低位直肠癌经肛提肌外腹会阴联合切除术与传统术式的疗效比较

目的比较腹会阴直肠癌根治术与传统腹会阴直肠癌根治术(APR)治疗低位直肠癌的并发症及短期手术效果。方法回顾性分析2012年1月至2015年9月54例行低位进展期直肠癌手术病人的临床资料,20例病人接受传统APR手术(APR组),34例接受肛提肌外腹会阴直肠癌根治术(ELAPE组)。结果与传统APR组比较,ELAPE组术中出血量较少,术中标本穿孔率及环周切缘阳性率低,差异有统计学意义(P0.05);与传统APR比较,ELAPE组术后会阴切口并发症发生率、尿潴留发生率更高,手术时间较长,差异有统计学意义(P0.05)。经过短期随访,ELAPE组1例出现复发,无死亡病例;传统APR组盆底复发1例,死亡1例。两组局部复发率及死亡率比较差异无统计学意义(P0.05)。结论 ELAPE手术虽然在一定程度上增加了会阴区相关并发症的发生率,但其明显降低了术中直肠穿孔率和术后标本环周切缘(CRM)阳性率,减少术中出血量,提高了手术根治效果,具有非常重要的临床价值。     

腹会阴联合切除与经肛提肌外腹会阴切除术治疗低位直肠癌的近期疗效比较

目的探讨经肛提肌外腹会阴切除术(ElAPE)治疗进展期低位直肠癌的可行性、安全性及有效性。方法回顾分析33例进展期低位直肠癌患者的临床资料,其中采用ELAPE手术18例,传统腹会阴联合切除术(APR)15例。结果两组患者年龄、性别、肿瘤分期、肿瘤位置、手术时间、术后并发症发生率比较差异无统计学意义(P0.05),ElAPE组与APR组患者术中失血.量、术后标本环周切缘阳性率及肠管穿孔率比较差异有统计学意义(P0.05)。结论进展期低位直肠癌行ELAPE手术安全可行,可减少术中出血,降低术中标本穿孔率及标本环周切缘阳性率,且未增加并发症发生率。     

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腹会阴联合切除术(APE)和全直肠系膜切除(TME)明显改善了直肠癌病人的预后。然而,与直肠癌前切除手术(AR)相比,低位直肠癌的环周切缘(CRM)阳性率和术中穿孔(IOP)的发生率仍然很高,这是导致复局部发率高的重要因素。提肛肌外腹会阴联合切除术(ELAPE)可明显降低CRM阳性率和IOP发生率,增加局部根治性。在欧洲,ELAPE被认为是治疗低位直肠癌的外科新理念。ELAPE手术要求在会阴区沿提肛肌外侧平面操作,腹部手术遵循TME原则。明确解剖标志和操作原则可缩短外科医生的学习曲线。     

肛提肌外腹会阴联合切除术的研究进展

腹会阴联合切除术（APE）和全直肠系膜切除术（TME）明显改善了直肠癌患者的预后。然而,与直肠癌前切除术相比,低位直肠癌的环周切缘（CRM）阳性率和术中穿孔（IOP）的发生率仍然很高。经肛提肌外腹会阴联合切除术（ELAPE）可以降低直肠癌手术的CRM阳性率和肿瘤穿孔率,降低术后局部复发率,从而可能提高患者的生存率。然而,术中操作时间长、创伤大和术后会阴并发症发生率高,使ELAPE备受争议。本文对ELAPE的操作要点、优缺点、研究现状和发展前景等进行综述。     

肛提肌外腹会阴联合切除术治疗低位直肠癌

为研究肛提肌外腹会阴联合切除术（ELAPE）治疗低位直肠癌的方法及效果,回顾性分析18例采用ELAPE治疗的低位直肠癌患者的临床资料。结果显示,平均手术时间为（2804-20）min,无术中输血病例,均为根治性手术切除,无手术死亡病例。术后会阴部切口感染1例,骶尾部疼痛1例,无排尿功能障碍。结果表明,ELAPE直视下解剖会阴部组织,可精确切除导致术后复发的关键性组织结构,可行必要的侧方淋巴结清扫,可降低局部复发率,提高患者生存率,是一种有效可行的手术方式。、     

肛提肌外腹会阴联合切除术治疗直肠癌的临床效果分析

目的探讨肛提肌外腹会阴联合切除术(ELAPE)治疗直肠癌的临床效果。方法回顾性分析本院90例直肠癌患者的临床资料,按照手术方式的不同将其分为观察组与对照组,其中观察组行ELAPE,对照组行传统腹会阴联合切除术(APE),每组各45例。对比两组手术相关指标(手术时间、术中出血量、排气时间、排便时间、禁食时间、会阴切口拆线时间、会阴切口平均引流量、术后住院时间、淋巴结清扫数目、环周切缘阳性率、术中穿孔率),观察两组术后并发症发生率,采用Kaplan-Meier生存曲线分析两组术后3年生存率。结果两组术中出血量、排气时间、排便时间、禁食时间、会阴拆线时间、会阴平均引流量、术后住院时间、淋巴结清扫数目比较差异均无统计学意义(均P0.05)。观察组手术时间长于对照组,环周切缘阳性率、术中穿孔率均低于对照组,差异均有统计学意义(均P0.05)。观察组会阴切口并发症发生率低于对照组(P0.05),两组性功能障碍、尿潴留、骶尾部慢性疼痛发生率差异均无统计学意义(均P0.05)。观察组术后3年生存率高于对照组(P0.05)。结论与传统APE术相比,ELAPE治疗直肠癌安全可行,可降低环周切缘阳性率、术中穿孔率,提高患者生存率,还可降低会阴切口并发症发生率,具有较好的临床应用前景。     

直肠癌行肛提肌外腹会阴联合切除术研究进展

肛提肌外腹会阴联合切除术（ELAPE）是治疗低位进展期直肠癌的重要术式。近年来,ELAPE手术方式和技术在逐渐发展,其突出的优点是手术简单、精准、根治性有所提高。腹腔镜和机器人手术系统行ELAPE亦取得肯定效果。多数研究认为,ELAPE降低了环周切缘阳性率、肿瘤穿孔发生率,并可能进一步降低局部复发率和提高存活率。由于切除了更多的肿瘤周围组织,ELAPE可能会增加术后会阴部伤口并发症、泌尿生殖功能障碍和骶尾部慢性疼痛的发生,但有关生活质量研究认为,ELAPE术后病人总体生活质量与传统经腹会阴联合切除术（APR）无显著差别。个体化ELAPE手术可能降低术后并发症发生率。应用生物补片重建盆底有助于缩短住院时间,减少住院花费。笔者认为,ELAPE从理念上强调了沿肛门外括约肌-提肛肌外侧筋膜平面切除的重要性,尽可能保留坐骨直肠窝脂肪,以解剖学基础指导手术,符合肿瘤根治的精准原则。     

经肛提肌外腹会阴联合切除术与传统腹会阴联合切除术对低位直肠癌疗效比较的Meta分析

目的系统比较经肛提肌外腹会阴联合切除术（ELAPE）与传统腹会阴联合切除术（APE）对低位直肠癌的治疗效果。方法计算机检索Cochrane图书馆、PubMed、EMbase、中国知网和维普等数据库中以低位直肠癌为研究对象、并设有ELAPE与APE对照的临床研究文献,采用Cochrane系统评价方法对两种术式的术中穿孔率、环周切缘阳性率、术后局部复发率及术后会阴切口并发症发生率进行Meta分析。结果共6篇文献（1篇随机对照研究和5篇非随机对照研究）656例病例纳入研究,其中ELAPE组346例,APE组310例。Meta分析结果显示,ELAPE组环周切缘阳性率（RR=0．48,95％CI：0．36-0．65）和局部复发率（RR=0．43,95％C1：0．19-0．99）明显低于APE组;而两组患者术中穿孔率（RR=0．45,95％CI：0．15-1．37）和术后会阴切口并发症发生率（RR=I．20,95％CI：0．57-2．50）的差异无统计学意义。结论相较于传统APE术,ELAPE术具有更低的环周切缘阳性率和局部复发率。     

肛提肌外腹会阴联合切除术(ELAPE)治疗低位直肠恶性肿瘤的临床体会

目的探讨肛提肌外腹会阴联合切除术(extra-levator abdominalperineal excision,ELAPE)在低位直肠癌非保肛手术中的应用价值。方法回顾性分析2012年3月~2014年4月间在我科行ELAPE的11例低位直肠恶性肿瘤患者的临床资料,肿瘤下缘距肛缘0~5 cm。结果本组患者手术时间平均为3.6(3~4)h,术中无直肠穿孔的发生,无围手术期死亡病例。标本游离并切除后呈圆柱状,由肛管、中下段直肠及直肠系膜、大部分肛提肌等组织构成,并有较多的组织结构覆盖在病变组织表面。病理检查结果示所有11例患者切除标本CRM阳性率为0。术后拔除骶前引流管时间平均为7(5~10)d。术后发生尿潴留2例(18.2%),予对症治疗后好转。行补片修补会阴部缺损的3例患者中,术后发生会阴部伤口感染1例(9.1%),遂行补片取出术,会阴部伤口积极换药,持续负压冲洗引流,伤口逐渐愈合。余均未发生会阴部并发症,术后第10~14 d出院。结论 ELAPE是一种全新、安全的低位直肠恶性肿瘤根治术,能明显减少术中肠穿孔发生率,降低CRM阳性率,从而降低肿瘤的局部复发率和远处转移率,并且可以减少会阴部切口并发症的发生率,提高患者的生活质量和生存率,具有重要的临床应用价值。     

肛提肌外腹会阴联合切除术的关键解剖和“两平面四边界”的手术原则

腹会阴联合切除术（APR）为目前治疗低位直肠癌的主要手术方式.最近研究发现,传统的APR存在较高的标本环周切缘（CRM）阳性率和术中穿孔率（IOP）,并被认为是导致APR术后局部复发和预后差的重要原因.肛提肌外腹会阴联合切除术（ELAPE）是由欧洲外科学家、影像学家和病理学家共同倡导的一种认为可降低环周切缘阳性率和术中穿孔率的新术式.明确的操作平面和解剖学边界是该术式的核心内容,也是确保手术安全及顺利实施的前提;而了解会阴区直肠周围的肌肉、筋膜和血管和神经解剖是开展该手术的基础.本文就ELAPE手术中所涉及的关键解剖进行了介绍,并将ELAPE手术操作要点归纳为“两平面、四边界”原则,以利于该术式的推广和应用。     

低位进展期直肠癌行ELAPE手术意义与争议

肛提肌外腹会阴联合切除术（ELAPE）是治疗低位进展期直肠癌的重要术式。近年来,ELAPE手术方式和技术在逐渐发展,其突出的优点是在精准解剖层面引导下提高了手术根治性,正被越来越多的结直肠外科医师认可。腹腔镜和机器人ELAPE手术取得了满意疗效,可以经腹切断肛提肌,避免术中翻身。多数研究认为,ELAPE降低了环周切缘阳性率、肿瘤穿孔率,并可能进一步降低局部复发率和提高存活率。由于切除了更多的肿瘤周围组织,ELAPE可能会增加术后会阴部切口并发症、泌尿生殖功能障碍和骶尾部慢性疼痛的发生,经会阴微创通路手术和个体化ELAPE手术可能有助于减少创伤和降低并发症发生率。生物补片重建盆底有助于缩短住院时间,减少住院花费,目前被普遍接受。总之,ELAPE从理念上强调了沿肛门外括约肌-肛提肌外侧筋膜平面切除的重要性,以解剖学基础指导手术,符合肿瘤根治的精准原则。     

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??Re-discussion on the necessity and surgical indication of extralevator abdominoperineal excision for low rectal cancer YAO Hong-wei*??LI Wen-di??LIU Yin-hua. *Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
Corresponding author: LIU Yin-hua, E-mail: liuyinhua@medmail.com.cn
Abstract The extralevator abdominoperineal excision??ELAPE??through the anatomical plane outside the levator meets with the holy plane of total mesorectal excision to ensure the integrity of the surgical specimen. The rates of positive circumferential resection margin and intra-operative perforation were decreased by extended resection of levator. In recent years, in the field of colorectal surgery a debate was risen that if ELAPE can replace abdominoperineal resection (APR). How to determine the indication of ELAPE? How to improve perineal incision complications of ELAPE? And how to determine the survival benefit of ELAPE? Along with the related research, ideas gradually clear. For low rectal cancer staging cT1-2 or ycT0-2, APR procedure is still the standard operation. In the absence of a high level of evidence based medicine, it’s too early to say that ELAPE can replace APR. Tumor staging ycT3-4 after neoadjuvant treatment is more suitable for ELAPE. The reduction of local recurrence rate and benefit of long-term survival is looked forward to.     

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??Progress of extralevator abdominoperineal excision for advanced low rectal cancer WANG Zhen-jun, HAN Jia-gang. Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, Beijing 100020, China
Corresponding author:WANG Zhen-jun,E-mail: wang3zj@sohu.com
Abstract Extralevator abdominoperineal excision (ELAPE), has been described as a method for improving the outcome of advanced low rectal cancer, probably because of more pelvic dissection and less positive circumferential resection margin (CRM). However, ELAPE might result in a significantly increased rate of perineal wound complications, urinary and sexual dysfunction and chronic perineal pain. Several studies suggest that ELAPE is not associated with deterioration in quality of life when compared with conventional APR. Individual ELAPE has the potential to reduce the risk of chronic perineal pain and sexual dysfunction without influenced the radical effect. Biologic meshes using in perineal reconstruction significantly reduce the operative time, length of stay in hospital and the cost per patient. Laparoscopic or robotic assistance enables ELAPE with acceptable perioperative and pathological outcomes. Although several studies show no benefit for ELAPE regarding oncological outcomes, ELAPE is still a milestone operation based on accurate surgery principle.     

Amputación abdominoperineal extraelevadora en posición prono

The Miles operation is every day more in the limelight. The abdominoperineal escision compared to anterior resection results in increased rate of circumferential resection margin (CRM) infiltration, increased iatrogenic tumor perforation rate and poorer quality of the mesorectum. These worse results may be caused by excessive dissection between the distal mesorectum and the plane of the levator ani and the consequent “waist” or “cone” effect in the specimen. A wider excision of the pelvic floor muscles, known as extraelevator abdominoperineal escision (ELAPE), would provide a “cylindrical” specimen which would hypothetically reduce the risk of tumor perforation and CRM infiltration and local recurrence rate. However, there is insufficient evidence to conclude that the ELAPE is oncologically superior compared to standard abdominoperineal escision. Independently from the surgical technique adopted, another actual point of discussion is the position of the patient during the perineal part of the operation. The position on “prone” provides excellent pelvic exposure, a top-down dissection under direct vision and is very comfortable for the operating surgeons. However, there is no clear scientific evidence of the superiority of prone ELAPE over supine ELAPE in terms of oncologic results, morbidity and mortality. The laparoscopy seems to be the best surgical approach for the abdominal part of the operation, although it has not been validated so far by large prospective studies.Prospective, controlled and randomized trials are necessary to resolve all these issues. The current interest in a more accurate and standardized perineal surgery to obtain a cylindrical specimen, undoubtedly, will improve results.     

腹腔镜提肛肌外腹会阴联合切除术治疗低位直肠癌的临床应用

目的:探讨腹腔镜提肛肌外腹会阴联合切除术(laparoscopic extralevator abdominoperineal excision,LELAPE)治疗低位直肠癌的临床效果。方法:回顾分析2011年6月至2013年1月为15例低位直肠癌患者行LELAPE的临床资料。结果:手术均顺利完成,手术时间平均(258.8±52.1)min,术中出血量平均(130±48.4)ml,术中未发生医源性肠管穿孔,切除标本为"柱状",无"外科腰"。术后下床活动时间平均(35.1±12.5)h,肠功能恢复时间平均(60.6±24.5)h,会阴部引流管拔除时间平均(6.2±1.5)d,会阴部切口拆线时间平均(15.6±2.52)d,术后平均住院(12.1±3.4)d;术后未发生排尿障碍及勃起障碍;1例发生会阴部切口延迟愈合,1例发生不全肠梗阻,经对症治疗后痊愈出院。无死亡病例。患者均获随访,随访1～19个月,无复发及死亡病例。结论:LELAPE可降低标本环周切缘阳性率及术中标本穿孔率,改善预后,未增加并发症发生率及会阴部创伤,为术者提供了良好的手术视野。LELAPE治疗低位直肠癌是安全、可行、理想的术式。