全直肠系膜切除术

全直肠系膜切除术 (ｔｏｔａｌｍｅｓｏｒｅｃｔａｌｅｘｃｉｓｉｏｎ ,ＴＭＥ)也称直肠周围系膜全切除术 (ｃｏｍｐｌｅｔｅｃｉｒｃｕｍｆｅｒｅｎｔｉａｌｍｅｓｏｒｅｃｔａｌｅｘｃｉ ｓｉｏｎ ,ＣＣＭＥ) ,是 1982年Ｈｅａｌｄ等[1] 提出来的 ,经过近二十年的临床实践 ,业已证明是一种比较好的中下部直肠癌根治性手术操作方式 ,现作为一种标准的直肠癌根治性手术被越来越多的临床医生所接受 ,其优点是术后局部复发率明显下降 ,术后排尿性功能受影响比较小。　　一、ＴＭＥ的解剖学基础　　盆腔的局部解剖发现[2 ] ,在直肠周围脂肪与盆…     

四孔经腹腔镜行直肠癌TME根治术的临床应用18例报告

自 198 2年英国学者Ｈｅａｌｄ提出全直肠系膜切除 (ＴｏｔａｌＭｅｓｏｒｅｃｔａｌＥｘｃｉｓｏｎ ,ＴＭＥ)治疗直肠癌概念后 ,直肠癌的局部复发率由 12 %～ 2 0 %降至 5 %。现将我院应用腹腔镜行直肠癌ＴＭＥ根治术的情况报告如下。1　资料与方法1 1　临床资料　本组男 10例 ,女 8例 ,36～ 74岁 ,平均 5 5岁 ,行Ｍｉｌｅｓ3例。无中转开腹。直肠癌下缘距肛门 4～ 7ｃｍ 10例 ,10～ 15ｃｍ 8例。ＤｕｋｅｓＡ期 5例 ,ＤｕｋｅｓＢ期 8例 ,ＤｕｋｅｓＣ期5例。病理结果 15例为腺癌 ,3例为腺癌样息肉。1 2　手术方法　于脐孔上缘 ,置入 10ｍ…     

直肠癌全直肠系膜切除术

目的 比较全直肠系膜切除（ＴＭＥ）和传统手术方法对直肠癌术后局部复发及长期生存率的影响。方法 将１９９３年９月起采用ＴＭＥ术的直肠癌患１６８例与１９８１～１９９２年行传统切除方法的１２６例患进行比较,分析两组的临床病理参数。结果 手术后并发症发生率无差异,ＴＭＥ组２年复发率为４．６％,明显低于对照组的２０．６％（Ｐ＝０．００１）,２年及３年生存率ＴＭＥ组分别为８７．１％和８０．３％,对照组分别为７６．１％和６８．７％,ＴＭＥ组生存率高于对照组（Ｐ＝０．０１３）。ＴＭＥ技术、肿瘤的Ｄｕｋｅｓ分期,患的年龄、肿瘤距肛门的距离等因素中,只有ＴＭＥ是独立影响生存率的指标,ＴＭＥ、肿瘤的Ｄｕｋｅｓ分期是独立的影局部复发的指标,结论 对于距离肛门１２ｃｍ范围内的直肠癌,采用ＴＭＥ技术能有效地降低局部复发率及提高患生     

微创化全直肠系膜切除保肛治疗低位直肠癌: 机遇与挑战

直肠癌的发病率逐年上升 ,居消化道恶性肿瘤之首 ;低位直肠癌位于腹膜返折以下 ,约占直肠癌总数的 70 % ,其中约 2 / 3属低位直肠癌患者需实施切除肛门的改道手术。所以 ,提高肿瘤切除率、降低局部复发率、提高 5年生存率、提高保肛率及改善患者术后的生活质量一直是普外学科努力的方向。全直肠系膜切除术 (ｔｏｔａｌｍｅｓｏｒｅｃｔａｌｅｘｃｉｓｉｏｎ ,ＴＭＥ)这一具有划时代意义的创新术式 ,应用于临床 2 0余年 ,降低了局部复发率 ,提高了 5年生存率及保肛率 ,已为越来越多的结、直肠外科医生作为直肠癌治疗的金标准。随着ＴＭＥ理念…     

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直肠癌外科的进展主要表现在三个方面 :(1)临床病理学的深入研究 ,发现直肠癌向远侧肠壁的浸润是有限的 ,超过 2 0ｃｍ的不足 3%。因此 ,对直肠癌远端的肠段切除大于 3 0ｃｍ就已经足够 ,扩大了直肠癌低位前切除的适应证。资料显示 ,中低位直肠癌的Ｄｉｘｏｎ手术率明显增加 ,但是局部复发率没有增加。 (2 )全直肠系膜切除 (ｔｏｔａｌｍｅｓｏｒｅｃｔａｌｅｘｃｉｓｉｏｎ ,ＴＭＥ)直肠癌手术原则的提出 ,使直肠癌根治术后的局部复发率大大降低。 (3)在直肠癌根治性切除术中注意了盆腔自主神经的保护 (ｐｅｌｖｉｃａｕｔｏｎｏｍｉｃｎ…     

直肠癌经肛门内镜显微外科术

近年由于各类诊断手段如便潜血、结肠镜等检查的普及,使早期直肠癌诊断数量明显增加。对待早期癌使用传统的根治术虽有切除彻底的优点,但手术引起的一些创伤弊端及死亡率,又使人们多在微创的局切术上加以考虑。而经肛门内镜显微外科术（ＴｒａｎｓａｎａｌｅｎｄｏｓｃｏｐiｃｍiｃｒｏｓｕｒｇｅｒｙＴEＭ或ＴＥＭＳ）就是继传统Ｐａｒｋｓ经肛门局切及Ｍａ－ｓｏｎ经括约肌局切术后的又一能使切除高度达到直肠中上段,并具有观察更精确、操作空间更为宽广的新型局切技术。１手术器械和方法此手术是通过一有４０ｍｍ直径粗的硬管直肠镜…     

加强基础与临床研究进一步提高肛肠外科诊治水平

20世纪是肛肠外科迅速发展的时期 ,对早期提出的一些经典学说或具有争议的问题 ,近年来都有了新的认识 ,即使对一些很常见的疾患的认识 ,也已经发生了根本的变化。长期流行的痔静脉曲张学说 ,已被否定。常见的慢性便秘症状 ,用肛肠动力学解释 ,已得到学术界的公认。全直肠系膜切除术 (ｔｏ ｔａｌｍｅｓｏｒｅｃｔａｌｅｘｃｉｓｉｏｎ ,ＴＭＥ)已被证明可明显降低直肠癌局部复发率。尤其是在当前注重提高直肠癌术后患者生活质量的情况下 ,ＴＭＥ手术在国内正迅速推广。肛肠外科作为独立学科的发展 ,在诊断、治疗、基础研究等方面 ,都已取得…     

直肠癌保肛术式的争论

直肠癌是我国常见亚性肿瘤之一，手术切除仍是目前治疗直肠癌的主要手段。Ｍｉｌｅｓ自１９０８年首创腹会阴联合切除治疗直肠癌至今已近９０年的历史，Ｍｉｌｅｓ手术一直被公认为治疗直肠癌的金标准。当Ｍｉｌｅｓ手术推行半个世纪以后，人们开始对该手术需做永久性腹部结肠造口，给患者带来精神上的负担、生少和社交上的不便引起重视。近年来随着对直肠癌的局部解剖、病理、生物学行为及其淋巴转移规律的深入研究，人们越来越重视在保住生命的同时又要有良好的生活质量，为此保肛手术也逐年在增加。然而对低位直肠癌选择做保肛手术一直存在着争议，争议的焦点是保肛手术是否影响直肠癌根治性切除，突出表现在两个方面：①保肛手术癌远端肠段切除的长度多少合理；②保肛手术是否增加局部复发率和影响５年生存率。现对上述两方面问题讨论如下。     

中低位直肠癌保肛手术67例临床分析

直肠癌是我国常见的大肠恶性肿瘤 ,发病率有逐年增高趋势 ,发病年龄也比欧美国家早 12～ 18年。我院从 1991年 1月～ 1999年 12月共行直肠癌手术 16 7例 ,其中Ｍｉｌｅｓ手术 10 0例 ,保肛手术 6 7例。保肛手术的方式为Ｄｉｘｏｎ手术、Ｂａｃｏｎ手术、改良Ｂａｃｏｎ手术和Ｐａｒｋｓ手术及应用吻合器低位吻合。经过认真随诊、对比 ,在术后局部复发率上两者无明显差异。现将保肛的 6 7例报道如下。1　资料和方法1 1　临床资料　本组男 39例 ,女 2 8例。年龄 2 3～79岁 ,平均 6 1岁。肿瘤下缘距肛缘 4～ 5ｃｍ 15例 ,6～ 7ｃｍ 4 6例 ,7ｃ…     

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目的 探讨中下段直肠癌局部切除的途径和方法。方法 对近１０年来采用Ｍａｓｏｎ手术作局部切除的３０例中下段直肠癌病例进行分析。结果 Ｔｉｓ期癌５例,Ｔ１期癌１３例,Ｔ２期癌１０例,Ｔ３期癌２例。所有标本切缘经病理检查未发现癌残留。平均随访为５２个月。５年存活率为９３％。目前未发现癌复发病例。结论 Ｍａｓｏｎ手术应作为中下段直肠癌局部切除术的首选术式。     

Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.     

男性直肠癌切除术后性功能障碍分析

对25例男性直肠癌切除后性功能进行调查。平均年龄为42．5岁，Miles手术18例，性欲减退8例（44．4％），勃起障碍11例（61.1％），射精障碍13例（72．2％）。Dixon手术7例，性欲减退1例（14.3％），勃起障碍1例（14.3％），射精障碍2例（28．6％）。认为手术损伤盆腔神经是造成术后病人性功能障碍的直接和主要因素。防治关键在于术中完整地保护植物神经，注意剥离层次和切除范围。     

Laparoscopic rectal surgery for middle and lower rectal cancer

Background  

The usefulness of laparoscopic low anterior resection for middle and lower rectal cancer remains controversial.     

Effect of rectal distension on rectal electromechanical activity.

The rectum possesses electric activity in the form of pacesetter potentials (PPs) and action potentials (APs). The latter are associated with rectal pressure elevation and share in the rectal motile activity. A recent study has shown that electric waves are transmitted by the longitudinal but not the circular rectal muscle fibers. Rectal motile activity under normal physiologic conditions was suggested to be induced by the electric waves, that effect longitudinal muscle contraction, as well as by circular muscle stretch resulting from rectal distension. The current study investigated the effect of rectal overdistension on the rectal electromechanical activity aiming at assessing the effect of stool accumulation in the rectum on rectal motile activity. Under general anesthesia, the abdomen of 16 mongrel dogs was opened, the rectum exposed, and 3 electrodes were sutured to the rectal serosa. The rectal pressure was measured by a 10-F catheter connected to a pressure transducer. Rectal distension was achieved by a balloon inflated with carbon dioxide (CO2). Simultaneous recording of the electric activity and rectal pressure was performed during rectal inflation in increments of 10 mL CO2. There was significant increase of rectal pressure as well as of frequency, amplitude, and conduction velocity of PPs and APs on rectal distension. The more the rectal balloon was distended, the more was the increase in rectal pressure and waves variables; the increase was maximal just before balloon expulsion at 40 mL distension. Upon rectal overdistension (50 and 60 mL), no PPs or APs were recorded and the rectal pressure was 0; no balloon expulsion occurred. Rectal overdistension (pathologic distension) appears to abort the electromechanical activity of the rectum and lead to failure of the rectum to expel the balloon. This effect is suggested to be due to overstretch of rectal musculature with a resulting loss of the rectal electric waves and noncontraction of the muscle fibers. These findings appear to explain the cause of rectal atony, which occurs in rectal inertia and leads to constipation.     

Recurrent rectal carcinoma after anterior resection and rectal stapling

Nine local recurrences have been diagnosed in 38 patients with carcinoma of the rectum operated on with anterior resection using the EEA-stapling instrument. The characteristics of these recurrences have been compared with those of other authors, currently a total of 27 recurrences. The presence of a locally advanced growth with extramural spread, a distal location and a short margin of clearance seems to increase the risk of local recurrence, with often distressing symptoms. It is proposed that even if the EEA-stapler offers technical possibilities for anterior resection in these growths, this operation should be restricted to less advanced tumours.     

Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids

Background  

Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events.     

Rectoanal pressures and rectal compliance in children with rectal prolapse

The results of anorectal manometry in 11 children with complete rectal prolapse were evaluated. Abnormalities of sphincter control or bowel movements occurred in 8 out of these 11 patients. Anal canal pressure of the patients was lower than in the controls, but there was no significant difference of resting pressure profiles of the anorectum between the patients and the controls. Rectoanal reflex was present in all the patients and in the controls. Rectal compliance was significantly lower in the patients, but there was no correlation between rectal compliance and sphincter control of the patients.     

低位直肠癌保肛手术中直肠冲洗治疗对预后的影响

目的研究低位直肠癌保肛术中应用直肠冲洗对预后的影响。方法随机选择98例低位直肠癌患者分为冲洗组（A组）和单纯手术组（B组）,各49例。在经腹低位直肠前切除中,A组进行远端直肠冲洗并将冲洗液进行细胞学检查。将两组2年局部复发率和1、3、5年生存率进行比较。结果A组有27例找到癌细胞,术后局部复发率为1413％,B组为30．6％,两组比较差异有统计学意义（P〈0．05）;A组术后1、3、5年生存率分别为96．8％、72．3％、52．3％,B组分别为95．7％、65．4％、43．0％,两组术后3、5年生存率比较,差异有统计学意义（P〈0．05）。结论低位直肠癌保肛术中远端直肠冲洗是必要的,可以提高低位直肠癌的治疗效果。