中国实用外科杂志

中国实用外科杂志 ›› 2025, Vol. 45 ›› Issue (06): 683-690.DOI: 10.19538/j.cjps.issn1005-2208.2025.06.15

• 论著 • 上一篇    下一篇

精细化手术分型在盆腔脏器联合切除术治疗局部晚期或复发直肠癌中应用价值研究

陶    禹1，陆    瑶1，张若昕1，彭    欢1，王治国1，苏    宁1，邵国益2，周海洋1，张    剑1   

  1. 1海军军医大学第二附属医院（上海长征医院）肛肠外科，上海200003；2南通大学附属江阴医院（江阴市人民医院）综合普外一科，江苏江阴 214400
  • 出版日期:2025-06-01 发布日期:2025-07-01

  • Online:2025-06-01 Published:2025-07-01

摘要： 目的    探索一种基于盆腔解剖结构的精细化盆腔脏器联合切除术（PE）手术分型，以实现局部晚期直肠癌（LARC）和局部复发直肠癌（LRRC）手术治疗的标准化和规范化。方法    采用前瞻性描述性病例系列研究设计，纳入自2023年1月至2024年12月31日期间在中国盆腔脏器联合切除数据库中连续接受PE治疗的200例LARC或LRRC病人。依据盆腔膜解剖分层标准，将PE分为骨盆腔内PE与联合骨盆壁PE，后者进一步细分为侧盆、盆底、后盆和前盆壁4个亚型，明确各型＞50%器官或组织切除的标准。主要观察指标包括手术时间、术中出血量及术后并发症（Clavien-Dindo分级），并对不同手术分型进行对比分析。结果    LARC与LRRC病人的R0切除率分别为96.3%与71.7%。所有病人中，骨盆腔内PE、侧盆、盆底、后盆和前盆壁的切除比例分别为96%、82%、71.5%、17%与12%。98%的病人接受生物补片隔离腹盆腔修复，65%的病人行大网膜瓣联合生物补片重建。总体术后严重并发症（Clavien-Dindo分级≥Ⅲb）发生率为38.8%，会阴切口愈合失败率为18.5%。在联合骨盆壁PE的亚组中，盆底组术后严重并发症发生率最高（LARC为33.3%，LRRC为38.5%，均P＜0.05）；LRRC中侧盆组的手术时间及术中出血量亦显著高于其他亚组（均P＜0.05）。结论    该手术分型方案基于盆腔解剖层次的精准划分，有助于术前准确评估切除范围、提高手术R0切除率、评估手术难度并制定个体化重建策略。尤其在侧盆累及且有放疗史情况下手术难度可能最大；盆底受累则与术后严重并发症高度相关。该分型有望促进PE的标准化与规范化，提升围手术期管理水平，未来需进一步验证其对长期生存及生活质量的影响。

关键词: 盆腔脏器联合切除术, 手术分型, 局部晚期/复发直肠癌, 围手术期并发症

Abstract: To establish a refined surgical classification for pelvic exenteration (PE) based on pelvic anatomical layers, in order to standardize and optimize the operative management of locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC). Methods    In this prospective descriptive case series, 200 consecutive patients with LARC or LRRC who underwent PE between January 2023 and December 31, 2024 were enrolled from the China Pelvic Exenteration Database. According to pelvic fascial anatomical planes, PE was classified into intra-pelvic PE and combined pelvic wall PE; the latter was further subdivided into lateral pelvic, pelvic floor, posterior pelvic wall and anterior pelvic wall subtypes, each defined by resection of >50% of the relevant organs or tissues. Primary endpoints included operative time, intraoperative blood loss and postoperative complications graded by the Clavien-Dindo classification; comparative analyses were performed across PE subtypes. Results    R0 resection rates were 96.3% for LARC and 71.7% for LRRC. Among all patients, proportions of intra-pelvic PE, lateral pelvic, pelvic floor, posterior pelvic wall and anterior pelvic wall resections were 96%, 82%, 71.5%, 17% and 12%, respectively. Biological mesh isolation for abdominopelvic repair was performed in 98% of cases, and omental flap combined with biological mesh reconstruction in 65%. The overall incidence of severe postoperative complications (Clavien-Dindo grade ≥ Ⅲb) was 38.8%, with perineal wound healing failure in 18.5%. In the combined pelvic wall PE subgroup, the pelvic floor group exhibited the highest rate of severe complications (33.3% for LARC and 38.5% for LRRC, both P＜0.05); within the LRRC cohort, the lateral pelvic group showed significantly longer operative times and greater blood loss compared to other subgroups (both P<0.05). Conclusion  This anatomically based classification enables precise preoperative assessment of resection extent, improvement of R0 resection rates, evaluation of surgical difficulty and tailored reconstruction planning. Lateral pelvic involvement, particularly with prior radiotherapy, poses the greatest technical challenge, while pelvic floor involvement correlates strongly with severe postoperative complications. Adoption of this scheme may promote standardization of PE procedures and enhance perioperative management; further studies are needed to assess its impact on long-term survival and quality of life.

Key words: pelvic exenteration, surgical classification, locally advanced/recurrent rectal cancer, perioperative complications