经肛门结肠外翻吻合在低位直肠癌保肛术中的应用

目的　探讨经肛门结肠外翻拉出吻合在低位直肠癌保肛术中的价值。方法　 2 7例患者肿瘤下缘距肛缘 5 .0～ 7.0cm ,按“无瘤术”原则清除与肿瘤相应的肠系膜及根部的淋巴结 ,经腹切除直肠癌 ,将近端结肠经肛门外翻拉出 ,与直肠断端在肛门外行一层吻合并回纳。结果　术后无瘤生存 2 5例 ,占 92 .6% ;局部复发和远处转移各 1例 ,各占 3 .70 % ;术后患者均较好地保持了正常的排便控制功能。结论　低位直肠癌经腹切除经肛门结肠外翻拉出吻合术是一种安全、经济、疗效可靠的术式。     

括约肌部分切除加平滑肌肛管成形原位肛门再造术

为探讨直肠恶性肿瘤手术后为恢复肛门功能,行括约肌部分切除加平滑肌肛管成形原位肛门再造术的效果,回顾性分析1995年1月~2006年1月间8例肿瘤距肛缘3~4 cm的直肠癌患者,行括约肌部分切除加平滑肌肛管成形原位肛门再造术,全组手术过程顺利,术后肛门功能恢复良好。括约肌部分切除加平滑肌肛管成形原位肛门再造术,利用平滑肌特性,在低位直肠癌病例行内括约肌及外括约肌深层合并切除能确保切缘无癌浸润,保持根治性的同时保留肛门,手术可行且临床效果良好。     

低位直肠癌经前会阴切除的技术与评价

低位直肠癌由于位于人体盆腔底部邻近肛门,深在又隐蔽,在肿瘤生长过程中又往往极易侵犯女性的子宫、阴道,男性的前列腺及盆壁等组织.造成外科治疗难度大、疗效差和保肛率低.永久性的人工肛门更使患者感到沮丧和痛苦.近年来国际上开展了一种所谓"经前会阴超低位直肠前切除术"的新术式,专用于低位直肠癌的外科治疗.该术式在设计上打破了同类手术上百年来一直遵循的从腹盆腔开始分离直肠和肿瘤,最终经肛门切除肿瘤,然后采用手工吻合肠道的传统保肛模式,采用经前会阴切口的肿瘤切除和吻合器技术的肠道吻合方式.同传统的低位直肠癌手术相比,该术式具有更高的保肛率和更为满意的肛门功能,并能做到真正意义上的直肠全系膜切除(TME).     

Laparoscopic-Assisted Modified Intersphincter Resection for Ultralow Rectal Cancer

Background

Intersphincter resection (ISR) is considered to be a superior technique offering sphincter preservation in patients with ultralow rectal cancer.1 Because high-definition laparoscopy offers wider and clearer vision into the narrow pelvic cavity and intersphincteric space, ISR has been further refined.2 However, functional outcome after ISR has not been optimal. More than half of patients receiving ISR suffer partial or even complete anal incontinence.3 We therefore propose a laparoscopic-assisted modified ISR, with the aim of improving sphincter function following ISR.

Methods

The video describes the technique for performing such laparoscopic-assisted modified ISR in a 62-year-old woman with ultralow rectal cancer (3 cm from anal verge). Preoperative staging by endorectal ultrasound and pelvic magnetic resonance imaging revealed stage I rectal cancer (cT₂N₀M₀). The operation consisted of an abdominal and a perineal phase. The abdominal phase routinely involved colonic mobilization with high ligation of inferior mesenteric vessels, total mesorectal excision (TME), as well as transabdominal intersphincteric dissection. The procedure for laparoscopic TME was performed according to our published method.4 Along the TME dissection plane, the puborectalis could be reached and the intersphincteric space was entered posterolaterally. The hiatal ligament at the posterior side of the rectum was transected afterwards. The dissection of the intersphincteric space was continued caudally at the anterior side of the rectum. The distal bowel wall was mobilized for 2 cm from the lower edge of the tumor to obtain adequate distal margin. At this point, circular dissection of the intersphincteric space was completed. After the abdominal phase, perineal dissection was performed with wide exposure by use of a hooked self-retaining retractor. The lower margin of the tumor was identified under direct vision. We developed a modified ISR technique. Resection of the mucosa and internal sphincter was initiated 2 cm distal to the lower edge of the tumor at the tumor side to obtain the necessary distal margin. Meanwhile, at the opposite side of the tumor, the resection line was just above the dentate line so that partial dentate line could be preserved. After removal of the specimen en bloc per anus, the pelvic cavity was generously irrigated with diluted povidone iodine solutions. The distal margin of the specimen was then examined by frozen section for presence of cancer. If clear, coloanal anastomosis was performed using a handsewn technique. The colon was rotated 90° and anastomosed to the anal canal with interrupted absorbable 3–0 sutures. Finally, a pelvic suction drain was placed, and a temporary diverting stoma made in the terminal ileum.

Results

There were no intraoperative complications. The operating time was 180 min. Blood loss was 50 mL. The distal margin was clear, and the final pathology was pT₂N₀M₀. The patient underwent an uneventful recovery. She began sphincter-strengthening exercises 2 weeks after surgery. The stoma was closed after examinations 3 months later. No local recurrence or distant metastasis was found. At 12-month follow-up, in terms of sphincteric function, the patient was continent to solids, liquids, and flatus.

Conclusions

Laparoscopic-assisted modified intersphincter resection for ultralow rectal cancer is safe and feasible. This technique should be considered whenever possible as a means to offer sphincter preservation and improve sphincter function in patients with ultralow rectal cancer.

     

括约肌间切除术在超低位直肠癌保肛手术中的应用

目的评价超低位直肠癌行括约肌间切除手术(ISR)后的肛门功能及肿瘤根治效果。方法近7年间本院为1 6例超低位直肠癌患者施行ISR手术。经腹按照TME原则游离直肠至肛提肌平面后,经肛门于括约肌间沟处切开肛管皮肤,分离内括约肌直至将直肠及内括约肌全部切除,再行结肠肛管吻合。术后7 d天开始肛门收缩功能锻炼,4周开始生物反馈训练。对Dukes B,C期患者,术后2周开始化疗,术后4周进行放疗。结果全组无术后死亡,无吻合口瘘。2例术后发生结肠黏膜脱出,2例肛管狭窄,1例切口脂肪液化。随访3个月至7年,无盆腔或吻合口局部复发;2例分别于术后1 7个月和2 1个月死于肝转移,1例术后6个月死于肺转移。按W illiams的排便自制标准,术后3,6,12个月分别有6 2.5%,8 0.0%,8 4.6%的患者达到功能良好效果。结论ISR手术并发症少,安全性高,肿瘤根治效果与排便功能的恢复满意。     

Flap-valve theory of anorectal continence

The most important component of continence is considered to be the puborectalis muscle which is reputed to function by creating a flap-valve mechanism in which the anterior rectal wall occludes the upper and canal. To elucidate this, anal and rectal pressures were measured simultaneously together with external anal sphincter and puborectalis electromyogram and synchronously superimposed on an image intensifier displaying the rectum outlined by barium. We studied 13 subjects at rest, and during a Valsalva manoeuvre. There was a significant rise in rectal and sphincter pressures (P less than 0.005) and external sphincter and puborectalis EMG (P less than 0.005). In a further 13 patients Valsalva manoeuvres were performed during proctography alone. In all subjects the anterior rectal wall was always clearly separated from the upper sphincter despite a maximal effort and a rectum filled with sufficient liquid to produce a desire to defaecate. These findings question the flap-valve theory of continence and suggest the puborectalis functions by sphincteric occlusion of the anal canal.     

Anterior perineal approach and three-flap anoplasty for imperforate anus: optimal reconstruction with minimal destruction.

Despite progress in the treatment of imperforate anus, anal stenosis, rectal prolapse, and other late complications may still arise. In 1987, we described the three-flap anoplasty for the treatment of rectal prolapse following pull-through operations. Since 1986, we have performed 14 three-flap anoplasties in combination with an anterior perineal rectal pull-through for primary treatment of imperforate anus. The mean age at definitive repair was 4.4 months (range, 0 to 14 months). Eleven of the 14 primary pull-through procedures could be performed through a perineal approach only. There were no deaths. At a mean follow-up of 24.2 months, none of the patients has developed prolapse, and only one has had a temporary stenosis. Three children are already fully continent, and soiling is absent in 12. All have a good sphincter tone. Although it is too early to evaluate long-term results, it appears that the three-flap anoplasty prevents mucosal prolapse through the interposition of a skin-lined anal canal. Moreover, a combination of this technique with the anterior perineal approach provides an excellent exposure with minimal dissection of the perineal and pelvic musculature and allows for easy and safe pull-through of the rectal pouch, making an abdominal counterincision unnecessary in most cases. It reproduces at the same time a normal anatomy while taking advantage of all existing structures.     

Diagnosis of anterior perineal anus (APA)--significance of electromyographic evaluation of the external anal sphincter location

APA is a common cause of constipation, and is the mild case of the imperforated anus. On diagnosing APA, anterior displacement of the anus and normal distribution of the external anal sphincter to the anus are essential. To determine the location of the anus in the perineum simple clinical technique was developed. In 61 normal cases, the result of measurement was almost same in each sex, but in 3 APA cases the location were anteriorly dislocated than normal cases. Distribution of the external anal sphincter was evaluated with electromyographic technique, and location map of the sphincter was made. In 3 APA cases, the anus was totally surrounded by the external anal sphincter, but in 17 ano-cutaneous fistula cases, the opening was anteriorly dislocated to the sphincter distribution map. As a conclusion, newly proposed simple clinical technique to determine anal location and electromyographic examination of the external and sphincter distribution are very useful in objective diagnosis of APA.     

Effect of anterior resection on anal sphincter function

Minor difficulties with continence may occur after low anterior resection. Intraoperative injury to the internal anal sphincter or its nerve supply may contribute to this. To study the effect of low anterior resection on the anal sphincter mechanism, anal manometry was performed on 20 patients before and 10 days after resection. Fifteen patients were studied again 6 months after operation. Resting, maximum squeeze and squeeze increment pressures were recorded. Intraoperative manometry (n = 11) and presacral nerve stimulation (n = 6) were performed to determine whether peroperative injury to the internal anal sphincter had occurred. Resting and maximum squeeze anal canal pressures were reduced by low anterior resection, and did not recover. The squeeze pressure increment did not change. Division of the inferior mesenteric artery, full mobilization of the rectum and mesorectum, and rectal transection did not affect resting anal pressure, which was reduced after EEA anastomosis (mean (s.e.m.) before, 40(5) mmHg; after, 27(4) mmHg; P less than 0.05, n = 5). Presacral nerve stimulation produced relaxation of the internal sphincter. Anal sphincter pressures are reduced after low anterior resection. The external anal sphincter and the nerve supply to the internal anal sphincter appear intact. A direct injury to the internal sphincter is postulated.     

低位直肠癌括约肌间切除超低位吻合的疗效评估

目的评价超低位直肠癌行括约肌间切除手术（ISR）后的舡肠动力学变化、肛门功能及肿瘤根治效果。方法总结分析2004年1月至2007年8月间施行ISR手术的30例超低位直肠癌患者的临床资料。结果30例患者肿瘤距肛缘2．5～4．0（平均3．4）cm。与术前比较．术后肛管静息压、肛门最大收缩压和直肠最大耐受容积明显降低（P〈0．01）．有27例（90．0％）患者术后肛门直肠抑制反射消失,且随着时间推移无明显恢复。按Williams的排便自制标准．术后3、6、12个月分别有86．7％、93．3％和96．7％的患者达到功能良好效果。全组患者随访1年至3年8个月．无死亡病例;未出现盆腔或吻合口局部复发、远处转移和吻合口瘘。10例术后出现肛周粪渍性湿疹,2例结肠黏膜脱出,1例肛管狭窄。结论ISR超低位吻合保肛手术治疗低位直肠癌可以达到良好的根治性．并能较好地保留肛门功能。     

Advantages of the laparoscopic approach for intersphincteric resection

Background  

Intersphincteric resection (IRS) is a surgical technique used to preserve sphincter function, mainly cases of low rectal cancer located less than 5 cm from the anal verge [1, 2]. There have been reports of laparoscopic ISR [3, 4], but discussion of the specific techniques used in this laparoscopic surgical procedure have not been sufficient. For better outcomes of this sophisticated procedure, extreme care must taken to prevent perforation of the rectal wall and to preserve the external sphincter muscle. The most difficult steps for ISR are the circular dissection and separation of the internal sphincter muscle from the external sphincter and puborectalis using the perineal approach. The authors’ techniques and the advantages of laparoscopic ISR are shown by a video presentation of three rectal tumor cases. Also, the perioperative outcomes for the patients who underwent laparoscopic ISR with this technique are described.     

腹腔镜全系膜切除术联合经肛门内括约肌切除术治疗超低位直肠癌42例

目的探讨腹腔镜全系膜切除术（TME）联合经肛门内括约肌切除保肛术（ISR）治疗超低位直肠癌的临床疗效。方法选择2009年1月至2012年6月42例超低位直肠癌患者采用腹腔镜TME联合ISR术治疗。按TME原则完全游离切除直肠后,经肛门内括约肌切除,完成超低位直肠癌保肛手术。对患者的临床资料、术后并发症及随访结果进行分析。结果42例患者均顺利完成手术,无中转开腹或者改行Mile’s术式,13例行回肠预防性造口,2例发生吻合口瘘,经保守治疗治愈。所有患者术后肛门括约肌功能比较满意,无围手术期死亡。随访9-40个月,1例于术后15个月发生肝脏多发转移再次入院进一步治疗。结论对于术前评估早中期超低位直肠癌,特别是肿瘤没有侵犯肛门内括约肌,采用腹腔镜TME联合IRS术是安全可行的,提高了保肛成功率,提高患者术后生活质量且局部复发率低。     

混合痔外剥内扎术后并发症与肛门括约肌损伤的相关性研究

为探讨混合痔外剥内扎术后并发症与肛门括约肌损伤的相关性,将术后切除痔核中含有肌纤维组织的52例患者作为观察组,不含肌纤维组织的55例患者作为对照组,对比观察两组患者术后第1、3、5、7天的肛门疼痛程度、肛缘水肿程度及肛门括约功能。结果显示,观察组术后第1、3、5天肛门疼痛程度均高于对照组,P〈0．05;术后第7天肛门疼痛程度两组比较差异无统计学意义,P〉0．05。观察组术后第1、3天肛缘水肿程度均高于对照组,P〈0．05;术后第5、7天肛缘水肿程度两组比较差异无统计学意义,P〉0．05。观察组术后第1、3、5、7天肛门括约功能均低于对照组,P〈0．05。结果表明,混合痔外剥内扎术后并发症的发生与肛门括约肌损伤有关。     

Anterior rectal wall excision for endometriosis using the circular stapler

Background: Endometriosis involving the rectum is rare but is associated with significant symptoms that are best relieved by resection of the involved segment of rectum. Resection necessitates either a segmental or anterior rectal wall excision with sutured closure. Application of a circular stapling device allows an alternative technique to resect endometriosis in this area. Method: Following laparascopic ablation of endometriosis elsewhere in the pelvis , the rectum must be mobilized around disease present on the anterior rectal wall. This will involve lateral and anterior extraperitoneal rectal dissection; the latter dissection mobilizing the vagina from the rectum by a sufficient length necessary to allow imbrication of the diseased area. Insertion of a circular stapler per anus allows the diseased area to be imbricated into the stapler, resulting in simultaneous excision and closure of the anterior rectal wall. Results: Thirty patients with anterior rectal wall endometriosis, estimated at <2 cm in diameter and not involving > one‐third of the total circumference of the rectum, have undergone successful management using this technique. Morbidity occurred in four patients, with one patient requiring further surgery. Conclusions: Laparascopic disc excision of deposits of endometriosis involving the anterior rectal wall can be safely performed utilizing the circular stapler without the need for open surgery, and with low morbidity.     

Successful operation for imperforate anus and imperforate rectum: Three year follow-up report

A newborn infant, born with complete absence of the anus, sphincter, anal canal and rectum, was successfully operated upon via proctoplasty eighteen hours after birth, bringing down the sigmoid colon to serve as the new anal canal and rectum. The boy is now three years old and normal in every other respect. The formation of scar in the new anal canal, together with more progressive use of the gluteus maximus muscles, has effectuated very good control of bowel movements. The author has proctoscoped the boy several times during the past year, never finding evidence of the rectal valves, or so-called folds of Houston. This, together with the appearance of the intestinal anatomy at the time of operation, is the basis for the author's conviction that it is not the rectum, but rather the sigmoid colon, which is now functioning as an anal canal and rectum.     

Anatomy of the rectum and anal canal

The rectum and anal canal are the terminal portions of large intestine and the entire gastrointestinal tract. They are thus readily accessible to direct inspection and examination. The rectum functions as a distensible reservoir for faeces, while the anal canal possesses a powerful muscular sphincter in its wall which is important in maintaining faecal continence. Diseases of the rectum and anal canal, both benign and malignant, account for a very large part of colorectal surgical practice worldwide. This article emphasizes the clinically and surgically relevant aspects of the anatomy of the rectum and anal canal.     

Anatomy of the rectum and anal canal

Collectively, the rectum and anal canal constitute the very terminal segment of the large intestine, and thus of the entire gastro-intestinal tract. Their distal location renders the rectum and anal canal readily accessible to direct inspection and examination. The prime function of the rectum is to act as a distensible reservoir for faeces, while the anal canal incorporates in its wall a powerful muscular sphincter which is of paramount importance in the mechanism of faecal continence. Diseases of the rectum and anal canal, both benign and malignant, account for a very large part of colorectal surgical practice worldwide. This article emphasizes the clinically and surgically relevant aspects of the anatomy of the rectum and anal canal.     

Lateral Internal Partial Sphincterotomy Technique for Chronic Anal Fissure

Lateral internal sphincterotomy is used for the treatment of a chronic anal fissure. There is a lack of consensus for the amount of internal sphincter division necessary in the surgical treatment of an anal fissure. The anatomy of the anal sphincters and the subcutaneous partial sphincterotomy technique are presented with fresh anal canal specimen photographs. Lateral internal partial sphincterotomy is performed in 43 patients in the office between 2012 and 2013. The patients were questioned about their bowel habitus and any problem with anal control before the operation. Postoperatively, the patients were followed up by office visits and telephone calls at 1 week, 1 month, and 6 months. Data were collected prospectively. Forty of the patients (93 %) were pain free in 1 week after the operation. Further sphincter fibers were divided in three patients (7 %) because of the persistent pain. The most common complication was the sensation of burning (n?=?9, 20.9 %) around the anus. Bleeding in three patients, itching around the anus in two patients, and incontinence to flatus in one patient were the other complications. None of the patients developed fecal incontinence in the follow-up period. Lateral internal partial sphincterotomy is a safe, effective, and reproducible technique for the management of chronic anal fissure pain.     

Anatomy of the rectum and anal canal

Collectively the rectum and anal canal constitute the very terminal segment of the large intestine, and thus of the entire gastro-intestinal tract. Their distal location renders the rectum and anal canal readily accessible to direct inspection and examination. The prime function of the rectum is to act as a distensible reservoir for faeces, while the anal canal incorporates in its wall a powerful muscular sphincter which is of paramount importance in the mechanism of faecal continence. Diseases of the rectum and anal canal, both benign and malignant, account for a very large part of colorectal surgical practice worldwide. This article emphasizes the clinically and surgically-relevant aspects of the anatomy of the rectum and anal canal.     

High and intermediate imperforate anus: results after surgical correction with special respect to internal sphincter function.

Embryologically a fistula in an anorectal malformation can be regarded as an ectopic anus. Since 1984 the so-called fistula has been saved and used as the new anal canal in the surgical reconstruction of 48 patients with high or intermediate imperforate anus. A positive rectoanal inhibitory reflex indicating internal sphincter function was recorded in 32 of 43 patients investigated with anorectal manometry. These patients showed significantly better anal continence. It is concluded that there is an internal sphincter "anlage" in the fistulous connection from the bowel to the urogenital tract. Internal sphincter function can be obtained in the majority of the patients, which seems advantageous for their anal function.