经肛门内窥镜下微创外科技术治疗直肠肿瘤120例临床经验

目的评价经肛门内窥镜微创外科技术（TEM）治疗直肠宽基腺瘤和早期直肠癌的应用效果。方法分析评价2005年5月至2009年2月120例TEM手术的临床资料。结果本组患者肿瘤直径中位值2．5cm，肿瘤下缘距齿状线距离（8．4±3．2）cm，肿瘤侵犯直肠周径范围（32．3±18．5）％。平均手术时间（80±45）min。平均住院日5．2d。无围手术期死亡。手术并发症有直肠穿孔、创面裂开和短暂性大便失禁。病理示直肠腺瘤72例、直肠腺癌34例、直肠类癌12例、直肠间质瘤2例。34例腺癌中pTis9例，pT119例和pT26例。直肠癌术前腔内超声分期符合率为83．3％。平均随访21个月，有2例患者有局部复发。结论TEM手术创伤小、痛苦少、住院时间短、保留肛门括约肌；既可作为直肠宽基腺瘤和pT1期直肠癌的治愈性手术，也可作为pT2直肠癌的姑息性治疗手段。     

经肛门内镜显微手术治疗直肠绒毛状腺瘤和早期直肠癌31例

目的探讨经肛门内镜显微手术（transanal endoscopicmic rosurgery，TEM）治疗直肠绒毛状腺瘤和早期直肠癌的疗效。方法1995年11月～2003年12月，我院行TEM治疗直肠肿瘤31例。全麻下根据肿瘤位置选择合适的体位，经肛门插入特殊的手术直肠镜，保持CO2充气状态，在立体视镜和腔镜系统下，采用针形电刀或5mm超声刀将直肠肿瘤完整切除（黏膜下或全层切除），手术创口在腔内连续缝合。结果31例直肠肿瘤均获完整切除，切缘均阴性。手术时间45～220min，平均95min；术中出血量0～180ml，平均40ml。手术并发症：暂时性排气失控2例，急性尿潴留1例，慢性阻塞性气道疾病急性发作1例，因服用阿斯匹林而出现继发性出血1例。术后病理分期：pT0期16例，pTis期2例，pT1期7例，pT2和pT3期各3例。31例随访2～92个月，平均23个月，肿瘤无原位复发。结论TEM是治疗直肠绒毛状腺瘤和早期直肠癌的一种安全、有效的微创手术方法。     

经肛门内镜显微手术在直肠肿瘤局部切除术中的应用

目的初步评价经肛门内镜显微手术(transanalendoscopicmicrosurgery,TEM)在直肠肿瘤局部切除术中的应用。方法2006年4月至9月对8例直肠肿瘤患者采用TEM行局部切除术。术前根据直肠腔内超声肿瘤分期uT0期6例,uTis期和uT1期各1例。肿瘤距肛缘距离平均7(4~9)cm;肿瘤直径平均1.5(1~2.5)cm;肿瘤占据肠腔周径比例平均20%(10%~30%)。结果8例直肠肿瘤均获完整切除(粘膜下切除3例,全层切除5例),各切缘均阴性。手术时间平均50(40~60)min;术中平均出血量30(10~50)ml。术后住院天数平均5(2~7)d。无一例出现手术并发症。术后病理分期pT0期5例,pTis期、pT1期和pT2期各1例。8例术后随访平均3(1~5)个月,肿瘤无局部复发。结论TEM显露良好、切除精确,手术安全、创伤小,经严格选择病例可用于良性直肠肿瘤和早期直肠癌的彻底切除。     

经肛门内镜显微手术治疗直肠肿瘤12例

为探讨经肛门内镜显微手术（TEM）治疗直肠肿瘤的手术效果,回顾分析12例行TEM的直肠肿瘤患者资料。结果显示,12例直肠肿瘤均获完整切除,平均手术时间90min（60-200min）。无术后出血、吻合口感染、吻合口漏。2例术后肛门轻度疼痛,2例暂时性不完全性肛门失禁。术后病理示9例腺瘤（管状腺瘤3例,绒毛状腺瘤4例,管状绒毛状腺瘤2例,其中2例伴高级别上皮内瘤变）,1例肌层内有钙化灶,1例直肠黏膜炎性组织,1例低危间质瘤（直径〈1．0cm）。随访1～12个月,1例管状腺瘤患者于术后3个月局部复发。结果表明,TEM治疗良性直肠腺瘤和早期直肠癌安全、有效。     

经肛门内镜微创手术治疗直肠肿瘤(附74例报告)

目的:探讨经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)治疗直肠腺瘤和早期直肠癌的临床价值和安全性。方法:回顾性分析我院2011年1月至2014年1月74例直肠腺瘤和早期直肠癌病人行TEM的治疗情况并总结相关经验。结果:所有74例病人均成功施行TEM,术前均行肠镜活检和经直肠内镜超声检查。术后病理检查结果示:直肠腺瘤46例、直肠高级别上皮内瘤变10例、直肠神经内分泌瘤G1期5例、直肠癌13例。13例直肠癌病人中7例T0期,5例T1期,1例T2期。TEM时间(58.3±27.2)min,术中出血(10.4±5.6)m L,术后住院1~4 d,无严重并发症。1例T2期,1例T1期侵及黏膜下层外1/3,予以再入院行腹腔镜直肠癌前切除术。所有病人均得到随访,平均随访时间(15±8)个月,2例直肠绒毛状腺瘤病人术后复发,均通过再次TEM完整切除。所有早期直肠癌和直肠神经内分泌瘤病人术后随访均未发现肿瘤复发或转移。结论:TEM创伤小,病人恢复快,治疗直肠腺瘤和部分经过选择的早期直肠癌病人安全可靠。完善的术前评估和术后随访十分重要。     

直肠癌经肛门内镜显微手术疗效及复发危险因素分析

目的 分析直肠癌经肛门内镜显微手术（TEM）疗效及复发危险因素,以探讨直肠癌TEM适应证.方法 对2006年6月至2009年6月间山东省千佛山医院胃肠外科收治的60例行TEM的直肠癌患者的临床资料进行回顾性分析.结果 本组直肠癌pTis期12例,pT1期38例 pT2期10例.全部病灶均一次性全层整块切除,标本切缘均阴性.手术时间30～190（65.0±36.5）min,术中失血量9～75（10.5±5.8）ml,住院时间3～9（4.5±2.7）d,无手术死亡和严重并发症出现.随访时间12～48（平均28.5）个月,无一例死亡.pTis患者均未现复发 38例pT1期患者中1例（2.6%）出现局部复发 10例pT2期患者中有4例（40.0%）出现局部复发,显著高于pT1期患者（P＜0.05）.肿瘤直径大于3 cm的21例患者中有4例复发,显著高于肿瘤直径小于3 cm者（1/39,P＜0.05）.多因素复发危险因素分析证实,浸润深度和肿瘤大小是TEM术后复发的独立风险因素.结论 对pTis、pT1期及肿瘤小于3 cm的早期直肠癌患者,TEM安全有效,值得推广.     

经肛内镜微创外科治疗早期直肠癌的价值

目的:评价经肛内镜微创外科技术(transanal endoscopic microsurgery,TEM)治疗早期直肠癌的应用效果。方法:分析评价我院2005年5月至2009年5月所治疗的84例TEM手术的临床资料。结果:本研究84例病人的肿瘤直径中位值为2.1 cm,肿瘤下缘距齿状线平均距离(8.3±2.2)cm,肿瘤侵犯直肠周径范围(33.2±17.5)%。平均手术时间(70±43)min。平均住院日期6.8 d。无一例病人发生围手术期死亡,术后部分病人有短暂性大便失禁。所有病人的肿瘤切缘皆无瘤细胞残留。术后病理证实,85例中pT060例,pT119例,pT25例。直肠癌术前腔内超声分期符合率达86.9%。平均随访26个月,2例病人出现局部复发。结论:TEM手术创伤小、保留肛门括约肌、缩短住院时间;既可作为直肠宽基腺瘤和pT1期直肠癌的根治性手术,也可作为pT2直肠癌的姑息性治疗手段。     

腔内超声与螺旋CT对直肠癌术前分期的对比研究

目的比较腔内超声（EUS）和螺旋CT（SCT）对直肠癌术前分期的诊断价值。方法对68例直肠癌患者术前行EUS和SCT检查，将检查结果与手术及病理结果对比；同时比较EUS和SCT对诊断直肠肿瘤浸润深度、区域淋巴结转移的准确性。结果判断T分期，EUS准确率为86．8％（59／68），SCT准确率为70．6％（48／68），两者比较差异有统计学意义（P〈0．05）。评价N分期，EUS的准确率为67．6％（46／68），SCT的准确率为63．2％（43／68），两者比较差异无统计学意义（P〉0．05）。结论EUS对判断直肠肿瘤浸润深度优于SCT，但两者对淋巴结转移的判断均存在一定的局限性。     

经肛门内镜微创手术治疗32例直肠腺瘤

目的 评估经肛门内镜微创手术（TEM）治疗直肠腺瘤临床应用的安全性及疗效.方法 2006年9月至2010年2月共32例术前诊断为直肠腺瘤的患者接受TEM治疗,总结其治疗结果.结果 全组患者肿瘤直径0.6～10.0（2.31.2）cm.手术时间为20～180（平均70）min,术中平均出血量小于10 ml,无中转开腹手术.22例（68.8%）行创面缝合,其中全层切除14例;有2例上段直肠肿瘤行全层切除时切穿至腹膜腔,予腔内连续缝合修补破损,术后均未发生肠漏.R0切除31例（96.9%）.术后病理示单纯腺瘤12例;腺瘤伴低级别上皮内瘤变10例;腺瘤伴高级别上皮内瘤变5例;腺瘤局灶癌变5例,均为T1期.术后并发肛门出血、急性尿潴留和肺部感染各1例.术后平均住院时间为4.5（3～8）d;平均随访23（2～43）个月,2例出现复发.结论 TEM手术创伤小、切除精确,是一种对直肠较大腺瘤安全有效的微创手术方法.     

经肛门内窥镜下微创治疗直肠肿瘤40例初步经验

目的 评价经肛门内窥镜微创外科技术(TEM)治疗直肠宽基腺瘤和早期直肠癌临床效果.方法 分析2005年5月至2007年4月40例TEM手术的临床效果,结果 40例肿瘤直径中位值2.3 cm,肿瘤下缘距齿状线距离为(8.2±3.2)cm,肿瘤侵犯直肠周径范围为(32.3±18.5)%.平均手术时间为(90±43)min.平均住院4.8 d.无围手术期死亡.切缘瘤细胞均为阴性.病理示直肠绒毛状腺瘤24例、直肠腺癌10例、直肠类癌6例,10例腺癌中pTis2例,PT16例和pT22例.平均随访11个月,所有病例无局部复发.结论 TEM手术创伤小、保留肛门括约肌、缩短住院时间;既可作为直肠宽基腺瘤和pT1期直肠癌的治愈性手术,也可作为pT2直肠癌的姑息性治疗手段.     

Local excision of rectal tumours by transanal endoscopic microsurgery

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM. METHODS: Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm. RESULTS: Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively. CONCLUSION: TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.     

Cost analysis of transanal endoscopic microsurgery for rectal tumours

OBJECTIVE: Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits. METHOD: We reviewed our prospective database of patients undergoing TEM excision of a rectal lesion between July 1997 and December 2003. A cost analysis was undertaken, including procedural and related costs of TEM and compared with the relevant open procedures. RESULTS: 124 patients (80 men, 44 women) with a median age of 71.5 years underwent TEM excision of rectal lesions (52 cancers and 72 adenomas). The morbidity rate was 8% and mortality was zero. A controlled case series of 52 patients undergoing open resection for early rectal cancers with similar characteristics as above was compared in terms of clinical outcome. The morbidity rate in these patients was 29.5%. The cost analysis comparison was undertaken using National Health Service mean reference costs for major large intestinal surgery, Intensive care unit/high dependency unit and hospital accommodation for each procedure. The average cost of open resection was 4135 pound, vs 567 pound for TEM excision. Our total saving over the series was 525,576 pound. Although the initial capital cost of the TEM equipment is high at approximately 40,000 pound given the massive cost savings, these initial equipment costs are recovered within a rapid time frame. CONCLUSION: This study has shown that TEM is a safe and extremely cost-effective approach for excision of selected rectal tumours including rectal adenomas and early well differentiated rectal cancers (pTis & pT1).     

The role of colonoscopic endoanal ultrasound scanning (EUS) in selecting patients suitable for resection by transanal endoscopic microsurgery (TEM)

OBJECTIVE: This study was performed to assess the accuracy of colonoscopic endoanal ultrasound scanning (EUS) in the selection of patients with rectal neoplasia suitable for local excision by transanal endoscopic microsurgery (TEM). Our policy is to offer TEM to patients with premalignant (T0) lesions or with T1 tumours that have early disease. PATIENTS AND METHODS: Data were collected prospectively on all patients undergoing EUS for the assessment of rectal neoplasia at our institution over a six-year period. A colonoscopic EUS probe was used to determine whether the tumour breached the muscularis propria (the interface between T1 and T2 disease). Subsequently patients underwent surgical resection, including TEM for those with T0/1 disease. The preoperative stage predicted by EUS (uT stage) was compared to the postoperative histopathological stage of the resected specimens (pT stage). RESULTS: One hundred and fifty-six EUS examinations were evaluated. Sixty-two patients went on to have TEM whilst the remaining 94 had another form of surgery. Of the 62 patients undergoing TEM, 3 were overstaged on EUS. No patients were understaged, giving an accuracy of 95%. Of the 94 patients undergoing an alternative procedure, 5 were overstaged on EUS as having T2 tumours when in fact their histology was T1. Accuracy of EUS at predicting more advanced disease fell to 89%, giving an overall accuracy of 92%. CONCLUSIONS: EUS is accurate at predicting T0/1 vs T2 disease in our institution, and we believe that it is a useful modality in assessing patient suitability for local excision.     

Preoperative staging of patients with rectal tumors suitable for transanal endoscopic microsurgery (TEM): comparison of endorectal ultrasound and histopathologic findings

Background  Accurate preoperative staging is the key to correct selection of rectal tumors for local excision. This study aims to assess the accuracy of endorectal ultrasound (ERUS) at our institution. Patients and methods  Retrospective analysis was carried out of patients treated by transanal endoscopic microsurgery (TEM) from 1996 to 2008. TEM was considered the treatment of choice for uT0-1/N0 lesions located between 2 and 12 cm from the anal verge. It was also proposed in selected uT2-3 patients. Preoperative staging was compared with histopathologic findings. Results  Eighty-one patients (46 males, mean age 66 years) underwent TEM. Mean distance of the tumor from the anal verge was 6.6 cm (range 2–12 cm). ERUS staged 15 of 27 adenomas (55%) as uT1. Of 54 carcinomas, 5 were pT0 because TEM was performed to remove resection margins of a malign polyp already snared. Five of 19 pTis (26%) were overstaged uT1, while 7 of 17 pT1 (41%) were understaged. Overall, ERUS enabled distinction between early and advanced rectal lesion with 96% sensitivity and 85% specificity, giving accuracy of 94% (65/67). Thirteen patients had advanced lesions (eight pT2 and five pT3). Only in two of them (15%) was depth of invasion underestimated by ERUS (one uT0, one uT1) and thus was subsequent salvage surgery necessary. Conclusions  ERUS is useful to confirm the diagnosis of adenoma and predict depth of mural invasion in early rectal cancer. Differentiation between T0/is and T1 lesions remains challenging, however this does not usually influence surgical strategy.     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

探讨经肛门内镜显微手术(TEM)在治疗局限性直肠肿瘤中的应用效果.方法 总结分析2006年4月至2008年12月接受TEM的75例直肠肿瘤患者的临床资料,分析TEM在直肠肿瘤治疗中的应用效果.结果 患者病灶平均直径为(1.6±0.8)cm(0.5～5.0 cm).病灶距肛缘平均(7.6±2.8)cm(5～20 cm).病灶在直肠内的部位:前壁25例,后壁24例,左侧壁14例,右侧壁12例.手术方式包括:肠壁全层切除64例,黏膜下及肌层部分切除11例.平均手术时间(73.7±32.1)min(30～180 min),术中平均失血(9.8±7.7)ml(3～50 ml).术后病理检查:直肠腺瘤28例,直肠腺瘤癌变和直肠癌25例(其中Tis期14例,T1期5例,T2期6例),直肠类癌7例,炎性息肉等15例.所有标本切缘均为阴性.全组术后4例(5.3%)发生并发症,其中并发肛门出血2例,肺部和泌尿系感染各1例.术后平均住院(3.4±1.2)d(2～7 d).术后平均随访8.4个月(3～26个月),未发现疾病或肿瘤有复发转移.结论 TEM治疗直肠肿瘤具有手术损伤小,出血少、疗效好、恢复快等优点,是目前直肠肿瘤局部切除的较佳方法.     

经肛门微创外科手术在直肠癌的临床应用

相对于直肠癌根治术而言,直肠癌局部切除术具有手术创伤小、风险低、能保肛以及术后无性功能和泌尿功能障碍等优点。经肛门内镜微创手术（TEM）是近年来国际上较为盛行的一种直肠癌局部切除技术．同传统的局部切除术相比．TEM具有优良的术野显露和宽敞的操作空间,更配有制造精良、性能优越的多种手术器械,为外科医师在术中精细的组织解剖、精准的肿瘤切除、降低和避免肿瘤切缘不足或切缘阳性提供了极佳的手术条件和技术上的保障。术前准确评估、仔细遴选病例以及严格掌握手术指征是获得良好疗效的基础。TEM最佳的适应证为直肠腺瘤高级别瘤变（Tis期）、T1期中低危组直肠癌以及癌仅侵及sm1和sin2的患者。经过新辅助治疗后降期明显（肿块缩小大于50％者）的T,期和L期直肠癌也可进入TEM的研究性治疗。TEM术中对病灶行局部根治性切除是预防肿瘤术后复发的关键。     

经肛手套通路联合结肠镜微创手术治疗直肠肿瘤

目的：探讨经肛手套通路联合结肠镜微创手术治疗直肠肿瘤的可行性及疗效。方法杭州市第三人民医院肛肠外科自2012年10月至2013年3月,选择经评估适合行局部切除的直肠肿瘤患者8例,使用经肛手套通路联合结肠镜微创手术治疗。经肛手套通路的建立：将手套袖口连同扩肛器缝合固定于肛周,再将手套5指经由透明肛门镜翻转出肛门,将超声刀、无损伤肠钳和肠镜镜头分别从3个指套伸入并结扎固定。结果8例患者均成功完成肿瘤切除手术,制作手套入路装置平均耗时12．5（10．0～15．0） min,平均手术时间55．6（30．0～110．0） min,平均住院时间为5．0（3．0～8．0） d,术后病理提示绒毛状腺瘤3例,管状腺瘤2瘤,管状绒毛状腺瘤2例,锯齿状腺瘤1例,其中2例伴低级别上皮内瘤变,1例高级别上皮内瘤变,所有肿瘤组织标本边缘及基底部均为阴性。术后2例患者少量便血,随访1～5（中位3．1）月,无肿瘤复发。结论采用经肛手套通路联合结肠镜微创手术治疗直肠早期肿瘤具有简单和安全的特点,具有一定的应用价值。     

Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision

Anterior resection and abdomino-perineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. Local recurrence rates of 10% to 14% are described after these conventional procedures. Preoperative neoadjuvant radiotherapy reduces local failure. Because local excision techniques can be applied to treat early rectal cancer in selected patients, we evaluated the results of preoperative high-dose radiotherapy and transanal endoscopic microsurgical excision (TEM) in patients with T2 rectal cancer. All patients underwent preoperative irradiation with 5,040 cGy, divided over 5 weeks. Forty days after completion of radiotherapy, the patients underwent complete full-thickness local excision of the rectal lesion including adjacent perirectal fat by TEM. The patients were followed for up to 8 years. Thirty-five patients, with pT2 rectal cancer as determined by pathological examination of the surgical specimen were enrolled in the present study. The tumors were responsive to preoperative radiotherapy in 82.8% of cases. No intraoperative complications and no conversion to open surgery were observed. No major complications and no mortality occurred during the 60-day postoperative period. Minor postoperative complications were observed in 5 patients (14.3%). The median follow-up of the patients was 38 months (range 24 to 96 months). One local recurrence (2.85%) was noted. The probability of surviving at 96 months after completion of treatment was 83%. Local excision by TEM combined with preoperative high-dose radiotherapy can achieve results similar to those observed after conventional surgery in patients with pT2 rectal cancer.