腹腔镜低位直肠癌切除保肛术的实践与技术

腹腔镜技术在低位直肠癌治疗中的应用仍是当前结直肠手术发展中极受关注的热点问题之一.正确合理的手术操作技术和充分的手术实践是腹腔镜直肠癌手术得以安全有效开展的基础.腹腔镜低位直肠前切除术、腹腔镜低位直肠前切除术联合经肛门括约肌间切除或经肛门直肠脱出外翻等术式是腹腔镜下低位直肠癌切除保肛手术可选的手术方法.而根据肿瘤位置的高低,还可选择吻合器法或经肛结肠肛管吻合等吻合方法.     

低位直肠癌保留肛门括约肌治疗进展

低位直肠癌一般指直肠下1/3部位,或距肛缘≤5～7.5cm的肿瘤.长期以来,经腹会阴根治术(APR)是低位直肠癌最常用的治疗术式,此术式治愈率较高,但需永久性结肠造口,且可导致生殖泌尿功能失常、男性阳萎等并发症.为了提高患者生活质量,又不影响根治疗效,近年来人们较多地关注保留肛门括约肌的手术方法.许多研究表明APR手术的存活率并不优于切缘阴性的保留肛门括约肌手术,1972～1986年,英国对低位直肠癌采用APR手术的比例由59%降至30%,且未降低存活率和增加局部复发率.1948年Dixon首先提出直肠前切除低位吻合的保肛疗法,此后成为保肛治疗的主要术式.目前保留肛门括约肌的治疗方法有3种:①局部治疗包括冷冻、电灼、肠腔内照射和局部手术切除;②局部切除加辅助治疗(放疗或加化疗);③术前放疗(或加化疗)加局部切除或直肠前切除结肠肛管吻合术.应根据肿瘤部位、浸润深度、肿瘤分期分级、对放(化)疗的反应、病人的体质状况和主观意愿来决定是否保肛以及选择何种保肛术式.     

低位直肠癌手术适应证和吻合方法选择的探讨

目的：探讨低位直肠癌保肛手术适应证选择，合理选择吻合方法。方法：根据直肠癌病理类型，肛门指诊，腔内超声，贫腔ＣＴ、ＭＲＩ，结合术者技术水平，病人具体情况，在不影响根治前提下，从８２８例低位直肠癌中选择５２８例实施保肛手术。外科切除范围：除端肛侧直肠（肛管），肛提肌肛门内外括约肌，坐骨直肠窝脂肪组织，肛周皮肤外，与Ｍｉｌｅｓ手术相同。术式：经肛门环扎式结肠－直肠（肛管）吻合术。结果：低位直肠癌保肛     

不同吻合技术在腹腔镜低位直肠癌保肛手术中的对比研究

目的:探讨各种吻合技术在腹腔镜低位直肠癌保肛手术中的应用价值。方法:回顾分析2003～2010年腹腔镜下利用不同吻合技术施行52例低位直肠癌保肛手术的临床资料。结果:52例手术均获成功,无中转开腹,术后肠管切缘病理切片均无癌浸润,其中利用双吻合器吻合技术12例,腹腔镜下荷包缝合直肠残端用吻合器完成结直肠吻合16例,肛门外拖出直肠远端闭合再用吻合器完成结直肠吻合14例,经肛门拖出式手工吻合10例。结论:消化道吻合技术是腹腔镜低位直肠癌保肛手术的技术难点,掌握不同的吻合技术可缩短腹腔镜直肠癌保肛手术的学习曲线,提高保肛率。     

腹部无切口经肛门切除标本的腹腔镜低位直肠癌根治套入式吻合手术配合

目的 探讨腹腔镜低位直肠癌根治腹部无切口经肛门切除标本套入式吻合保肛术手术配合方法及配合模式.方法 对30例低位直肠癌经腹腔镜下根治腹部无切口经肛门切除标本行套入式吻合保肛术的手术配合,均采用统一的整体规范管理模式,四做到：术前访视患者、术前与手术医师沟通、术前熟悉解剖与手术程序、术前特殊仪器和器械准备.六配合：手术体位配合、气腹建立配合、上夹切断肠系膜下动静脉配合、游离直肠下段配合、肛门显露与切除标本配合、套入式吻合配合.结果 本组30例低位直肠癌患者,平均手术时间为178 min,腹部手术时间约为132 min,经肛门套入式吻合操作时间46 min,术中无任何意外发生,无中转手术,均顺利完成手术.结论 腹部无切口经肛门切除标本的腹腔镜低位直肠癌根治套入式吻合是一个创新手术,手术配合强调规范化,四做到、六配合模式是有效配合手术医师顺利完成手术的重要保证.     

拖出式直肠适形切除在低位直肠肿瘤保肛手术中的应用

随着手术技术不断提高,越来越多的低位直肠癌患者可以保留肛门,但采用经盆腔及经肛门直肠内离断直肠操作因手术视野狭窄,可能造成对远端直肠及周围组织切除不足或过多,导致低位直肠癌保肛术后局部复发率、并发症发生率增加及肛门控便功能明显减退.自2010年以来我们采用经肛直肠拖出适形切除肿瘤保肛手术治疗低位直肠肿瘤,取得了较好效果,报告如下.     

肛门外结直肠手法吻合治疗中低位直肠癌146例分析

目的：探讨中低位直肠癌非吻合器吻合保肛手术方法的效果。方法：采用结直肠肛门外低位手法吻合的方法,对146例中低位直肠癌行保肛手术,直肠肿瘤远端及其系膜的切除范围为3～6cm。结果：手术成功145例,并发吻合口瘘11例,仅1例行肠造口;2年内复发和转移13例,其中吻合口复发2例;术后肛门对成形粪便控制力良好,无大便完全失禁者。结论：肛门外结直肠低位手法吻合是中低位直肠癌行保肛手术既可靠又经济的方法。     

经腹及肛门切除保肛术治疗低位直肠癌23例

目的探讨经腹部及肛门切除低位直肠癌根治保肛术治疗低位直肠癌的临床疗效。方法对23例肿瘤距齿状线1.5～3 cm的低位直肠癌经腹部及肛门切除保肛术进行回顾性分析。结果23例术后随访率为100%（23/23）,中位随访时间为4.8年。术后发生吻合口狭窄1例（4.35%）,未发生大便失禁。术后5年局部复发率4.35%。术后5年生存率69.57%。结论经腹部及肛门切除保肛术治疗低位直肠癌,既能保存良好的肛门排便功能,又不降低5年生存率,是一种安全有效的低位直肠癌保肛术式。     

经直肠肛门外翻切除标本全腹腔镜中低位直肠癌保肛术的近期效果

目的 探讨经直肠肛门外翻切除标本全腹腔镜中低位直肠癌保肛术的近期效果.方法 回顾性分析漯河市第六人民医院2018-10—2020-08间行腹腔镜保肛术治疗的70例中低位直肠癌患者的临床资料.按手术方法分为经直肠肛门外翻切除标本组(NOSES组)和传统腹腔镜低位前切除术组(LAR组),各35例.比较2组患者的基线资料、术...     

男性低位直肠癌患者腹腔镜下全直肠系膜切除联合直肠经肛门拖出式吻合术的治疗体会

目的探讨男性低位直肠癌患者行腹腔镜下全直肠系膜切除联合直肠经肛门拖出式吻合术的治疗效果。方法回顾性总结23例男性低位直肠癌患者保肛手术成功的经验。结果本组病例行腹腔镜全直肠系膜切除术,充分游离直肠下端并离断肿瘤近端后,将远端直肠和肿瘤一并经肛门拖出,闭合器切闭肿瘤远端,管状吻合器行直肠与降结肠端端吻合。23例患者均成功保留肛门,无手术死亡。术中及术后病理检查残端无肿瘤残留,术后均未发生吻合口漏。结论针对骨盆相对狭窄的男性患者,利用腹腔镜行全直肠系膜切除联合直肠经肛门拖出式吻合术,对于低位直肠癌保留肛门是安全可靠的,它可以简化手术难度,提高低位直肠癌保肛手术的成功率。     

腹腔镜辅助经前会阴超低位直肠前切除术首例报道

目的 报道1例腹腔镜辅助经前会阴超低位直肠前切除术(APPEAR)的临床资料.方法 2010年10月12日,北京协和医院基本外科对1例新辅助放化疗后的低位直肠癌患者予以腹腔镜辅助APPEAR手术.手术首先经腹腔镜进行传统全直肠系膜切除:然后于会阴中部做一新月形皮肤切口,经前会阴入路在直视下使刚电刀游离被肛提肌包围的远端...     

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??Sphincter-preserving surgery for low rectal cancer??Selection and evaluation XU Jian-min, FENG Qing-yang. Department of General Surgery, Zhongshan Hospital??Fudan University, Shanghai200032,China
Corresponding author??XU Jian-min??E-mail??xujmin@aliyun.com
Abstract The lymphatic drainage of rectal cancer is the basis of sphincter-preserving surgery. The main difficulty of sphincter-preserving surgery for low rectal cancer locates in balancing the distal resection margin and the length of remaining rectum. Different sphincter-preserving surgical approaches have their own advantages. Rectal cancer anterior resection is the most common surgical approach of sphincter-preserving surgery. But for less than 2cm of remaining rectum after tumor resection??the anterior resection is not appropriate. Compared with traditional approaches??the intersphincteric resection (ISR) and anterior perineal plane for ultra-low anterior resection (APPEAR) can achieve sphincter preservation for lower position of tumors. With the development of surgical instruments??minimally invasive techniques have been gradually applied in sphincter-preserving surgery. The advantages of robotic surgery mainly focus on more convenient operation and better protection of pelvic organs??compared with conventional laparoscopy. Surgical techniques of local excision have also made great progress. But the indications should be rigorously evaluated.     

低位直肠癌保肛手术术式选择及评价

直肠癌的淋巴引流是低位直肠癌保肛手术的基础。低位直肠癌保肛手术的主要难点在于平衡远端切缘与剩余肠管的长度。针对不同长度的剩余直肠,不同手术方式各有优势。直肠癌前切除术是最常用的保肛术式,但针对切除后剩余直肠不足2 cm的肿瘤,前切除术并不合适。相较传统保肛手术,内括约肌切除术和经前会阴超低位直肠前切除术提供了更低位置肿瘤的保肛可能。随着手术器械的发展,微创技术也逐步应用于保肛手术。相较传统腹腔镜,机器人手术的操作更为简便,也能更好地保护盆腔器官功能。局部切除的手术技术也有了长足进步,但其适用人群仍应当严格评估。     

经前会阴超低位直肠前切除术的临床应用

目的总结经前会阴超低位直肠前切除术（APPEAR）治疗低位直肠癌的临床经验。方法回顾性分析2009年9月至2011年8月间在北京协和医院基本外科施行APPEAR手术的26例低位直肠癌患者的临床和随访资料。结果26例患者中男19例,女7例,年龄（63．4±9．5）岁。术前检查见肿瘤距肛缘距离（4．6±0．7）cm。14例患者术前接受新辅助放化疗。26例患者均顺利保肛,手术时间（170±21）min,术中出血量（140±69）ml。术中发生直肠破损1例,术后发生会阴切口感染4例。术后病理：高中分化腺癌10例,中分化腺癌伴部分黏液腺癌7例,低分化腺癌1例,绒毛状腺瘤高级别上皮内瘤变1例．直肠绒毛状腺瘤1例,标本未找到癌细胞6例。术后全组均获随访,随访时间（11．4±5．6）个月,随访期间未出现泌尿功能障碍和肿瘤复发。18例患者于术后6个月行横结肠造口还纳术,术后wexner控粪功能评分平均为5．5分。肛门直肠功能测压显示,肛门括约肌最大主动收缩压为（224．0±59.3）mmHg,肛门括约肌最大静息压为（42．5±11．8）mmHg,直肠最大耐受量为（120．0±27．4）m1,直肠肛门抑制反射均存在。结论经前会阴超低位直肠前切除术适用于部分保留肛门的低位直肠癌手术．并能取得较为满意的肛门排粪功能。     

Abdominosacral resection of the rectum

Abdominosacral resection is the most reliable radical sphincter saving operation for midrectal cancers which are too low for anterior resection. The posterior incision provides maximum exposure for wide resection of the tumor, a measured distal margin, and an accurate anastomosis. The procedure can be carried out consistently to the pelvic floor without disrupting the anal sphincters and their innervation. Sphincter function is consistently preserved. The risk of abdominosacral resection is comparable to that incurred for anterior resection or abdominoperineal resection. Mortality rate is 2%. Morbidity can be limited by the selective use of a protective colostomy. The use of abdominosacral resection has extended sphincter saving resection to include 77% of 646 consecutive patients with rectal cancer. Abdominosacral resection provides the maximum clearance around the tumor and long term follow up has revealed no greater risk of local recurrence or death from cancer.     

Treatment of rectal cancer by low anterior resection with coloanal anastomosis.

OBJECTIVE: Our institution's experience with low anterior resection in combination with coloanal anastomosis (LAR/CAA) for primary rectal cancer was reviewed (1) to determine cancer treatment results, 2) to identify risk factors for pelvic recurrence, and 3) to assess the long-term success of sphincter preservation. SUMMARY BACKGROUND DATA: Use of sphincter-preserving resection for mid-rectal and selected distal-rectal cancers continues to increase. As surgical techniques and adjuvant therapy evolve, treatment results must be carefully assessed. METHODS: One hundred thirty-four patients treated for primary rectal cancer by LAR/CAA between 1977 and 1990 were studied retrospectively. All pathologic slides were reviewed. Median follow-up was 4 years. RESULTS: Actuarial 5-year survival for all patients was 73%. Among 36 patients who relapsed, distant metastatic disease had developed at the time of first clinical relapse in most (86%). Pelvic recurrence was detected in 13 patients, an actuarial rate of 11% at 5 years. Mesenteric implants, positive microscopic resection margin, T3 tumor, perineural invasion, blood vessel invasion, and high tumor grade were associated with increased risk for pelvic recurrence. Eleven patients ultimately required permanent colostomy, and in eight instances the cause was pelvic recurrence. CONCLUSIONS: Low anterior resection combined with coloanal anastomosis provides good treatment for mid-rectal cancers and for some distal rectal cancers. Pelvic recurrence is not associated with short distal resection margins but is correlated with the presence of histopathologic markers of aggressive disease in the primary tumor. Long-term preservation of anal sphincter function depends primarily on control of pelvic tumor and can be achieved in more than 90% of patients.     

TME技术在中、低位直肠癌手术中的应用价值

目的：探讨TME技术在中、低位直肠癌手术中的应用。方法：回顺性分析采用TME技术治疗37例直肠中、低位癌病人资料，评价采用TME技术的治疗结果及与传统手术技术的区别。结果：37例病人中，AR3例、LAR 25例、APR 7例、Parks 2例，吻合口瘘2例、口狭窄1例、卣肠阴道瘘1例、骶前出血1例，保肛率81％、骶前出血率2．7％。结论：TME技术是中、低位直肠癌手术应遵循的原则，不仅能提高保肛率、减少出血率、降低并发症发生率，而且能明显改善性功能和膀胱功能，提高患者的生活质量。     

腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术已在临床上受到广泛认可。术中手术层面的识别与游离、盆腔自主神经的保护对于手术成功与否以及患者术后生活质量尤为重要。腹腔镜直肠癌低位前切除术中需注意：(1)直肠系膜与神经前筋膜之间游离;(2)紧贴直肠系膜游离间隙;(3)保证直肠系膜后方、两侧方和前方的完整;(4)TME手术直肠系膜终止线位于肛门直肠环,游离应到位,不能残留直肠系膜。实践证实,基于膜解剖的直肠癌全系膜切除有助于盆腔自主神经保护以及实现肿瘤的根治性切除。     

Rectal carcinoma. Optimizing therapy by partial or total mesorectum removal]

The role of total mesorectal excision for rectal cancer treatment is one of the most exciting findings in surgical oncology of the recent years. The patient's prognosis largely depends on the surgical quality of rectal resection. The excision of the cancer bearing rectum has to follow very precisely along the mesorectal fascia by sharp dissection without damaging the mesorectum itself. This technique reduces the local recurrence rate to below 10% and allows long-term survival in two thirds of all patients. Rectal cancers of the middle and lower third of the rectum need to be treated by total mesorectal excision down to the muscular pelvic floor, the ones of the upper third and the sigmoideo-rectal junction are appropriately treated by partial mesorectal excision down to 5 cm below the tumor. No additional survival benefit may be expected when pelvic lymphadenectomy has been performed. The direct tumor spread along the bowel wall and the lymphatic tumor spread in a caudal direction are uncommon and late findings in rectal cancer disease. Low and ultralow rectal carcinomas may therefore be treated by a sphincter preserving procedure respecting a safety margin of at least 1 to 2 cm. Thus, continence preserving surgery may be performed in over 80% of patients suffering from rectal cancer without compromising long-term outcome.     

低位直肠癌行双吻合器保肛手术

目的探讨低位直肠癌行双吻合器保肛手术的效果。方法回顾性分析近5年间应用双吻合器行保肛手术的78例低位直肠癌患者的临床资料。结果所有患者直肠闭合及吻合均成功,术后切缘病理均未见癌细胞浸润,无吻合口漏及手术死亡。73例(93.6%)随访9～65个月,盆腔复发2例(2.7%),腹腔广泛转移1例(1.4%),肝脏转移7例(9.6%),吻合口局部复发1例(1.4%,术后11个月再行Miles术)。结论双吻合技术可为低位直肠癌患者提供保肛机会,使用得当可有效预防吻合口漏等并发症的发生。