经肛门内镜微创手术的适应证与并发症

目的探讨经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)的适应证和并发症。 方法回顾2011年5月至2014年5月在我院接受TEM治疗的135例直肠病变患者的临床资料,分析TEM在直肠病变治疗中的主要适应证和常见并发症。 结果本组135例患者均成功实施TEM,其中行直肠壁全层切除115例,黏膜下及肌层部分切除20例。平均手术时间(66.5±25.0)min(25～120 min),术中平均失血量(10.5±5.5)ml(3～50 ml)。术后病理学检查确诊：直肠腺瘤60例,直肠腺瘤癌变(pTis期)10例,早期直肠癌(pT1期)11例,进展期直肠癌(pT2期)10例,直肠癌经术前放化疗后病理完全缓解(ypT0期)2例,直肠类癌或类癌内镜电切后残灶24例,直肠胃肠道间质瘤5例,直肠平滑肌瘤1例,非肿瘤性息肉10例,直肠子宫内膜异位症2例。所有标本切缘均阴性。术中3例上段直肠前壁肿瘤行全层切除时切入腹腔,即刻行腔内缝合修补成功,未并发腹膜炎或盆腔感染。术后继发肛门出血2例,肺部、泌尿系感染和尿潴留各1例。并发症发生率为5.9%(8/135)。术后平均住院日(2.5±1.2)d(2～8 d)。术后平均随访15.5个月(6～36月),未发现肿瘤复发转移。 结论适合局部切除的直肠局限性肿瘤是TEM的主要适应证。严格选择没有淋巴结转移证据的直肠癌行TEM是安全有效的,已成为直肠局部切除术的首选方式。但目前的循证医学证据仍然有限,仍需要进一步研究论证。     

经肛门内镜微创手术治疗老年人结直肠腺瘤

目的 探讨经肛门内镜微创手术(TEM)治疗老年人结直肠腺瘤的临床价值.方法 2007年12月至2010年9月我院开展TEM治疗老年人结直肠腺瘤21例,肿瘤距肛缘距离为4～20 cm,平均8.9cm,肿瘤直径为1.1～3.5 cm,平均1.9 cm.术前均行全结肠镜和直肠腔内超声检查(EUS),术前病理诊断:管状腺瘤12例,绒毛状腺瘤9例.全麻下根据肿瘤位置选择合适的体位,经肛门插入特殊的手术直肠镜,保持CO2充气状态,在立体视镜和腔镜系统下,采用5 mm超声刀将肿瘤(黏膜下或全层)完整切除,手术创口在腔内连续缝合.结果 21例肿瘤均获完整切除(12例黏膜下切除,9例全层切除),切缘均阴性;手术时间40～100min,平均76 min;术中出血量10～80ml,平均50ml;术后住院时间2～10 d,平均4.5d;术后病理分期:pT0 16例,pTia5例;病理诊断:管状腺瘤9例,绒毛状腺瘤12例,其中低级别上皮内瘤变5例,高级别上皮内瘤变5例;20例随访2～20个月,平均11个月,肿瘤无原位复发.结论 TEM微创并发症少,是治疗老年结直肠腺瘤的一种安全、有效的手术方法,术前EUS检查对TEM非常重要.     

经肛门内镜下手术治疗直肠腺瘤和早期直肠癌

目的探讨经肛门内镜下手术治疗直肠腺瘤和早期直肠癌的疗效。 方法2011年6月至2012年6月,在吉林大学第二医院行TEM治疗的直肠肿瘤患者21例。全麻下根据肿瘤位置选择合适的体位,经肛门插入特殊的手术直肠镜,保持CO₂充气状态,在立体视镜和腔镜系统辅助下,采用针形电刀或5 mm超声刀将直肠肿瘤完整切除(黏膜下或全层切除),在腔内连续缝合手术创口。 结果21例直肠肿瘤患者均获完整切除,术中快速病理确定切缘均阴性。手术时间45～160 min,平均90 min;术中出血量0～60 ml,平均15 ml。手术并发症：发热5例,急性尿潴留1例,因长期服用阿司匹林出血2例。术后病理分期：T₀期11例,Tis期5例,T₁期3例,T₂期2例。21例均随访12个月,肿瘤无原位复发及远处转移。 结论TEM是治疗直肠腺瘤和早期直肠癌的一种安全、有效的微创手术方法。     

内镜下全层切除术联合新辅助放化疗治疗局部进展期低位直肠癌1例（含视频）

本文报道了1例内镜下全层切除术联合新辅助放化疗治疗局部进展期低位直肠癌的病例。1例保肛意愿强烈的局部进展期低位直肠癌患者行新辅助放化疗达近临床完全缓解后，进一步行内镜下全层切除术切除病灶。病理示直肠腺癌，浸润肠壁深肌层，局部浸润深肌层外结缔组织。术后患者进一步追加辅助放疗，随访至今肛门功能良好，无复发转移征象。     

TEM治疗直肠肿瘤19例体会

目的总结经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)治疗直肠肿瘤的手术经验及技巧。 方法2011年5月～2013年12月,对19例直肠肿瘤行TEM治疗,选择适当体位使直肠肿瘤位于TEM器械视野下半区,距肿瘤边缘至少0.5～1 cm行肠壁全层或粘膜下切除,创面连续缝合关闭。 结果19例直肠病变均获得完整切除,2例合并横结肠癌同时行横结肠癌根治术,平均手术时间(55.8±37.7)分钟,术后平均住院时间(8.5±3.3)天。术后2例患者出现肛门出血,1例绒毛状管状腺瘤复发,其余病例均无复发。 结论TEM手术体位选择非常重要,病变切除及创面缝合过程应遵循一定的手术方法,不同病变选择不同的切除方式;TEM存在学习曲线,初学者应选择手术相对简单的病例进行经验积累。     

直肠类癌内镜诊断及治疗46例

目的:探讨内镜下直肠类癌的诊断率及其内镜治疗方法的安全性和有效性.方法:对46例直肠类癌病例进行回顾性分析,总结其内镜下表现,对瘤体直径小于2.0 cm的16例直肠类癌采用内镜下黏膜切除术进行治疗.结果:本组共诊断直肠类癌46例,内镜下治疗16例,术中或术后即刻出血2例,迟发性出血1例,术中穿孔1例,均经内镜治疗及内科保守治疗痊愈,无患者死亡.1例肿瘤切除不完全,转外科追加手术治疗.1例术后3 mo随访时见复发,转外科行手术治疗.结论:直肠类癌可通过内镜下钳取组织行病理检查或全瘤切除后活检而确诊,内镜治疗对于直径小于1.0 cm的直肠类癌是一种简单、安全有效的方法,术后应定期随访.     

经肛门内镜显微外科手术（TEM）治疗直肠少见肿瘤

目的探讨经肛门内镜显微外科手术（TEM）在直肠少见肿瘤治疗中的应用。 方法2006年4月至2018年5月,北京协和医院共收治157例直肠少见肿瘤患者。收集临床资料,建立回顾性准确数据库。其中男性89例,女性68例。平均肿瘤直径（1.2±0.7）cm（0.2~5.3 cm）,距肛缘平均距离（6.6±2.3）cm（2~12 cm）。分析人口学特征、手术细节、肿瘤特点、并发症和随访资料。 结果所有患者均获得全层完全切除,切缘阴性。术中并发症3例,术后并发症21例。病理组织学结果报告神经内分泌肿瘤（NETs）114例;胃肠道间质肿瘤（GISTs）35例,黑色素瘤、淋巴瘤和平滑肌瘤各2例;脂肪瘤和鳞癌各1例。145例患者平均随访（56.25±32.13）个月（19~144个月）,2例死亡,1例局部复发,1例出现淋巴结转移。1例在术后1个月出现直肠阴道瘘。其余患者无局部复发、转移、大便失禁。神经内分泌瘤亚组分析中,初次手术组与内镜术后补救组之间比较,手术时长、术中出血量、术后住院天数等方面差异无统计学意义。在间质瘤亚组分析中,新辅助治疗组与直接手术组之间,同样在手术时长、术中出血量、术后住院天数等方面差异无统计学意义。 结论TEM是治疗直肠少见肿瘤的可靠方法。并发症发生率低,疗效满意。     

腹腔镜下直肠低位前切除经肛门取标本手术八例

目的探讨腹腔镜下直肠低位前切除经肛门取标本手术的安全性和可行性。 方法采用回顾性描述性研究方法,收集2015年4月至2017年3月成都医学院第一附属医院胃肠外科开展的8例腹腔镜下直肠低位前切除经肛门取标本手术患者的临床和病理资料、随访情况。 结果患者平均年龄（66.9±11.7）岁,平均BMI（22.2±4.3）Kg/m²,手术平均用时（247.5±66.3）min,平均出血（22.5±3.8）ml;患者术后首次排气时间为（56.6±11.7）h,术后首次进流食时间为（36.6±7.6）h;TNM分期：Ⅰ期4例,Ⅱ期2例,Ⅲ期2例;一例患者术后出现吻合口漏,患者术后平均住院时间为（15.5±5.1）d;患者随访术后肛门功能正常,未见肿瘤复发和转移征象。 结论腹腔镜下直肠低位前切除经肛门取标本手术安全、可行。     

腹腔镜结肠次全切除逆蠕动盲肠直肠吻合术治疗结肠慢传输型便秘

目的 探讨腹腔镜结肠次全切除、逆蠕动盲肠直肠吻合术在治疗结肠慢传输型便秘中的临床应用价值.方法 2007年9月至2010年10月对收治的31例结肠慢传输型便秘患者进行腹腔镜结肠次全切除、逆蠕动盲肠直肠吻合术,术后3个月和12个月进行随访,以评定手术效果.结果 全组患者手术均成功,无中转开腹手术,手术时间平均260 min(180～310 min),术中出血量平均60 ml(30～120 ml),术后平均住院日8 d(6～11 d),无吻合口瘘、粘连性肠梗阻、切口及腹腔内感染等手术近期并发症.术后3个月随访,便秘症状明显缓解23例,轻度腹泻5例,腹泻2例,症状轻度复发1例.术后12个月随访,便秘症状明显缓解25例,轻度腹泻5例,症状轻度复发1例.结论 腹腔镜结肠次全切除、逆蠕动盲肠直肠吻合术治疗结肠慢传输型便秘,具有创伤小、术后恢复快的优势,临床安全有效,值得临床运用.     

腹腔镜全结直肠切除治疗家族性腺瘤性息肉病伴癌变

目的 探讨腹腔镜辅助全结直肠切除手术在家族性腺瘤性息肉病(FAP)伴癌变中的安全性、可行性。方法 3例FAP伴癌变病例施行腹腔镜辅助全结直肠切除手术,总结手术经验,观察手术安全性、术后恢复情况以及短期随访结果。取同期开腹全结肠切除手术8例作为对照组。结果 腹腔镜组3例均顺利施行腹腔镜辅助全结肠、直肠切除术,无中转开腹手术病例,平均手术时间243.33(200-310)min,显著长于开腹组(P=0.028)。 平均术中出血量146.66(90-200)ml,肛门排气时间为术后1.33 d,住院时间14 d,略短于开腹组,尚未达统汁学差异;平均手术切口长度腹腔镜组为4.33 cm,显著短于开腹组19.38 cm(P<0.01)。腹腔镜组3例术后无严重并发症,术后均证实为FAP伴癌变,随访时间分别为25、15、10个月,无肿瘤局部复发与远处转移。结论 由具丰富腹腔镜外科经验的医师施行腹腔镜辅助全结直肠切除术治疗FAP安全、可行、有效,但需要进一步的手术病例积累及随机对照研究。     

Local excision with transanal endoscopic microsurgery (TEM) after endoscopic R1/R2-polypectomy of pT1 "low-risk" carcinomas of the rectum

The transanal endoscopic microsurgery (TEM) is an adequate method for the local full-thickness excision of large rectum polyps and pT1 "low-risk" rectal carcinomas. We studied prospectively the relevance of this surgical technique concerning complete tumour excision after R1/R2-polypectomy of malignant rectal polyps. 16 patients with pT1 "low-risk" rectal carcinoma and macroscopic (R2) or microscopic (R1) incomplete endoscopic polypectomy were locally resected by TEM. In 12 patients (75 %) no residual tumour was found. In the remaining four cases (25 %), one adenoma with high-grade atypia, two pT1 "low-risk" carcinomas and one tumour infiltration in the mesorectal fat were diagnosed. The patient with the mesorectal infiltration was immediately operated on with radical resection. No further tumour cells were found in this specimen. The median follow-up was 21 months. One patient with a pT1 "low-risk" carcinoma developed a local recurrence and a single hepatic metastasis in the left liver lobe after TEM. Both were completely resected. Currently, all patients are living without evidence of tumour recurrence. Transanal endoscopic microsurgery is a suitable method for the treatment of pT1 "low-risk" rectal carcinomas after incomplete endoscopic polypectomy. In cases of a "high-risk" tumour or deeper tumour infiltration (pT> 1) after TEM radical resection must be carried out.     

Transanal endoscopic microsurgery (TEM) for minimally invasive resection of rectal adenomas and "Low-risk" carcinomas (uT1, G1 - 2)

Transanal endoscopic microsurgery (TEM) presents a minimally invasive procedure for local removal of large rectal adenomas (>/= 2 cm) and early, so called "low-risk" carcinomas (uT1, G1 - 2) in curative as well as of advanced tumors in palliative intent. Over a 6-year period 92 TEM excisions of rectal tumors were carried out including 91 patients with 56 adenomas, 35 carcinomas (9 pTis, 17 pT1, 5 pT2, 3 pT3, 1 Ca after snare diathermy) and one neurinoma. Two patients of the carcinoma group had to be reoperated by means of anterior resection due to false preoperative rectal ultrasound examination (2 x uT1--> pT2). 4 patients required palliative therapy on account of age or high morbidity.After a mean follow-up time of 23 months (adenomas 23 months, pT1 carcinoma 26 months and advanced tumors 38 months) we encountered a total of 7 complications, of which in 5 cases surgical reintervention was necessary (5,4 %). One 86-year-old patient with a pT2-carcinoma, who was unsuitable for low anterior resection due to a high morbidity risk, died from myocardial infarction after emergency reintervention caused by postoperative bleeding. To date, overall 9 recurrences occurred (9,8 %). In the specific target group of TEM (adenomas and pT1, G1-2 carcinomas) consisting of n = 83 cases, the overall recurrence rate was 7,2 %, of which 5,3 % were due to adenomas and 11,5 % due to carcinomas. After palliative excision 2 recurrences occurred.These results of transanal endoscopic microsurgery (TEM) indicate that this technique has a useful place in curative, as well as in palliative management of rectal tumors.     

Giant adenomas of the rectum: complete resection by transanal endoscopic microsurgery (TEM)

Background Large sessile adenomas of the rectum, with a diameter greater than 5 cm, have a high risk to undergo malignant transformation. Transanal endoscopic microsurgery (TEM) offers an alternative operation method to low-anterior rectum resection in this potentially benign tumor situation.Patients We retrospectively investigated patients with giant adenomas of the rectum (>5 cm) who were treated by TEM over the last 10 years. A total of 33 patients met the criteria and were analyzed for postoperative complications, histology, and incidence of occult adenocarcinoma; residual tumor status; and tumor recurrence.Results Partial suture-line insufficiency (n=5, 15%) was the major postoperative complication, but could be managed conservatively in four cases. The residual adenoma status was 18% (n=6), especially in patients with tumors sizes more than 30 cm². In case of adenoma recurrence (n=4, 12%), a conventional transanal excision (Parks) was applicable, as these tumors were mostly located within the suture-line region of the lower rectum. Incidentally, five carcinomas were found in the specimens. In case of advanced tumors (1×pT2, 1×pT3), anterior rectum resection was carried out, whereas for the early tumors (2×pT1 low risk, 1×1 pTis), no further therapy was added. All patients (adenomas and carcinomas, n=33) were without recurrence during follow-up.Conclusion TEM is an alternative method for the resection of large benign rectal tumors located in the mid- and upper third of the rectum. The main postoperative complication is suture-line insufficiency, which generally heals by conservative treatment.     

Transanal endoscopic microsurgery: a forgotten minimally invasive technique]

OBJECTIVES: The aim of this study was to evaluate transanal endoscopic microsurgery in patients with benign and malignant rectal tumours with special reference to feasibility, morbidity, and recurrence rate.METHODS: Forty-three patients underwent transanal endoscopic microsurgical excision of rectal tumours between 1996 and 2000. The histological diagnosis was benign adenoma in 30 and invasive carcinoma in 13. The mean height of the tumour above the anal verge was 11.2 +/- 3 cm and the mean diameter of the lesion was 3.4 +/- 1.5 cm.RESULTS: The mean operative time was 85 +/- 26 min and in one case (2%), it was necessary to convert to an anterior resection. The morbidity rate was 18%. Mean hospital stay was 3.9 +/- 2.4 days. Complete excision of the tumour with histological confirmation was achieved in 42 cases (98%). With a mean follow-up of 26 months, benign tumour recurrence was observed in one patient (3%). Of the 13 patients with carcinoma, two had immediate further radical resection. For the remaining 11 patients, with a mean follow-up of 19 months, the recurrence rate was 75% for T2 tumours and nil for T1 tumours.CONCLUSIONS: Transanal endoscopic microsurgery is safe and feasible technique which should have a useful place in the management of sessile adenomas of the mid and upper rectum. Its role in the management of rectal cancer is limited, although it may be appropriate for carefully selected cases.     

Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection

BACKGROUND AND AIMS: The minimally invasive technique of transanal endoscopic microsurgery (TEM) combines the benefits of local resections, a low complication rate and high patient comfort, with low recurrence rate and excellent survival rate after radical surgery (RS). The use of an ultrasonically activated scalpel rather than electrosurgery further improves the results of TEM. PATIENTS AND METHODS: A retrospective study was performed of 182 operations on 162 patients with early rectal carcinoma (pT1, G1/2) or adenoma to compare the outcome following four different kinds of surgical resection techniques: RS (anterior or abdominoperineal resection; n=27), conventional transanal resection using Park's retractor (TP; n=76), transanal endoscopic microsurgery (TEM) with electrosurgery (TEM-ES; n=45), and TEM with UltraCision (TEM-UC; n=34). One-third of the patients with RS (33%) received either a colostomy or a protective loop-ileostomy. RESULTS: Operation time with TEM-UC was significantly shorter than with TEM-ES or RS. Hospitalization was significantly longer with RS than for TEM or TP. Complication rate with TEM was significantly lower than with RS. Recurrence rate with RS and TEM was significantly lower than with TP, with a trend to TEM-UC being better than TEM-ES. Mortality rate was 3.7% with RS and 0 with TP and TEM. The 2-year survival rate was 96.3% with RS and 100% each with TP and TEM. CONCLUSION: TEM using UC seems to be the technique of choice. TP leads to an unacceptable recurrence rate, and RS results in a higher incidence of complication and impairment of life quality.