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。     

基于一种螺纹扩肛器的超低位直肠癌精准保肛（PPS）手术

目的探究自制新型透明螺纹扩肛器应用于自然腔道取标本手术（NOSES）治疗超低位直肠癌的安全性及优势。 方法回顾性分析2018年5月~2018年6月上海市第十人民医院胃肠外科采用自制螺纹扩肛器完成腹腔镜联合经肛手工吻合超低位直肠癌精准保肛（PPS）NOSES手术5例患者的临床资料,总结患者的手术时间、术中出血量、术后住院时间、并发症、肛门功能情况等相关指标。 结果5例患者顺均利完成超低位直肠癌PPS术,平均手术时间为（217.01±37.75）min,平均术中出血量为（108.32±53.15）mL,平均术后住院时间为（6.34±1.72）天,术后肛门功能Wexner、Vaizey平均评分均为3分,术后均无显著并发症发生。 结论应用新型螺纹扩肛器完成PPS手术治疗超低位直肠癌安全有效,避免了腹部辅助切口、显著减少了手术创伤,同时可在直视下精准地切除病灶,极大限度地保存及改善了患者术后的肛门功能,提高了术后生活质量,可操作性强且经济实用,值得在临床上推广应用,但上述结论仍需大样本临床研究进一步验证。     

机器人辅助下经自然腔道取标本手术应用于乙状结肠癌和直肠癌患者的近期疗效分析

目的探讨机器人辅助下经自然腔道取标本手术（NOSES）应用于乙状结肠癌和直肠癌患者的近期疗效。 方法回顾性分析2021年7月至2021年10月于中国医学科学院肿瘤医院接受机器人辅助的结直肠癌患者31例,包括直肠肿瘤18例,乙状结肠肿瘤13例。所有患者根据术中情况决定手术方式,观察手术和术后恢复情况、术后病理学结果,了解患者术后生存、肿瘤进展情况。 结果31例患者顺利完成手术,17例患者接受NOSES手术,剩余14例采取常规手术方式取标本。NOSES组患者的BMI更低［（22.59±2.70）cm比（25.48±2.34）cm,t=1.142,P=0.004］;N分期淋巴结转移率更低（χ²=7.343,P=0.025）;术中出血量更少［（24.12±14.17）cm比（35.71±11.58）cm,t=0.896,P=0.020］,并且术后首次离床活动时间更早［（27.41±10.95）cm比（40.00±9.51）cm,t=1.227,P=0.002］。31名患者在围手术期内均未发生手术相关并发症。术后随访时间3~6个月,所有患者均未发生肿瘤复发、进展和死亡。 结论机器人辅助下NOSES应用于乙状结肠癌和直肠癌患者安全可行,近期疗效满意。     

腹腔镜下低位直肠癌经肛外翻拖出切除的自然腔道取标本手术操作技巧探讨

［摘要］　目的　探讨腹腔镜下低位直肠癌经肛外翻拖出切除的自然腔道取标本手术（NOSES）操作技巧。方法　选择2017年1月至2021年12月于四川省肿瘤医院行腹腔镜下经肛外翻拖出切除的NOSES的低位直肠癌患者67例,分析其手术时间、术中出血、术后并发症、住院时间及肿瘤复发、转移等情况。结果　本组67例患者均顺利完成手术,无一例中转开腹。其中,3例患者同时行单侧侧方淋巴结清扫,43例（64.2%）术中行预防性回肠造瘘。手术时间为200～590 min,平均为320.1 min;术中出血量为5～300 ml,平均为64.3 ml。无一例发生腹腔污染。术后平均21.9 h（1～88 h）经肛门或造瘘口排气。术后发生吻合口漏1例,尿潴留3例,不全性肠梗阻5例,均行保守治疗后痊愈。术后平均住院时间为10.6 d（7～26 d）。术后随访至2022年6月,发现盆腔复发1例,出现远处转移5例。结论　腹腔镜下经肛外翻拖出切除的NOSES具有创伤小、恢复快、疗效好等优点。只要术前严格把控适应证,恪守无菌和无瘤原则,掌握关键操作技巧,可以有效地避免腹腔污染,降低肿瘤医源性扩散风险。     

TEM器械联合塑料保护套经肛门取标本法在直肠癌NOSES中应用七例

目的介绍本中心腹腔镜直肠癌根治术、自然腔道取标本手术（NOSES）中,采用TEM器械联合塑料保护套经肛门取标本的经验,并对其中的技术要点及争议问题进行阐述。 方法回顾分析吉林大学第一医院2017年9月至2018年1月收治的进展期直肠癌手术患者7例,记录肿瘤大小（最大直径）,手术时间,术中出血量,清扫淋巴结数目,术后排气时间等近期疗效指标。 结果本组7例患者均顺利完成直肠癌的NOSES,采用TEM器械联合塑料保护套经肛门取标本获得成功,肿瘤直径5~6.5 cm,手术时间为120~150 min,出血量50~100 ml,清扫淋巴结数目为15~27枚,术后肛门排气时间2~4 d,术后进食流质时间3 d,术后均无并发症发生。 结论TEM器械联合塑料保护套经肛门能取出较大直肠癌标本,降低取出标本难度,取得良好的近期疗效。     

腹腔镜下经肛拖出直肠癌根治术超低位保肛的临床研究

目的探讨腹腔镜下经肛拖出直肠癌根治术超低位保肛的可行性、安全性、根治性及短期临床疗效。方法回顾我院收治的127例超低位直肠癌,运用腹腔镜经肛拖出直肠癌根治术行超低位保肛65例（腹腔镜组）、直肠癌超低位前切除术62例（开腹组）,比较两组术中、术后及愈后各项指标。结果腹腔镜组术中出血量及术后肠道功能恢复时间、止痛药物使用时间、住院时间均优于开腹组（P〈0.05）。两组手术时间、清扫淋巴结数量、术后吻合口漏、吻合口狭窄、复发、转移、大便失禁和总生存率各项差异无统计学意义（P〉0.05）。结论腹腔镜下经肛拖出直肠癌根治术超低位保肛符合肿瘤学根治性原则,安全可行,术后恢复快,适合用于超低位直肠癌保肛。     

TME在低位直肠癌根治术中的应用效果观察

53例接受低位直肠癌根治术患者，术中应用全直肠系膜切除（TME）与一次性吻合器低位吻合，手术过程均顺利。术中出血量50-180ml，无手术死亡。术后8例肛门排便功能受影响，半年后恢复。1例出现吻合口漏，保守治疗后治愈。45例获随访，时间3个月-5a，8例（14.9％）盆腔局部复发。认为采用TME和吻合器低位吻合保留肛门的方法行低位直肠癌根治术安全可行，效果满意。     

内镜纳米炭标记对直肠癌新辅助放化疗疗效判断及手术的价值

目的 探讨局部进展期直肠癌新辅助放化疗前行内镜注射纳米炭标记对疗效判断及后续治疗的临床价值。 方法 前瞻性纳入2015年7月至2015年12月在福州总医院治疗的局部进展期直肠癌患者18例,其中男11例、女7例,年龄35～68岁,平均（45.8±12.5）岁。患者在新辅助放化疗前均接受内镜下标记,黏膜下注射生理盐水后,于肿瘤病灶肛侧距肿瘤边缘1 cm处前、后、左、右4个象限正常肠壁黏膜下层多点注射纳米炭混悬液（5 mg／处）进行标记;标记后经新辅助放化疗+休息时间共5～11周,平均（8±2）周后,再行外科手术。观察内镜纳米炭标记在判断患者新辅助放化疗前后肿瘤大小、肿瘤下缘距肛缘距离、术中情况及手术保肛率等变化的效果。 结果 内镜纳米炭标记操作时间5～15 min,平均（10.0±3.5）min,未见不良反应,未发生出血、穿孔等并发症。新辅助放化疗后肿瘤全部缩小,其中完全消失7例,占38.9％;病理完全缓解6例,占33.3％;肿瘤下缘距肛缘距离为4.5～10.0 cm,平均（6.4±1.8） cm。术中肠管外可见100％病灶黑染,位置清晰,部分区域淋巴结黑染;行保肛手术8例,手术保肛率44.4％。 结论 局部进展期直肠癌患者新辅助放化疗前行内镜注射纳米炭标记既可更好地判断新辅助放化疗的疗效,又有助于手术精准定位,示踪淋巴结,且染色效果持久,有利于后续外科手术或随访观察。     

43例直肠癌根治术患者的术后护理体会

2006年12月～2007年11月,我们共收治直肠癌患者43例（男25例,女18例;年龄42～81岁）,肿瘤位置为低位23例,中位11例,高位9例。均行直肠癌根治术,其中行Miles术式13例,Dixon术式30例（10例行双吻合低位保肛手术）,手术顺利,术后2例出现吻合口瘘,5例发生切口感染（腹部4例,会阴部1例）,经相应处理均治愈出院。现报告护理体会。     

双吻合器低位前切除治疗低位直肠癌207例报告

采用双吻合关闭器低位前切除术治疗低位直肠癌 (癌肿下缘距肛缘 4～ 7cm)患者 2 0 7例。均无手术死亡 ;发生吻合口漏 10例 ,吻合口狭窄 19例。术后 2～ 4周肛门排便功能优良 ,排便次数控制在 2～ 4次 / d。术后平均随访 37(8～ 72 )个月 ,局部复发 13例 ;3年和 5年生存率平均为 89.2 %和 6 96 1%。认为只要合理选择手术适应症 ,双吻合器低位直肠癌前切除是一种安全、有效的术式     

Anus-preserving rectectomy via telescopic colorectal mucosal anastomosis for low rectal cancer: Experience from a Chinese cohort

AIM: To investigate the safety and efficacy of anus-preserving rectectomy via telescopic colorectal mucosal anastomosis (TCMA) for low rectal cancer. METHODS: From August 1993 to October 2012, 420 patients including 253 males and 167 females with low rectal cancer underwent transabdominal and transanal anterior resection, followed by TCMA. The distance be-tween the anus and inferior margin of the tumor ranged from 5 to 7 cm, and was 5 cm in 6 patients, 6 cm in 127, and 7 cm in 287 patients. Tumor-node-metastasis staging showed that 136 patients had stage Ⅰ, 252 had stage Ⅱ and 32 had stage Ⅲ. Fifty-six patients with T3 or over received preoperative neoadjuvant chemoradio-therapy. RESULTS: The postoperative follow-up rate was 91.9% (386/420) with a median time of 6.4 years. All 420 pa-tients underwent radical resection. No postoperativedeath occurred. Postoperative complications included anastomotic leakage in 13 (3.1%) patients and anas-tomotic stenosis in 7 (1.6%). The local recurrence rate after surgery was 6.2%, the hepatic metastasis rate was 13.2% and the pulmonary metastasis rate was 2.3%. The 5-year survival rate was 74.0% and the disease-free survival rate was 71.0%. Kirwan classification showed that continence was good in 94.4% of patients with stage I when scored 12 mo after resection. CONCLUSION: TCMA for patients with low rectal cancer leads to better quality of life and satisfactory defecation function, and lowers anastomotic leakage occurrence, and might be one of the safe operative procedures in anus-preserving rectectomy.     

测量骶骨岬至直肠残端的距离在腹腔镜直肠癌根治术精准吻合中的应用价值

目的评估术中精确测量直肠残端至骶骨岬的距离(Drp)在腹腔镜直肠癌手术精准吻合中的应用价值。方法纳入陕西省人民医院普外科2019年1月1日到2020年10月1日连续入院的并接受择期腹腔镜手术的中低位直肠癌病例39例,收集临床病例资料并回顾手术视频;术中测量步骤如下:使用线段测量Drp;拉展左半结肠及其系膜至骶骨岬水平,使用钛夹标记相应结肠为A点;以A点为起点,以原Drp线段测量A点以远Drp+3 cm处为直肠癌近端切除线。行结直肠端端吻合,经肛留置肛管行肠腔内减压,新辅助放化疗术后病例行末段回肠造口,评价指标包括术中,术后及标本质量三方面;本研究采用描述性统计方法。结果手术时间(247±57)min,估计术中出血量(35±15)m L。吻合前游离脾区结肠7例;吻合后盆腔结肠无"悬空架桥"的病例;无吻合后游离近端结肠及再次裁剪系膜的病例;远切缘距肿瘤下缘的距离(2.3±1.1)cm,Drp(17.7±4.6)cm,近切端距肿瘤上缘的距离(16.4±3.2)cm,直肠全系膜切除的标本质量均为A级,直肠癌远近切缘无阳性病例;术后无B、C级吻合口漏发生,吻合口出血1例;肛管排气时间(3.1±1.2)天,排便时间(3.4±1.6)天,术后住院时间(9.1±2.3)天。结论测量Drp能够精确地确定拟吻合结肠的长度,促进腹腔镜根治性直肠癌切除术的精准吻合。     

Routine defunctioning stoma after chemoradiation and total mesorectal excision:A single-surgeon experience

AIM:To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution.METHODS:From Oct 1998 to Feb 2009,we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge.All patients received neoadjuvant chemoradiation(CRT) for 6 wk.Among them,85% of the patients received 225 mg/m2/d 5-fluorouracil using a portable infusion pump.The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk.The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk.Total mesorectal excision(TME) and routine defunctioning stoma construction were performed by one surgeon.The distal resection margin,circumferential resection margin,tumor regression grade(TRG) and other parameters were recorded.We used TRG to evaluate the tumor response after neoadjuvant CRT.We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma.RESULTS:The median distance from the lower margin of rectal cancer to the anal verge was 5 cm:6 cm in 9 patients,5 cm in 32 patients,4 cm in 10 patients,and 3 cm in 11 patients.Before receiving neoadjuvant CRT,45 patients(72.6%) had a cT3-4 tumor,and 21(33.9%) patients had a cN1-2 lymph node status.After CRT,30 patients(48.4%) had a greater than 50% clinical reduction in tumor size.The final pathology reports revealed that 33 patients(53.2%) had a ypT3-4 tumor and 12(19.4%) patients had ypN1-2 lymph node involvement.All patients completed the entire course of neoadjuvant CRT.Most patients developed only Grade 1-2 toxicities during CRT.Thirteen patients(21%) achieved a pathologic complete response.Few post-operative complications occurred.Nearly 90% of the defunctioning stomas were closed within 6 mo.The local recurrence rate was 3.2%.Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence(36.5% vs 76.5%,P = 0.006).Ne     

Functional outcome following rectal surgery—predisposing factors for low anterior resection syndrome

Purpose

Developments in surgical techniques and neoadjuvant treatment have enabled an increasing proportion of patients with rectal cancer to undergo sphincter-sparing resections. The avoidance of a permanent stoma can come at the cost of poor bowel function which can significantly impact patients’ quality of life. The objective of this study was to identify the incidence and risk factors for the development of bowel dysfunction following rectal cancer surgery.

Methods

Patients undergoing anterior resection for rectal cancer between January 2009 and January 2015 were identified from a rectal cancer database at a single centre. All patients who had bowel continuity restored and underwent curative resection were sent a validated low anterior resection syndrome (LARS) questionnaire. Pre-, inter- and postoperative factors were compared between patients with major LARS and those with minor or no LARS using conditional logistic regression.

Results

There was an 80% response rate (n = 68). Thirty-eight patients (56%) had major LARS symptoms. Neoadjuvant radiotherapy, predominantly long-course chemoradiotherapy (LCCRT), was an independent risk factor for development of major LARS symptoms, while restoration of bowel continuity within 6 months was protective.

Conclusions

The use of neoadjuvant radiotherapy (LCCRT) and timing of stoma reversal are risk factors for the development of severe bowel dysfunction. The potential for long-term poor functional results after LCCRT should be discussed with patients and form a part of the decision-making in individual treatment plans. The timing of the ileostomy closure, where safe and feasible, should be performed within 6 months to improve outcome.

     

结直肠肿瘤经自然腔道取标本手术203例回顾性研究

目的通过对结直肠肿瘤经自然腔道取标本手术（NOSES）病例进行回顾性研究，探讨NOSES的可行性和安全性。 方法纳入2013年5月至2017年5月行NOSES手术的结直肠肿瘤患者203例，收集资料包括患者术前一般资料、术后病理资料、手术资料及随访资料。 结果患者平均年龄为（58.7±11.9）岁，平均BMI指数为（22.6±3.0）kg/m²，肿瘤位于直肠者占70.8%。术后病理资料显示，中分化腺癌者占69.4%，平均检出淋巴结（12.9±5.1）枚，平均肿瘤最大直径为（3.6±1.4）cm，TNM分期I~IV期患者分别占23.2%，41.4%，24.1%和3.4%。手术资料显示平均手术时间为（198.9±55.2）分钟，平均术中出血量为（73.7±54.2）mL；经直肠取标本者占87.2%，经阴道取标本者占12.8%；平均术后排气时间为（44.5±20.5）小时，平均进食时间为（63.8±15.5）小时。患者术后平均住院（12.3±4.1）天，11.9%的患者出现了术后并发症，住院期间二次手术者仅2例。随访资料显示术后肛门功能障碍者仅占2.2%，无阴道功能障碍者。 结论NOSES术具有良好的可行性、安全性及近期疗效，但仍需在临床实践中不断探索和发展。     

Colorectal anastomosis using a novel double-stapling technique for lower rectal carcinoma

Background The conventional double-stapling technique (DST) using a standard linear stapler horizontally is sometimes difficult to apply to an anastomosis where the pelvis is narrow or the anastomosis is ultralow. In this report, we review our experiences of a novel DST (IO-DST) that employs vertical division of the rectum using an endostapler. Materials and methods One-hundred and five consecutive patients who underwent low anterior resection for rectal carcinoma below the peritoneal reflection were enrolled into this study. The clinical, oncological, and functional outcomes were studied retrospectively. Results The median distance from the anal verge to the tumor was 5.0 cm in “high risk” T1 tumors and 6.5 cm in more-advanced tumors. More than 2 cm of distal surgical margin was obtained in 80.6% of the patients with tumors deeper than T1. The median distance from the anal verge to the anastomosis was 4.2 cm in T1 tumors and 4.0 cm in more-advanced tumors. The median blood loss was 315 ml, and the median operative time was 262 min. There was no mortality in the IO-DST. Recurrence presented in 12 (13.0%) of the patients who underwent curative surgery, with local recurrence in four patients (4.3%) during a median follow-up of 46.2 months. However, no patients experienced suture-line recurrence. The early bowel frequency was four times/day after stoma closure in patients with transient covering colostomy and 3.5 times/day in patients without colostomy. The late bowel frequency was three times/day in patients with transient covering colostomy, and two times/day in patients without colostomy. Conclusions The IO-DST is a feasible and safe procedure for facilitating lower anastomosis in rectal carcinoma below the peritoneal reflection.     

Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer

AIM:To investigate whether transanal natural orifice specimen extraction(NOSE)is a better technique for rectal cancer resection.METHODS:A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classifcations from March 2011to February 2012 at the First Affliated Hospital of Sun Yat-Sen University was analyzed.Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge.Demographic data,operative parameters,and postoperative outcomes were assessed.RESULTS:None of the patients was converted to laparotomy.Respectively,there were 16 cases in the low anastomosis and fve in the ultralow anastomosis groups.Mean age of the patients was 45.4 years,and mean body mass index was 23.1 kg/m2.Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm.Mean operating time was 132 min,and mean intraoperative blood loss was 84 mL.According to the principle of rectal cancer surgery,we performed D2 lymph node dissection in 13 cases and D3 in eight.Mean lymph nodes harvest was 17.8,and the number of positive lymph nodes was 3.4.Median hospital stay was 6.7 d.No serious postoperative complication occurred except for one anastomotic leakage.All patients remained disease free.Mean Wexner score was 3.7 at11 mo after the operation.CONCLUSION:Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible,safe and oncologically sound.Further studies with long-term outcomes are needed to explore its potential advantages.