察组术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管及引流管时间、住院时间等均短于对照组，但手术时间长于对照组，差异有统计学意义(P<0.05)。对照组术后首次进食时间早于术后肠蠕动恢复时间，是因为7例患者术后第2天少量饮水，以刺激能否提前恢复肠蠕动，故出现了首次进食时间早于肠蠕动恢复时间(表3)。
2.4 两组手术并发症发生情况比较
观察组发生吻合口瘘2例，对照组发生吻合口瘘、肠梗阻、切口感染、输尿管损伤各1例。两组并发症发生率比较，差异无统计学意义(4.1% vs. 7.8%，P>0.05，表4)。
2.5 两组术后病理检查结果比较
观察组与对照组肿瘤横径、浸润深度(T分期)、淋巴结转移(N分期)、远处转移(M分期)、组织学分化程度及淋巴结检出数目等比较，差异均无统计学意义(P>0.05)；两组切缘阳性率均为0(表5)。
2.6 两组术后疼痛评分比较
观察组术后第1、2、3天VAS评分均低于对照组，差异有统计学意义[术后第1天：(3.1±1.3)分vs. (5.8±2.6)分，P=0.028；术后第2天：(2.3±1.5)分vs. (4.6±1.8)分，P=0.017；术后第3天：(1.2±0.3)分vs. (4.2±2.3)分，P=0.021]。
3 讨论
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结直肠癌是较常见的恶性肿瘤，其发病率呈逐年上升趋势。在美国结直肠癌是第三大高发癌症，也是癌症相关死亡的第三大病因。我国结直肠癌发病率和致死病因在恶性肿瘤中分别居第3位和第5位，其中直肠癌占所有结直肠癌的44.4%~66.5%，中低位(超低位)直肠癌占直肠癌的70%~80%[7-10]。
ERAS是通过优化围手术期措施，包括术前、术中及术后处理等一系列围手术期治疗干预措施，减轻患者机体内平衡的干扰，从而减轻各种应激反应，提高手术疗效及减少术后并发症，加快术后康复，缩短住院时间。ERAS理念最早由Kehlet教授提出，2007年由黎介寿院士引入国内[11-12]。ERAS围绕以人为本的理念，完善围手术期患者的处理措施，优化临床路径，以减轻手术应激，加快术后快速康复。NOSES是使用腹腔镜、机器人、肛门内镜微创手术(transanal endoscopie miorosurgery，TEM)或软质内镜等设备平台完成腹盆腔内各种常规手术操作(切除与重建)，经人体自然腔道(直肠、阴道或口腔)取标本的腹壁无辅助切口手术[13-15]。NOSES被称为微创中的微创，避免了腹部切口，有效地减轻患者术后疼痛，从而利于快速康复[16-22]。因此，微创手术是ERAS措施中的一个重要环节，对患者的康复起至关重要的作用。NOSES与ERAS相辅相成、相互促进。
本研究结果显示，观察组与对照组术后炎性指标存在明显差异(P<0.05)，而K+浓度无明显差异，提示观察组实施的NOSES手术联合ERAS减轻了患者创伤应激等一系列生理及心理反应，有利于快速康复。观察组手术时间较对照组长，主要原因是抵钉座的置入、标本的取出及术中无瘤无菌技术操作相较常规腹腔镜手术耗时。而观察组术后相关指标(术后肠蠕动恢复时间、首次离床活动时间、首次进流食时间、拔除尿管及引流管时间、住院时间、术后疼痛等)均优于对照组，并发症发生率(4.1% vs. 7.8%)及术后病理情况比较无明显差异(P>0.05)。分析原因为NOSES与ERAS联合，可使患者的切口更小、应激反应更轻、手术耐受更好、术后疼痛更轻、下床活动时间更早、器官功能恢复更快。值得注意的是，两组术后病理分期与术前存在差异，主要原因为术前影像学分期可能存在不准确的问题。
综上所述，本研究结果表明，NOSES与ERAS联合安全可行，且有利于提高术后疗效，促进患者快速康复，值得广泛推广。
基金
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  • 西北民族大学创新团队项目(31920200016)
  • 联勤保障部队第940医院科研计划项目(2021yxky044)
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参考文献 引证文献
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2024年第49卷第1期
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文章信息
doi: 10.11855/j.issn.0577-7402.2526.2023.0719
  • 接收时间：2022-12-05
  • 首发时间：2025-11-23
  • 出版时间：2024-01-28
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  • 收稿日期：2022-12-05
  • 录用日期：2023-03-14
基金
Innovation Team Project of Northwest Minzu University(31920200016)
西北民族大学创新团队项目(31920200016)
Scientific Research Programs of the 940th Hospital of Joint Logistics Support Force of PLA(2021yxky044)
联勤保障部队第940医院科研计划项目(2021yxky044)
作者信息
    1解放军联勤保障部队第940医院结直肠肛门外科，甘肃兰州 730050
    2解放军联勤保障部队第944医院结直肠肛门外科，甘肃酒泉 753000
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https://castjournals.cast.org.cn/joweb/jfjyxzz/CN/10.11855/j.issn.0577-7402.2526.2023.0719
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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