[Retrospective investigation of patients receiving additional surgery after endoscopic non-curative resection for early colorectal cancer].

Objective: To investigate the clinical application of additional surgery after non-curative endoscopic resection for early colorectal cancer. Methods: A retrospectively descriptive cohort study was conducted. Inclusion criteria: (1) pathologically confirmed primary colorectal adenocarcinoma;(2) receiving additional surgery after endoscopic resection; (3) semi-elective operation. Exclusion criteria: familial adenomatous polyposis, appendiceal neoplasms, anal canal neoplasms, neuroendocrine tumors, and surgery because of perforation or bleeding after endoscopic resection. Indications of additional surgery: (1) pathologically positive lateral or basal resection margin; (2) submucosal invasion depth ≥ 1000 μm; (3) lymphovascular invasion; (4) poorly differentiated, undifferentiated or mucinous adenocarcinoma; (5) more than grade G2 in tumor budding; (6) incomplete resection or piecemeal specimen with margin impossible to evaluate; (7) patient's consent due to undetermined pathology. According to the above criteria, clinical data of 92 patients at the Colorectal Surgery Department, the First Affiliated Hospital of Nanjing Medical University between January 2013 and December 2018 were collected. Demographic data, pathological examinations, operative methods and outcomes were analyzed. Results: There were 61 (66.3%) male and 31 female (33.7%) patients with an average age of (58.2±10.7) years. The average BMI was (23.8±3.5) kg/m(2). The lesions located in the right-sided colon, left-sided colon and rectum in 19, 37 and 36 patients respectively. Sixteen patients received endoscopic snare resection, 45 received endoscopic mucosal resection and 31 received endoscopic submucosal dissection. Reasons for additional surgery included endoscopic specimen with pathologically positive margin (n=22, 23.9%), submucosal invasion depth ≥ 1000 μm (n=9, 9.8%), lymphovascular invasion (n=4, 4.3%), poorly differentiated, undifferentiated or mucinous adenocarcinoma (n=5, 5.4%), piecemeal resection (n=13, 14.1%), undetermined pathology (n=52, 56.5%). The median duration from endoscopic resection to additional surgery was 16 days. Thirty-four patients (37.0%) received preoperative endoscopic localization with carbon nanoparticles suspension injection and 5 (5.4%) were marked with titanium clip. Seventy-four patients (80.4%) received laparoscopic surgery, 17 (18.5%) received open surgery, while 1 patient (1.1%) was converted to open surgery due to missing titanium clip. Three patients (3.3%) were treated with transanal excision, 2 (2.2%) with bowel resection, and 87 (94.6%) with radical excision. After additional surgery, histopathological examination of surgical specimens revealed the presence of residual tumor in 5 patients (5.4%), lymph node metastasis in 8 (8.7%), lymphovascular invasion in 1 (1.1%) and tumor deposit in 1 (1.1%). Twelve patients (13.0%) developed postoperative complications, including 4 mid-low rectal cancer patients (4.3%) with anastomostic leakage or bleeding. After surgery, according to the TNM staging system, 83 patients (90.2%) were classified as TNM stage 0-I, 9 (9.8%) as TNM stage II-IV. One patient of stage IV with liver metastasis underwent concomitant hepatectomy. One patient of stage II received regular follow-up after operation. Seven cases of stage III and 1 of stage IV received postoperative chemotherapy. Eighty-five patients (92.4%) were followed up with a median time of 12.8 (IQR: 8.1, 24.3) months. No recurrence or metastasis was observed. Conclusions: Surgery is an effective salvage measure for non-curative endoscopic resection of early colorectal cancer. Since surgery may have complications, indications of the additional surgery should be considered carefully. Preoperative endoscopic localization should be performed in order to ensure the safety and efficacy of surgery.目的： 探讨早期结直肠癌非治愈性内镜切除术后追加外科手术的临床应用价值。 方法： 采用描述性病例系列研究方法。病例纳入标准：（1）病理证实结直肠原发性腺癌；（2）内镜治疗后追加外科手术；（3）限期手术患者。排除标准：家族性腺瘤性息肉病、阑尾肿瘤、肛管肿瘤、神经内分泌肿瘤以及内镜治疗并发穿孔或出血而追加手术的病例。追加外科手术指征：（1）切除标本侧切缘和基底切缘阳性；（2）黏膜下层高度浸润（黏膜下层浸润1 000 μm以上）；（3）脉管侵袭阳性；（4）低分化腺癌、未分化癌、黏液腺癌；（5）癌瘤出芽分级G2以上；（6）非完整切除或标本破碎切缘无法评价；（7）病理检查结果不明确，经与患者共同商讨决定手术。根据以上标准，收集2013年1月至2018年12月期间，就诊于南京医科大学第一附属医院结直肠外科92例早期结直肠癌患者的临床资料。总结患者内镜切除肿瘤后追加外科手术治疗情况，包括追加外科手术指征、病变定位方法、手术术式、术后并发症、术后病理等。 结果： 全组患者男61例（66.3%），女31例（33.7%），年龄（58.2±10.7）岁，体质指数（23.8±3.5）kg/m(2)。病变位于右半结肠19例、左半结肠37例、直肠36例。内镜治疗采用圈套器电切16例、内镜下黏膜切除术45例、内镜黏膜下剥离术31例。追加外科手术的指征包括切缘阳性（22例，23.9%）、黏膜下层高度浸润（9例，9.8%）、脉管侵犯（4例，4.3%）、低分化腺癌及黏液腺癌（5例，5.4%）、非完整切除或标本破碎切缘无法评价（13例，14.1%）和病理检查结果不明确（52例，56.5%）。内镜治疗至追加外科手术中位间隔时间为16 d。病变采用纳米碳示踪剂定位34例（37.0%），钛夹定位5例（5.4%）。腹腔镜手术74例（80.4%），开腹手术17例（18.5%），1例（1.1%）因为定位钛夹无法探寻，中转开腹。采用经肛局部切除3例（3.3%），肠段切除2例（2.2%），肠癌根治术87例（94.6%）。追加外科手术术后病理示：肿瘤残留5例（5.4%），淋巴结转移8例（8.7%），脉管侵犯1例（1.1%），癌结节1例（1.1%）。术后并发症12例（13.0%），其中4例（4.3%）吻合口漏或吻合口出血，均为中低位直肠癌患者。全组患者肿瘤病理分期：0~Ⅰ期83例（90.2%），Ⅱ~Ⅳ期患者共9例（9.8%）；1例Ⅳ期患者同期行肝转移灶切除，1例Ⅱ期患者术后定期随访复查，7例Ⅲ期患者及1例Ⅳ期患者均接受术后化疗。85例（92.4%）患者获得随访，中位随访时间12.8（P(25)，P(75)：8.1，24.3）个月，未见复发和转移。 结论： 外科手术是早期结直肠癌内镜下非治愈性切除的补救措施。追加外科手术同样存在并发症风险，需要明确适应证，必要时做好术前定位，确保追加外科手术的安全与疗效。.