完全腹腔镜下结、直肠癌根治术196例分析

目的探讨完全腹腔镜下结直肠癌根治术的临床疗效和可行性。 方法回顾分析2012年10月至2015年4月我院行完全腹腔镜下结直肠癌根治术治疗的196例患者资料,评价其可行性及疗效。 结果196例手术全部获得成功,无中转开腹病例,术中出血量50~200 ml,平均80 ml。平均手术时间2小时,平均术后住院时间10天,术后平均开始进食时间48小时,术后并发症共3例,1例吻合口瘘,2例切口感染,无围手术期死亡病例。 结论完全腹腔镜下结、直肠癌根治术,因其创伤小,并发症少,术后恢复很快,而且操作过程解剖清晰,手术安全可行,因此临床效果非常满意。要求术者基本功扎实、经验丰富。     

达芬奇机器人与腹腔镜手术在直肠癌根治术中的病例对比研究

目的达芬奇机器人手术系统在直肠癌根治性切除术中的作用仍不明确。本文总结我科开展达芬奇机器人直肠癌根治手术以来的初步临床经验,对手术的安全性、术后近期疗效和并发症与腹腔镜直肠癌根治手术对比进行分析。 方法2013年11月至2014年8月我科共施行达芬奇机器人根治性直肠癌切除手术33例。选择年龄、性别、体重指数(BMI)、肿瘤部位≤15 cm和术前临床分期大致相同的33例接受腹腔镜直肠癌根治手术的患者进行病例对比研究。 结果达芬奇组较腹腔镜组术中出血量显著减少(89.1±44.5 ml vs 116.7±60.8 ml,P＝0.04),但手术时间较腹腔镜组延长(168.0±39.0 min vs 148.5±40.2 min,P＝0.05)。两组均无中转开腹病例。达芬奇组术后首次排气时间明显早于腹腔镜组(53.3±15.4 h vs 62.5±11.9 h,P<0.01),尿管拔除时间亦早于腹腔镜组(3.0±0.9 d vs 4.8±0.9 d,P<0.01)。达芬奇组术后第24小时疼痛指数明显低于腹腔镜组。两组所有患者肿瘤远侧切缘均未查见癌细胞。两组淋巴结清扫数目、肿瘤远切缘距离及术后平均住院日方面均无明显差别。术后平均随访124天(6～302天),达芬奇组和腹腔镜组各出现一例吻合口瘘,经保守治疗治愈。 结论达芬奇机器人行直肠癌根治性切除术是一项安全有效的新技术,较传统腹腔镜手术具有创伤小、术后疼痛轻、肠功能和排尿功能恢复快的优点。两者对直肠癌手术的长期疗效有待进一步观察。     

机器人和腹腔镜治疗中低位直肠癌对照研究

目的对比机器人和腹腔镜治疗中低位直肠癌的近期疗效。 方法自2017年3月18日至2017年10月25日,共有56例中低位直肠癌患者在解放军总医院普通外二科接受直肠癌根治术,患者被随机分组接受机器人或腹腔镜手术,对两组的临床资料进行了比较。 结果最终机器人组27例,腹腔镜组29例。机器人组较腹腔镜组在手术时间、术后镇痛时间、排气时间、恢复饮食时间、导尿管留置时间、住院日和淋巴结清扫数目方面差异均无统计学意义（均P>0.05）。机器人组术中失血量比腹腔镜少［（77.0±50.0）mL vs.（121.0±129.8）mL］,但差异无统计学意义（Z=-1.825,P=0.068）。机器人组术后有1例吻合口漏和1例肠梗阻,腹腔镜组术后有1例吻合口出血和1例肺部感染,术后并发症发生率方面差异无统计学意义（7.4% vs. 6.9%,χ²=0.006,P=1.000）。 结论机器人和腹腔镜直肠癌根治术围术期效果相当,远期功能学和肿瘤学效果有待进一步随访。     

手助腹腔镜与全腹腔镜外科治疗结直肠癌的对比研究

目的比较手助腹腔镜与全腹腔镜在外科治疗结直肠癌中的近期疗效,另外对手辅助腹腔镜外科治疗结直肠癌的安全性做出评估。 方法选取2011年11月至2014年4月哈尔滨医科大学附属第二医院结直肠肿瘤外科的79例结直肠癌患者,其中接受腹腔镜下结直肠癌根治术者41例,接受手辅助腹腔镜下结直肠癌根治术者38例。根据2种术式分为全腹腔镜组（LAC组）和手助腹腔镜组（HALS组）。通过回顾性分析,比较2组患者的一般资料包括年龄、性别、肿瘤位置、肿瘤病理类型、分期、ASA分级、BMI指数等;手术资料包括手术时间、麻醉时间、术中出血量、中转开腹率、取标本切口长度、Trocar数目等;术后资料包括术后第一次排气时间、术后住院时间、住院费用、术后并发症情况等。 结果HALS组和LAC组两组手术时间、麻醉时间、术中出血量、Trocar使用数目、取标本切口长度、术后首次排气时间存在差异（P<0.05）;术后住院时间、住院费用、术后并发症差异无统计学意义（P>0.05）。 结论手辅助腹腔镜下结直肠癌根治术与全腹腔镜下结直肠癌根治术相比具有手术时间短、创伤小、术后恢复快等优点,是一种安全有效,可靠的技术。     

老年结直肠癌患者腹腔镜与开放手术应激反应的临床对比研究

目的比较腹腔镜和开腹结直肠癌手术对老年患者机体应激反应的影响。方法选择南京医科大学第二附属医院胃肠外科自2012年5月至2013年7月收治的老年结直肠癌患者78例,随机分为腹腔镜组42例和开腹组36例。比较2组围手术期血糖、胰岛素、白细胞介素-6（IL-6）、C-反应蛋白（CRP）及相关临床指标的变化。结果腹腔镜组平均手术时间长于开腹组（P〈0.05）;开腹组术中平均出血量多于腹腔镜组（P〈0.05）。2组患者术后第1天血糖、IL-6和CRP均明显升高,胰岛素水平明显降低,术后第2天腹腔镜组血糖、胰岛素恢复到术前水平,开腹组于术后第3天恢复至术前水平。术后第3天腹腔镜组IL-6恢复至术前水平,开腹组明显高于腹腔镜组（P〈0.05）。术后第5天2组CRP仍显著高于术前水平（P均〈0.05）,且开腹组高于腹腔镜组（P〈0.05）。结论老年患者腹腔镜结直肠癌根治术具有良好的安全性和可行性,手术后应激反应比开腹手术轻,强度低,持续时间短。     

双入路法在腹腔镜下游离结肠脾曲的直肠癌保肛术中的应用

目的总结腹腔镜双入路法在游离脾曲的直肠癌保肛术的操作经验及应用价值。 方法回顾分析2016年4月至2017年9月由同一组手术医师完成的双入路法腹腔镜下游离结肠脾曲的直肠癌保肛手术38例患者的临床资料及短期随访结果。 结果所有手术均获成功,无中转开腹病例,术中无左侧输尿管、左肾、脾脏及胰腺损伤。手术时间为142.4±35.3 min,术中出血量98.7±34.5 ml,切除标本长度为21.1±6.7 cm,肿瘤距下切缘4.5±2.8 cm,清除淋巴结为12.7±6.3枚,术后排气时间3.6±1.7 d,住院时间12.4±3.2 d。术后并发症4例（10.5%）,其中切口感染2例（5.26%）,尿潴留1例（2.63%）,肺部感染1例（2.63%）,无吻合口漏、吻合口出血等并发症发生。全组患者随访至今,均未见肿瘤复发。 结论双入路法在腹腔镜下游离结肠脾曲的直肠癌保肛术中径路准确,解剖层面清晰、易于掌握,值得推广应用。     

腹腔镜直肠全系膜切除术治疗直肠癌84例临床分析

目的探讨腹腔镜直肠全系膜切除(TME)术治疗直肠癌的临床疗效。方法回顾分析2005-09～2009-12在腹腔镜下实施TME术84例直肠癌患者的临床资料。结果 82例患者手术均顺利,2例中转开腹,平均手术时间164(115～280)min,术中平均出血量77.1(30～200)ml,术后1～2d恢复肠道功能并下床活动,术后平均住院时间9.1(6～15)d,术后2例发生吻合口瘘,3例肺部感染。术后随访一个月至4年未见复发。结论应用腹腔镜TME术治疗直肠癌,创伤小、出血少、术后恢复快,是一项具有应用前景的微创外科技术。     

3D与2D腹腔镜直肠癌根治术近期疗效的Meta分析

目的系统评价3D与2D腹腔镜在直肠癌根治术的近期临床疗效。 方法计算机检索PubMed、The Cochrane Library、Web of Science、Embase、CNKI、WanFang和VIP国内外数据库中比较3D与2D腹腔镜直肠癌根治术近期疗效的文献,并搜集相关文献的参考文献,检索时间从数据库建立至2019年3月1日。运用Review Manager 5.2软件对相关指标进行Meta分析。 结果最终纳入11个研究,包含2个随机对照研究（RCT）,9个非RCT,共1 169例患者纳入分析,其中3D腹腔镜组601例,2D腹腔镜组568例。3D腹腔镜组术中出血量（P<0.00001）、手术时间（P<0.00001）、首次排气时间（P<0.0001）、住院时间（P=0.04）、并发症发生率（P=0.04）、淋巴结获取数目（P<0.00001）均优于2D腹腔镜组,差异有统计学意义。两组中转开腹、环周切缘（CRM）阳性率比较,差异无统计学意义（P>0.05）。手术时间的漏斗图提示无发表偏倚（P=0.693）。 结论与2D腹腔镜直肠癌手术相比,3D腹腔镜同样能够达到直肠癌根治性切除,且具有手术时间短、术中失血量少、术后并发症低、住院时间短、清扫淋巴结数目多等优势。     

腹腔镜下结直肠癌肝转移一期切除的临床研究

目的分析腹腔镜下同时行结直肠癌切除术合并肝转移癌切除术的可行性及安全性。 方法选取26例江苏省人民医院结直肠外科在2013年8月至2015年5月期间完成一期切除结直肠癌原发灶合并肝转移癌切除术的病历资料,观察一期切除的可行性（术中出血、手术时间和中转开腹率）、安全性（术后并发症）和治疗效果（术后恢复情况）。 结果26例一期手术过程顺利,都获得成功。其中腔镜下结直肠癌原发灶及肝转移癌同时切除共有16例,腔镜下结直肠癌切除术加开放肝转移癌切除术共有10例。手术时间为（205.12±49.09）min,术中出血量为（296.84±376.53）ml,术后消化道排气时间（2.62±0.56）d,术后住院时间（13.92±6.80）d。术后发生腹腔感染2例,肠瘘1例,自发性气胸1例。余者均恢复良好。 结论腹腔镜结直肠癌原发灶及肝转移癌的一期切除安全可行,具有较好的疗效。     

结直肠癌患者术后吻合口漏的危险因素分析

目的探讨结直肠癌术后发生吻合口漏（AL）的危险因素。 方法回顾性分析2010年12月~2014年4月在上海长征医院普外科接受手术治疗的926例结直肠癌患者的病例资料,通过病例对照分析和χ²检验,在临床病理分类的变量中筛选AL的危险因素,通过Logistic回归进行多因素分析,筛选独立的危险因素。 结果高血压病史、腹腔镜手术、未预防性造口是AL的独立危险因素（OR=1.907,2.252,5.556;P=0.016,0.006,0.001）。亚组分析显示：结肠癌亚组中,左半结肠是AL的危险因素（OR=2.519,P=0.032）;直肠癌亚组中,高血压病史、腹腔镜手术和未预防性造口是AL的独立危险因素（OR=2.597,7.609,9.346;P=0.012,0.007,<0.001）;腹腔镜手术亚组中,高血压病史、未预防性造口、术中出血≥ 400 mL是AL的独立危险因素（OR=2.407,5.376,3.922;P=0.006,0.002,0.001）;未预防性造口亚组中,高血压病史、腹腔镜手术和直肠癌是AL的独立危险因素（OR=1.969,1.859,1.716;P=0.015,0.046,0.059）;直肠癌未预防性造瘘亚组中,高血压、腹腔镜和手术时间≥ 3 h是AL的独立危险因素（OR=2.796,7.346,2.287;P=0.012,0.008,0.046）;开腹手术亚组和预防性造口亚组无AL的危险因素。 结论对于存在高血压病史、腹腔镜手术且未预防性造口的直肠癌患者,需要密切关注、针对性预防,以期减少术后AL的发生。     

套袖式吻合技术在腹腔镜超低位直肠癌保肛手术中的应用

目的探讨套袖式吻合技术在腹腔镜超低位直肠癌保肛手术的安全性、有效性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年4月至2019年2月采用套袖式吻合技术完成的腹腔镜超低位直肠癌保肛手术患者的临床资料,统计并分析患者的临床特征、病理特征、手术和术后恢复情况、围手术期并发症及术后肛门功能等资料。 结果共有40例患者成功完成应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术,2例患者术中因结肠残端血供较差行预防性回肠造口,其中21例（52.5%）患者术前行新辅助治疗,肿瘤距肛缘中位距离为4 cm,中位手术时间为166.5 min,中位术中出血量为20.0 mL。肿瘤中位长径为2.5 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为13.10枚。患者术后中位下地时间、进食时间、排气时间和住院时间分别为19.0 h、12.5 h、20.5 h和6.0 d,中位住院费用为47 646.0元。随访过程中,结肠残端回缩入盆腔的中位时间为12.0 d,其中4例（10%）患者术后出现吻合口漏,行临时性肠造口手术后逐渐好转,1例（2.5%）患者术后出现结肠残端出血,4例（10%）患者术后出现肛周粪水性皮炎,2例（5%）患者术后出现肛周疼痛,均予对症止处理后好转。术后3个月采用低前切除综合征（LARS）评分量表评估肛门功能,其中,8例（20%）无LARS,23例（57.5%）轻度LARS,9例（22.5%）重度LARS。随访期间无患者肿瘤复发或者转移。 结论应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术安全可行,避免了常规预防性造口,近期疗效较为满意,其远期疗效待进一步随访观察。     

Laparoscopic resection of lower rectal cancer with telescopic anastomosis without abdominal incisions

AIM:To assess laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions.METHODS:From March 2010 to June 2014, 30 patients(14 men and 16 women, aged 36-78 years, mean age 59.8 years) underwent laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through anus-preserving transanal resection.The tumors were 5-7 cm away from the anal margin in 24 cases, and 4 cm in six cases.In preoperative assessment, there were 21 cases of T1N0M0 and nine of T2N0M0.Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel and the roots of the inferior mesenteric artery and vein were dissected, clamped and cut.Following the total mesorectal excision principle, the rectum was separated until the anorectal ring reached 3-5 cm from the distal end of the tumor.For perineal surgery, a ring incision was made 2 cm above the dentate line, and sharp dissection was performed submucosally towards the superior direction, until the plane of the levator ani muscle, to transect the rectum.The rectum and distal sigmoid colon were removed together from the anus, followed by a telescopic anastomosis between the full thickness of the proximal colon and the mucosa and submucosal tissue of the rectum.RESULTS:For the present cohort of 30 cases,the mean operative time was 178 min,with an average of 13 positive lymph nodes detected.One case of postoperative anastomotic leak was observed,requiring temporary colostomy,which was closed and recovered3 mo later.The postoperative pathology showed T1-T2N0M0 in 19 cases and T2N1M0 in 11 cases.Twelve months after surgery,94.4%patients achieved anal function Kirwan grade 1,indicating that their analfunction returned to normal.The patients were followed up for 1-36 mo,with an average of 23 mo.There was no local recurrence,and 17 patients survived for3years(with a survival rate of 100%).CONCLUSION:Laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe and feasible.     

腹腔镜下全直肠系膜切除经肛门取出标本的直肠癌根治术

目的探讨应用腹腔镜技术经人体自然通路对直肠癌患者行全直肠系膜切除术的可行性。 方法对2011年3至7月,中山大学附属第一医院12例经病理活检确诊的直肠癌患者,在腹腔镜下进行根治性全直肠系膜切除,低位直肠癌8例,高位直肠癌4例;男5例,女7例,平均年龄(61.18±7.5)岁。操作如下：肠系膜下动静脉根部切断,夹闭,切断左结肠和乙状结肠动静脉Ⅰ～Ⅲ分支,保留边缘动脉弓,用腔镜下切割缝合器在肿瘤近端预切断处切断、闭合肠管,经肛门在肿瘤远端预切断处缝闭直肠,在缝闭处下缘切断肠管。扩肛到5～6 cm直径大小,用标本袋保护,经肛门取出标本。近端结肠经肛门拖出并行荷包缝合,置入抵钉座、结扎。远端直肠(肛管)用肛门直肠扩张器显露,经肛门荷包缝合直肠残端,腹腔镜下完成经肛的结肠直肠(肛管)吻合。 结果无一例中转开腹,手术时间平均(123±85)min,平均失血量为87 ml。下切缘为2～5 cm;术后平均住院时间为8 d ;吻合口漏1例,无盆腔感染、肠梗阻、腹腔以及盆腔出血、吻合口出血以及吻合口狭窄等并发症。术后标本评估：全直肠系膜完全切除12例,环周切缘阴性12例,下切缘均为阴性,R0切除12例;平均淋巴结个数为(16.7±4.6)个,阳性淋巴结数为(4.6±1.8)个;高分化腺癌8例,低分化及黏液腺癌4例;TNM分期：Ⅱ期5例,Ⅲ期7例。 结论对直肠癌患者行腹腔镜辅助下根治性全直肠系膜切除术,经自然腔道取出标本,完成低位(超低位)前切除术,不违背肿瘤根治原则,同时在技术上是安全和可行的,可避免另加腹部小切口取出标本。     

利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术20例临床分析

目的探讨利用套袖式吻合技术的低位直肠癌新辅助放化疗后经自然腔道取标本手术（NOSES）的安全性、可行性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年10月至2021年10月20例利用套袖式吻合技术完成NOSES手术的低位直肠癌新辅助放化疗后患者的临床资料,统计并分析患者的临床特征、手术情况、术后恢复、病理特征、围手术期并发症以及术后复发转移等资料,并分别于术后1个月、3个月及6个月采用低位前切除综合征（LARS）评分量表评估肛门功能。 结果20例低位直肠癌新辅助放化疗后患者均成功完成利用套袖式吻合技术的NOSES手术,术前肿瘤距肛缘中位距离为4.0 cm,术中未行预防性造口,中位手术时间为171.5 min,中位吻合时间为17.0 min,中位术中出血量为35.0 mL。患者术后中位下地时间、进食时间、排气时间和住院时间分别为18.5 h、12.0 h、30.0 h和7.0 d,中位住院费用为47 678.0元。术后病理显示中位肿瘤长径为3.3 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为14.5枚。随访过程中,结肠残端回缩入盆腔的中位时间为11.5 d,其中1例（5.0%）患者于术后第五天出现吻合口漏,另外有3例（15.0%）患者出现肛周粪水性皮炎伴肛周疼痛,均予对症止处理后好转。1例（5.0%）患者术后1年出现肝转移,其余患者无肿瘤局部复发或转移。12例（60%）患者术后1个月LARS评分较高,但术后3个月15例（75%）患者肛门功能较为满意。 结论利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术安全可行,避免了预防性造口,经对症指导治疗肛门功能恢复满意,具有较好的近期疗效,其远期疗效待进一步随访观察。     

机器人与腹腔镜在低位直肠癌经括约肌间切除术的近期疗效对比

目的比较机器人和腹腔镜在低位直肠癌经括约肌间切除术的近期疗效，探讨机器人经括约肌间切除术的安全性及可行性。 方法回顾性分析2015年10月至2017年10月甘肃省人民医院肛肠科确诊为低位直肠癌并行机器人或者腹腔镜经括约肌间切除患者的人口及临床资料。收集并比较两组的手术时间、术中出血量、中转开腹率、首次通气时间、术后住院时间、并发症、肿瘤距远切缘的距离、环周切缘的阳性数、清扫淋巴结数量等。 结果机器人组流质饮食时间、首次通气时间、术后住院时间较腹腔镜组短（均P<0.05）；机器人组术中失血量多于腹腔镜组（P<0.05）；机器人与腹腔镜组在手术时间上差异无统计学意义，两组的术后并发症的差异无统计学意义，机器人组的总费用高于腹腔镜组（P<0.001）。 结论机器人低位直肠癌经括约肌间切除术是安全、可行的。与腹腔镜组手术相比，机器人组术后肠功能恢复快，住院时间短，近期肿瘤学的结果安全可靠，可作为低位直肠癌治疗的有效手段之一。     

Iatrogenic colorectal perforation induced by anorectal manometry： Report of two cases after restorative proctectomy for distal rectal cancer

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed alter restorative proctectomy for distal rectal cancer.     

Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m²) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.     

Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection

Background We experienced some technical difficulty in dividing the middle and lower rectum through the right-lower quadrant intracorporeally. The aim of this study was to determine whether multiple stapler firings during rectal division are associated with anastomotic leakage after laparoscopic rectal resection. Methods Laparoscopic anterior resection with double-stapling technique anastomosis was performed in 180 consecutive rectal cancer patients. We often used vertical rectal division through a suprapubic site instead of the standard transverse rectal division for laparoscopic total mesorectal excision (LapTME). We attempted to determine whether there was an association between the number of stapler firings and procedures in rectal division. Moreover, we identified risk factors for anastomotic leakage after laparoscopic rectal resection by multivariate analysis. Results Anastomotic leakage occurred in 5% of the subjects of this study. Vertical rectal division through the suprapubic site after Lap TME required fewer staples than transverse division through the right-lower port and a smaller percentage of patients required three or more staples for vertical rectal division than for transverse division (15% vs. 45%, p = 0.03). In the multivariate analysis, TME and the number of staplers used for rectal division were the factors found to be associated with a significantly greater risk of subsequent leakage (odd’s ratio = 5.3; 95% CI 1.2–22.7 and odd’s ratio = 4.6; 95% CI 1.1–19.2). Conclusion TME and multiple stapler firings during distal rectal division were associated with anastomotic leakage after laparoscopic rectal resection. Vertical rectal division through a suprapubic site was a useful method of avoiding multiple stapler firings during laparoscopic TME.     

Magnetic resonance imaging based rectal cancer classification: Landmarks and technical standardization

Rectal cancer classification is important to determine the preoperative chemoradiation therapy and to select appropriate surgical technique. We reviewed the Western and Japanese rectal cancer classification and we propose our new classification based of Magnetic resonance imaging(MRI). We determine the relation of the tumor to fixed parameters in MRI, which areperitoneal reflection and levator ani muscle. Then, we classify the rectal cancer into four levels based on tumor distal margin and invasion to MRI parameters. We applied all three classifications to 60 retrospectively collected patients of different rectal cancer distance and we compared our classifications to the others. Based on each level we standardize our surgical approach. For stages Ⅰ-Ⅲ, We found that level Ⅰ where tumor distal margin is located above the peritoneal reflection and all of them were received low anterior resection(LAR) without chemoradiation. Level Ⅱ where tumor distal margin is located from the peritoneal reflection and above the levator ani insertion on the rectum. 90% of them were received LAR ± chemoradiation. Level Ⅲ where tumor distal margin is located at the level of levator ani insertion or invading any part of the levator ani. 60% of them had ULAR + coloanal anastomosis ± chemoradiation. Level Ⅳ where the tumor distal margin is located below the levator ani insertion; 77% were received APR ± chemoradiation. The overall kappa for all levels between surgeons and radiologist was 0.93(95%CI: 0.87-0.99), which is indicating almost perfect agreement. We concluded that the management of rectal tumors differed among each tumor level and our new MRI based classification might facilitate the prediction of surgical and chemoradiation management with better communication among a multidisciplinary team comparing to other classifications.     

Laparoscopic low anterior resection with total mesorectal excision for rectal cancer

Rectal resections are the only treatment with curative intent currently accepted world wide. When performed in elective circumstances, laparoscopic rectal excision is technically feasible in surgical approach of mid-rectal cancer in a considerable number of patients. There are many benefits of the laparoscopic approach to rectal resection such as short hospitalization, less pain, less postoperative complications and improved quality of life. However, one mandatory condition in laparoscopic resection of rectum includes complete excision of the rectum and mesorectum, generally ensuring a minimal distal margin of 2cm and circumferential radial clearance before performing a coloanal anastomosis. Here, we present a laparoscopic approach for rectal cancer treatment consisting in a wide resection of the rectum, including the entire fascia with the enclosed mesentery of the rectum.