直肠癌术后低位前切除综合征的评估与治疗进展

目的了解目前直肠癌术后低位前切除综合征(LARS)的评估方法以及治疗进展。方法复习近年来关于直肠癌术后LARS相关研究的文献并加以综述。结果 LARS的发生机制与手术前肛门功能状态、手术中对肛门直肠周围神经、肌肉损伤以及新建直肠容积、顺应性等均有密切关系。针对LARS的症状群,临床现有主观、客观等多种评估办法,包括多种生活质量评分量表、大便失禁相关量表、LARS评分量表、肛管直肠测压、肛门括约肌影像学检查等手段。治疗包括经肛门灌洗、综合康复训练、骶神经刺激、中医疗法等多种治疗方法。结论术前、术中、术后多重因素影响LARS的发生,详尽的评估、规范的手术及治疗以及有效的患者教育都可以预防或减轻LARS,提升患者术后生活质量。     

直肠癌术后低位前切除综合征的研究进展

随着外科器械的发展和外科技术的提高,有更多的低位直肠癌患者在得到根治肿瘤效果的同时也可以保留肛门,但术后有60%～90%的患者会出现低位前切除综合征,其排便功能紊乱会严重影响患者术后的生活质量。本文将从低位前切除综合征的概念、症状、可能的发病机制、防治措施等方面进行阐述,为LARS诊治和预防提供帮助。     

腹腔镜直肠癌保肛术后低位前切除综合征转归的影响因素分析

为研究腹腔镜直肠癌保肛术后低位前切除综合征(LARS)转归的影响因素,选取2017年1月至2020年1月我院腹腔镜直肠癌保肛术后65例LARS患者作为研究对象,根据LARS患者转归情况分为好转组40例和无改变组25例,通过12个月随访资料及LARS评分量表,分析LARS转归影响因素。结果显示,65例患者中好转患者40例,转归率为61.54%。好转组患者在距手术完成<3个月、术前放疗、吻合口距离肛缘<5cm、骶尾骨间径<119mm比例优于无好转组,差异具有统计学意义(P <0.05);经多因素Logistic回归分析,发现吻合口距离肛缘<5cm、术前放疗及距手术时间<3个月是术后LARS发生的危险因素(P <0.05)。结果表明,腹腔镜直肠癌保肛术后LARS的转归率随时间延长而逐渐升高;吻合口距离肛缘<5cm、术前放疗及距手术时间<3个月是影响LARS转归的独立危险因素。     

直肠癌低位前切除综合征中医药治疗研究进展

近年来直肠癌发病率愈来愈高,直肠癌低位前切除术成为低位未转移直肠癌的首选,然而临床研究表明术后部分患者出现各类排便功能障碍,严重妨碍正常生活,中医药对于治疗此类疾病优势明显,临床疗效显著,弥补了西医治疗的不足之处,近年来关于中医药治疗直肠癌低位前切除综合征的文献见于大量报道,故兹以综合分类叙述,以便未来更好应用于临床研...     

直肠癌低位前切除综合征临床研究进展

直肠癌是常见的胃肠道肿瘤,外科手术是其首选的治疗方法。近年来,随着手术技术与器械的不断发展,直肠癌保肛术的临床应用比例不断提高。低位前切除术（lowanteriorresection,LAR）,尤其是超低位前切除术和经括约肌切除术后,超过90％的患者会出现不同程度的肛门功能障碍,即所谓的低位前切除综合征（lowanteriorresectionsyn—drome,LARS）,严重影响患者的术后生活质量。临床研究提示直肠癌LARS的发生可能与多因素相关,本文就LARS发生机制与治疗的临床研究进展做一综述。     

低位直肠癌低位前切除保肛术的可行性

目的 探讨低位直肠癌行保肛术的可行性。方法 对26例低位直肠癌行低位、超低位Dixon术。结果 全组手术进程顺利。术后肛门功能优良率92．3％。肿瘤术后局部复发率为11％，3年存活率为88．2％，5年存活率为69．5％。结论 低位直肠癌行低位、超低位Dixon术是可行的。     

国产吻合器在低位直肠癌前切除吻合中的应用

目的 探讨应用国产吻合器行直肠癌前切除双吻合器吻合术的可行性。方法 对３８例直肠癌患者行前切除时，应用国产直线及管状吻合器行双吻合器吻合。结果 术后发生吻合口漏２例（５．３％），１例可能与术后早期腹腔化疗有关，另１例慎肠阴道瘘。人组无吻合品狭窄。结论国产吻俣器在使用上虽不如进口一闪怀吻合器方便，但如何操作得当，技术熟练，仍可获类似其费用仅为进口吻合器的１／３０。新的改进型中国产品应用更方便，更易使     

腹腔镜低位直肠癌手术中肠系膜下动脉高位结扎和低位结扎对低位前切除综合征影响研究

目的 分析腹腔镜低位直肠癌前切除术肠系膜下动脉高位结扎和低位结扎对低位前切除综合征（LARS）的影响。方法 采用回顾性队列研究方法,收集2019年1月至2020年8月期间在上海交通大学医学院附属仁济医院胃肠外科腹腔镜低位直肠癌前切除术的282例病人的临床资料。根据术中是否保留左结肠动脉（LCA）,分为低位结扎组（n=126）和高位结扎组（n=156）,比较两组术后LARS发生率和严重程度,并通过单因素和多因素分析LARS的危险因素。结果 对126例低位结扎病人术后3个月,6个月和12个月的影像学随访发现,117例（92.86%）病人术后左结肠动脉通畅,仅9例（7.14%）病人术后左结肠动脉闭塞。282例病人术后3个月,6个月,12个月LARS总发生率为：57.44%(162/282),42.91%(121/282),34.04%(96/282);术后3个月后无新发LARS病例。低位结扎组的术后3个月、6个月LARS的发生率明显低于高位结扎组（46.83%vs. 66.03%,P=0.00;35.71%vs. 48.72%,P=0.03）。而术后12个月低位结扎组和高位结扎组LARS发生...     

直肠癌前切除超低位吻合术

虽然近年来我国直肠癌在全部结直肠癌中的发病比例有所下降，但仍约占全部结直肠癌的三分之二，而且我国的直肠癌患者大部分是低位直肠癌。随着外科技术和器械的进步，近年来中低位直肠癌的治疗已经有了较大的进步。几十年来，人们不断尝试和探索低位直肠癌的手术重建方法，特别是吻合方法。自1939年Dixon倡导保肛手术以来，直肠癌的吻合技术就在不断进步和完善。正确认识和评价直肠癌的前切除及其吻合方式对直肠癌的外科治疗具有十分重要的意义。     

低位直肠癌前切除超低位吻合手术应用体会（附23例报告）

目的探讨低位直肠癌前切除超低位吻合手术的应用及效果。方法通过经腹游离至提肛肌后,完整切除直肠系膜,保留盆腔植物神经,分离耻骨直肠肌、外括约肌深部与内括约肌间隙,游离外括约肌全层达齿状线。采用双吻合技术,切除直肠及部分内括约肌,完成吻合。结果 23例低位直肠癌成功的完成了前切除超低位吻合保留肛门的手术,2例吻合口漏,1例局部复发,1例腰椎转移。控便情况：完全自制7例,便频12例,排气失禁2例,偶尔漏稀便2例。结论低位直肠癌前切除超低位吻合,达到了根治的目的,成功保留了肛门及功能,提高了生活质量,效果满意。     

Laparoscopy-Assisted Low Anterior Resection with a Prolapsing Technique for Low Rectal Cancer

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.     

直肠癌超低位前切除术吻合口漏预防方法的探讨

目的探讨直肠癌超低位前切除术吻合口漏的原因及对策。方法2002年1月~2003年12月采用常规方法行双吻合器直肠癌超低位前切除11例(对照组),2004年1月~2005年11月采用改良技术行双吻器直肠癌超低位前切除术31例(改良组),术中行会阴助推,注意吻合器穿刺头穿刺点的选择,行远侧直肠密闭试验及吻合口压力试验,经肛门置管至吻合口以上,骶前放置引流管经腹壁引出。结果对照组发生吻合口漏2例,经横结肠造瘘或保守治疗治愈。改良组无吻合口漏,其会阴助推方法显示盆腔直肠的长度平均增加3 cm;远侧直肠密闭试验阳性6例,均经缝合后消除,吻合口漏气4例,其中3例经缝合后消除,另1例因位置太低无法缝合而行预防性回肠造瘘,术后未发生吻合口漏。结论会阴助推、注意吻合器穿刺头穿刺点的选择、远侧直肠密闭试验与吻合口压力试验在双吻合器直肠癌超低位前切除术中的应用,对预防吻合口漏有一定的帮助。     

Transanal Inside-Out Rectal Resection for Ultra-Low Rectal Cancer

ABSTRACT

Two major issues encountered in the surgical resection of low rectal cancers (tumor located <6 cm from anal verge) are tumor-free surgical resection margin and adequate fields of colo-anal pull-through anastomosis. The clinical consequences of ensuring gross tumor-free surgical resection margin by transanal inside-out rectal resection technique were assessed for ultra-low rectal cancer patients. From February 2009 to September 2011, ultra-low anterior resection with a new method of eversion of the rectum through the anal canal after resecting the distal rectum and colo-anal anastomosis extracorporally performed in 30 patients (age range, 41–80 years) was reviewed. All patients received preoperative neoadjuvant concurrent chemoradiotherapy (CCRT) before the surgical resection. The median operating time was 265 min (range, 220–400 min), and the median intraoperative blood loss was 325 ml (range, 80–855 ml). No in-hospital mortality was noted among these patients. R0 resection (tumor-free margin range, 0.9–2.5 cm) was confirmed in all patients by pathologic reports, except one patient with 0.5 cm tumor-free margin. The new surgical technique of transanal inside-out rectal resection and colo-anal pull-through anastomosis for selected patients with ultra-low rectal cancers seems to be a safe and alternative procedure.     

高龄直肠或肛管癌患者的两种极限保肛术式的术后近期结果的比较研究

目的比较低位／超低位前切除术和外翻切除术治疗高龄直肠或肛管癌的手术效果。方法回顾性分析2009年1月至2011年12月期间我院结直肠外科专业组收治的符合纳入条件的184例行直肠或肛管癌根治手术患者的临床资料,比较行低位／超低位前切除（低位／超低位前切除组,n=99）与外翻切除术（外翻切除术组,n=85）的术中、术后情况及并发症发生情况。结果①2组基线资料如年龄、身体质量指数、性别、肿瘤直径、TNM分期、分化程度、大体类型、组织学类型及内科合并症方面差异均无统计学意义（P〉0．05）。②外翻切除术组的肿瘤距肛距离较低位／超低位前切除术组更近P〈0．05）,且远端切除距离长于低位／超低位前切除术组P〈0．05）。③2组在手术时间、术中出血量、美国麻醉医师协会分级及术后并发症方面差异均无统计学意义（P〉0．05）。④2组在拔除胃管、尿管、引流管时间及首次排气、排便、经口进食、首次下床活动时间以及总费用方面比较差异均无统计学意义（P〉0．05）;但外翻切除术组的术后住院时间和总住院时间均明显长于低位／超低位前切除术组P〈0．05）。⑤术后全部获得随访,平均随访时间13个月。随访期间,外翻切除组有1例局部复发;低位／超低位前切除组和外翻切除组各有1例远处转移;低位／超低位前切除组死亡4例（4．04％）,外翻切除组死亡4例（4．71％）。2组术后复发率、远处转移率及死亡率比较,差异均无统计学意义（P〉0．05）。存活患者的肛门控便功能均恢复良好。结论低位／超低位前切除术和外翻切除术都可以应用在高龄极低位直肠癌和肛管癌患者,外翻切除术的远端切除距离长于低位／超低位前切除术,适用于位置更低的肿瘤。     

腹腔镜低位直肠前切除术并发症的影响因素分析

目的探讨腹腔镜直肠癌低位前切除术并发症的影响因素，为降低并发症的发生、提高手术疗效提供依据。方法回顾性研究2004年8月～2007年7月我院132例根治性腹腔镜直肠癌低位前切除术的临床资料，收集所有手术并发症病例，通过单因素和多因素统计分析筛选其危险因素。结果除5例术中采用手助方式外，余127例为腹腔镜辅助下低位直肠前切除术，无中转开腹。手术并发症发生率为20．5％（27／132），其中吻合口漏（8．3％，11／132）的发生率最高。二分类Logistie回归方程筛选得出肿瘤大小（直径≥3cm）、肿瘤部位（距肛缘距离≤6cm）和病理TNM分期为影响并发症发生的独立危险因素，相对危险度分别为1．149、0．552、2．816。结论手术并发症中吻合口漏的发生率最高；肿瘤大小、肿瘤部位和病理分期是影响手术并发症发生的独立危险因素。     

Long-Term Functional Outcome of Colonic J-pouch Reconstruction After Low Anterior Resection for Rectal Cancer

Purpose To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study. Methods We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry. Results Among the patients with an ultralow anastomosis (≤4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5–8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups. Conclusion J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.     

直肠癌超低位前切除术中行预防性回肠造口的临床评价

目的评价预防性回肠造口在直肠癌超低位前切术中对降低吻合口瘘发生率的临床价值。方法1999年1月~2005年11月行直肠癌超低位前切术64例,36例(A组)未施行预防性回肠造口,28例(B组)同时行预防性回肠造口,比较两组吻合口瘘发生率、住院时间等。结果A组9例发生吻合口瘘,B组无一例发生吻合口瘘;A、B组平均住院日分别为33 d和25 d;两组比较有显著性差异(P<0.05)。结论在直肠癌超低位前切术中施行预防性回肠造口能有效地降低吻合口瘘的发生率。     

腹腔镜低位直肠癌经肛拖出切除吻合术的临床应用

目的 探讨腹腔镜低位直肠癌经肛拖出切除吻合术的临床应用价值.方法 2009年6月～ 2011年9月,对45例低位直肠癌行腹腔镜经肛拖出切除吻合术,均行腹腔镜下全直肠系膜切除,并行预防性回肠造瘘.结果 45例均完成手术,无中转开腹,切割圈均完整,无输尿管损伤.手术时间185 ～ 260 min,平均215 min,术中出血量50 ～250 ml,平均110ml.切除淋巴结15 ～ 20枚,平均16.5枚,术后病理9例有阳性淋巴结.术后回肠造瘘排气时间3～5d,平均3.5d,留置导尿3～4d.术后无切口感染、肠粘连、切口裂开,术后住院时间12～ 17 d,平均15 d.随访15～28个月,平均23个月,未发现局部复发及远处转移.回肠造瘘回纳后,肛门控便、控气功能良好.结论 腹腔镜低位直肠癌经肛拖出切除吻合术安全可行,为瘤体较小、组织学分型好的早、中期的低位直肠癌提供一种较好的术式选择.     

Short- and Medium-Term Outcome of Robot-Assisted and Traditional Laparoscopic Rectal Resection

Background:

Traditional laparoscopic anterior rectal resection (TLAR) has recently been used for rectal cancer, offering good functional results compared with open anterior resection and resulting in a better postoperative early outcome. However, laparoscopic rectal resection can be technically demanding, especially when a total mesorectal excision is required. The aim of this study was to verify whether robot-assisted anterior rectal resection (RLAR) could overcome limitations of the laparoscopic approach.

Methods:

Sixty-six patients with rectal cancer were enrolled in the study. Twenty-nine patients underwent RLAR and 37 TLAR. Groups were matched for age, BMI, sex ratio, ASA status, and TNM stage, and were followed up for a mean time of 12 months.

Results:

Robot-assisted laparoscopic rectal resection results in shorter operative time when a total mesorectal excision is performed (165.9±10 vs 210±37 minutes; P<0.05). The conversion rate is significantly lower for RLAR (P<0.05). Postoperative morbidity was comparable between groups. Overall survival and disease-free survival were comparable between groups, even though a trend towards better disease-free survival in the RLAR group was observed.

Conclusion:

RLAR is a safe and feasible procedure that facilitates laparoscopic total mesorectal excision. Randomized clinical trials and longer follow-ups are needed to evaluate a possible influence of RLAR on patient survival.