全直肠系膜切除加双吻合器法在低位直肠癌保肛根治手术中的应用（附65例分析）

目的：总结全直肠系膜切除（TME）加双吻合器（DST）在低位直肠癌保肛手术应用中的经验。方法：对我院2000-2010年间65例直肠癌应用全直肠系膜切除加双吻合器法行低位直肠癌保肛根治术的临床及随访资料进行回顾性分析。结果：术后发生吻合口瘘2例,吻合口狭窄3例,局部复发7例,性功能障碍1例,无大便失禁及排尿困难。结论：全直肠系膜切除加双吻合器应用可有效保护盆腔脏器的功能,使一部分超低位直肠癌保肛成为可能,适于在低位直肠癌中应用。     

双吻合器在低位直肠癌保肛手术中的应用

目的　评价双吻合器吻合技术在低位直肠癌保肛手术中的应用。方法　回顾性分析采用该技术行低位直肠癌保肛手术 5 6例的经验。结果　 5 6例吻合器切除圈完整。无吻合口漏、吻合口出血发生 ,无手术死亡。吻合口狭窄 1例 (1% ) ,神经性膀胱排空障碍 2例 (3% ) ,切口感染 2例 (3% )。结论　双吻合器吻合技术可以完成既往手法缝合无法完成的低位结肠直肠吻合术 ,是低位直肠癌保肛手术的理想术式。     

全直肠系膜切除联合双器械吻合在低位直肠癌保肛术中的应用

 目的　探讨双器械吻合技术联合全直肠系膜切除在低位直肠癌保肛手术中的应用方法和临床疗效。方法　在全直肠系膜切除的基础上，应用双器械吻合技术对97例低位直肠癌患者行低位吻合，随访最短6个月，最长3年，回顾性分析其根治性、术后排便功能、手术并发症、局部复发率。结果　97例均无切端癌残留，无大便失禁，无吻合口瘘；全组无手术死亡；肿瘤局部复发率6.2 %（6／97）。结论　在全直肠系膜切除基础上，利用双器械吻合技术行低位直肠癌保肛手术是保持排便功能，减少并发症，减少局部复发，提高生活质量的有效方法。     

直肠全系膜切除联合双吻合器在低位直肠癌保肛术中的应用(附32例报告)

目的评估直肠全系膜切除(TME)联合双吻合器在低位直肠癌保肛术中应用的安全性和实用性。方法回顾总结2006年5月至2010年5月32例低位直肠癌保肛术应用TME联合双吻合器的临床资料。结果所有患者吻合器切除圈完整。术后吻合口瘘2例(2/32,6.3%),神经性膀胱排空障碍2例(2/32,6.3%),切口感染3例(3/32,9.3%),吻合口出血1例(1/32,3.1%)。20例患者随访3～5年,3例肠粘连,1例吻合口狭窄,1例吻合口出血,1例因肿瘤转移死亡。结论 TME联合双吻合器在低位直肠癌保肛术中的应用安全可靠。     

双吻合器技术在83例直肠癌保肛手术中的应用

目的评估双吻合器吻合法在直肠癌保肛手术应用中的安全性。方法回顾总结5年中采用该技术行直肠癌手术83例。结果所有患者吻合器切除圈完整。吻合口瘘3例,肿瘤距肛缘小于6.5cm时,吻合口瘘发生率增高。结论双吻合器吻合法可作为低位直肠癌保肛手术的一种安全可靠的术式选择。     

双吻合器在低位直肠癌保肛手术中的应用

目的：评价双吻合器吻合技术在低位直肠癌保肛手术中的应用。方法：回顾性分析采用该技术行低位直肠癌保肛手术56例的经验。结果：56例吻合器切除圈定整。无吻合口漏、吻合口出前发生，无手术死亡。吻合口狭窄1例（1％），神经性膀胱排空障碍2例（3％），切口感染2例（3％）。结论：双吻合器吻合技术可以完成既往手法缝合无法完成的低位结肠直肠吻合术，最低位直肠癌保肛手术的理想术式。     

老年低位直肠癌患者行全直肠系膜切除保肛术后吻合口瘘的防治

目的探讨老年低位直肠癌患者行全直肠系膜切除(TME)保肛术后吻合口瘘的预防和治疗。方法回顾分析42例按TME原则行低位直肠癌保肛术的老年患者(>60岁)的临床资料。结果 42例中,发生吻合口瘘3例,占7.1%(3/42),其中吻合器吻合术后发生吻合口瘘1例,经肛门结肠肛管吻合术后发生吻合口瘘2例。3例吻合口瘘保守治疗1例,结肠造口2例,均痊愈。结论重视术前准备、保证吻合口的良好血供及恰当使用吻合器可有效预防老年低位直肠癌患者保肛术后吻合口瘘的发生,若发生吻合口瘘,应视具体病情采用个体化治疗。     

单吻合器在直肠癌超低位前切除术中的应用

目的:探讨单吻合器在直肠癌超低位前切除术(ULAR)中的临床应用效果。方法:对44例单吻合器直肠癌超低位吻合术的临床资料进行回顾性分析。结果:所有病例均顺利接受手术,吻合口距肛缘位置为2.5～4cm,术后肛门控便功能良好,吻合口漏2例(4.5%),无吻合口出血及狭窄,局部复发3例(6.8%),1、3年生存率分别为97.44%、79.48%。结论:单吻合器同样可以完成直肠癌超低位吻合术,且手术效果及肛门功能良好,费用较低。熟练、正确地掌握单吻合器技术操作及提高全直肠系膜切除的手术技巧是手术成败的关键。     

单吻合器技术71例直肠癌保肛术应用分析

[目的]评价单吻合器技术在直肠癌保肛术中的作用。[方法]回顾性分析2004年5月至2010年2月在全直肠系膜切除理论指导下采用单吻合器技术对71例直肠癌患者施行保肛手术的临床资料。[结果]71例手术顺利,全组无手术死亡,无吻合口出血,切缘无肿瘤残留,吻合口瘘2例（2.8%）,吻合口狭窄1例（1.4%）。随访6～58个月,局部复发1例,远处转移2例。[结论]单吻合器技术在直肠癌保肛术中的应用安全、实用。     

中低位直肠癌全系膜切除机械内吻合术的应用

目的探讨对中低位直肠癌行全直肠系膜切除并应用单钉机械吻合术行结肠-直肠行低位吻合的疗效.方法对32例中低位直肠癌实施TME原则的根治性手术,应用可重复的单钉吻合器行低位结肠-直肠端端吻合术.结果 32例均能完整切除直肠系膜,吻合口距齿状线2～5 cm者21例,2 cm以内者11例.术后1例吻合口瘘,改行Mile术后治愈.术后患者肛门括约肌功能、排尿功能良好.结论 TME术式应用可重复单钉机械吻合保肛吻合可靠,操作简单,费用少,符合肛门生理.     

直肠癌全系膜切除术后吻合口瘘原因分析及防治措施

目的：分析直肠癌全直肠系膜切除术后发生吻合口瘘的原因及防治措施.方法：回顾性分析自2003年1月至2007年12月在我院行全直肠系膜切除保肛手术的214例中低位直肠癌患者的临床资料.结果：214例患者术后共发生吻合口瘘16例（7.5％）.发生时间为术后4-15d,平均（6.8±1.4）d.其中性别、肿瘤Dukes分期、病理类型及有无结肠储袋等对术后吻合口瘘的发生率没有显著影响,差异无统计学意义（P＞0.05）.而年龄、术前有无贫血及低蛋白血症、糖尿病史、有无合并肠梗阻、手术方式、吻合器应用、吻合器吻合后手工缝合减张及术后直肠留置肛管引流减压对术后吻合口瘘的发生率均有明显影响（P＜0.05）.4例严重吻合口瘘的患者并发弥漫性腹膜炎行横结肠造瘘术,术后4个月成功闭瘘.12例较轻的吻合口瘘患者采用单纯完全静脉营养、抗生素治疗、经引流管局部冲洗等措施全部治愈,愈合时间为14d至3个月,平均（28.7±2.3）d.术后无死亡患者.结论：高龄、贫血、低蛋白血症、合并糖尿病及肠梗阻、低位吻合口等是术后发生吻合口瘘的高危因素.吻合器吻合后手工缝合加固减张,术后直肠内留置肛管减压引流可显著减少吻合口瘘的发生.积极合理的采取非手术或手术措施治疗吻合口瘘是促进吻合口愈合的关键.     

A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study

BACKGROUND: In many patients with rectal cancer, defunctioning stomas are created to limit the consequences of anastomotic leakage. Although intended to be temporary, a substantial proportion of these stomas might never be reversed for various reasons. We aimed to describe stoma policy by use of data from the total mesorectal excision (TME) trial in patients with rectal cancer and to identify factors that limit stoma reversal. METHODS: 924 Dutch patients with rectal cancer who underwent a low anterior resection were selected from the TME trial, a prospective, randomised multicentre trial studying the effects of short-term preoperative radiotherapy in 1861 patients who underwent TME. Creation of stomas and time to stoma reversal were analysed retrospectively by use of multivariate analysis. FINDINGS: In 523 of 924 (57%) patients, a primary stoma (defined as a stoma created at the time of TME) was constructed after a low anterior resection. Geographical differences in the number of primary stomas constructed were reported throughout the Netherlands. 19% of stomas that were created were never reversed. Postoperative complications and secondary constructed stomas (defined as a stoma created during a second or subsequent procedure after TME) were associated with a high likelihood of a permanent stoma. However, perioperative complications were not a limiting factor for stoma closure. INTERPRETATION: Postoperative complications are an important limiting factor for stoma reversal because, after occurrence of these complications, patients and surgeons might be reluctant to reverse the stoma, so a substantial proportion of these stomas are never closed. Future guidelines for stoma creation and closure should consider these factors.     

低位/超低位直肠癌行腹腔镜下经肛拖出式全直肠系膜切除联合应用双吻合器的临床意义

  目的  探讨低位/超低位直肠癌患者接受腹腔镜下经肛门拖出全直肠系膜切除结合双吻合器手术的临床意义。  方法  选择于2010年1月至2012年11月间就诊于吉林大学第二医院普通外科疾病诊疗中心的46例低位/超低位直肠癌患者, 施行腹腔镜经肛门拖出全直肠系膜切除结合应用双吻合器手术。回顾性分析手术成功率、术后并发症及远期治疗效果。  结果  46例手术均获成功, 无中转开腹, 手术时间平均167 min, 出血量平均42 mL。术后切缘病理检查均未见癌细胞, 无手术死亡病例, 无吻合口瘘及输尿管损伤等严重并发症, 平均随访12.6个月, 无局部或吻合口复发、戳卡种植转移。  结论  施行低位/超低位直肠癌腹腔镜辅助下经肛门拖出全直肠系膜切除结合应用双吻合器具有安全可行的优点, 并且能够保证足够的肿瘤远端切缘。      

直肠癌根治术中双吻合器的应用分析

:[目的]介绍和评价双吻合器在直肠癌低位前切除术中的应用。[方法]对90例直肠癌根治术中行双吻合器吻合的病例进行回顾性分析。[结果]行传统根治术75例 ,扩大根治术7例 ,直肠全系膜切除术(TME)者8例 ,吻合过程顺利。术后切口感染3例(3.33 %) ,吻合口狭窄5例(5.56 %) ,吻合口瘘3例(3.33%)。无手术死亡病例。术后吻合口复发2例 ,腹腔淋巴结转移3例 ,随访期间肝转移5例。全部病例中83例获得随访 ,5年生存率58.6%。[结论]双吻合器应用于直肠癌前切除术中的结直肠吻合具有操作简单 ,节约手术时间和安全等优点 ,并可适当提高低位直肠癌保肛率。     

Results after change of treatment policy for rectal cancer--report from a single hospital in China.

BACKGROUND: Great changes have occurred in the management of rectal cancer. This study presents the outcome of total mesorectal excision (TME) for rectal cancer in a single Chinese institution and evaluates TME's role in the comprehensive management of rectal cancer. METHODS: We reviewed the data of rectal cancer patients surgically treated by three colorectal surgeons from January 2000 to August 2004. Patients who received surgical resection for rectal cancer from January 1996 to December 1999, before the introduction of TME, were chosen as controls. Data regarding characteristics of patients and tumors, surgical procedures, postoperative complications, and results of follow-up were collected for analysis. RESULTS: Three hundred and seventy-seven patients with rectal cancer were enrolled in our study, with 175 patients in the TME group and 202 as controls. Mortality and morbidity rates were 1% and 14% in TME patients and 1% and 31% in controls, respectively. The TME group had a shorter operation time and hospital stay, and less bleeding, wound and urinary complications. The local recurrence (LR) rate was 6% and 12% in the TME and the control groups, respectively (P<0.05). With a median follow-up of 35 months, the actuarial 5-year survival rate was 66%. Consistent with the univariate analysis result, multivariate analysis demonstrated that TNM stage, tumor grade, age, and surgeons were independent prognostic factors. TME was not an independent prognostic factor for patients' survival. CONCLUSIONS: TME is a safe and efficient option in reducing LR. However, it is not an independent predictor for patients' survival. In addition to the standardized usage of TME, further knowledge on the molecular mechanism of cancer is needed.     

Risk Assessment on Anastomotic Leakage after Rectal Cancer Surgery: An Analysis of 753 Patients

Purpose: To investigate the risk factors for anastomotic leakage (AL) after anterior resection for rectalcancer with a double stapling technique. Patients and Methods: Between January 2004 and December 2011,753 consecutive patients in Jiangsu Cancer Hospital and Research Institute diagnosed with rectal cancer andundergoing anterior resection with a double stapling technique were recruited. All patients experienced atotal mesorectal excision (TME) operation. Additionally, decrease of postoperative tumor supplied group offactors (TSGF), which have not been reported before, was proposed as a new indicator for AL. Univariate andmultivariate analysis were performed to determine risk factors for AL. Results: AL was detected in 57 (7.6%) of753 patients with rectal cancer. The diagnosis of anastomotic leakage was confirmed between the 6th and 12thpostoperative day (POD; mean 8th POD). After univariate analysis and multivariate analysis, age (p<0.001),gender (p=0.002), level of anastomosis (p < 0.001), preoperative body mass index (BMI) (p = 0.001) and reductionof TSGF in 5th POD was less than 10 m/ml (p < 0.001) were selected as 5 independent risk factors for AL. It wasalso indicated that a temporary defunctioning transverse ileostomy (p = 0.04) would decrease the occurrence ofAL. Conclusion: AL after anterior resection for rectal carcinoma is related to elderly status, low level site of thetumor (below the peritoneal reflection), being male, preoperative BMI and the decrease of TSGF in 5th POD isless than 10 m/ml. Preventive ileostomy is advisable after TME for low rectal tumors to prevent AL.     

Surgical outcomes after total mesorectal excision for rectal cancer

BACKGROUND AND OBJECTIVES: This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer. METHODS: Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures. RESULTS: The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012). CONCLUSIONS: With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.     

腹腔镜辅助直肠外翻低位直肠癌前切除27例

  目的  遵循直肠癌全直肠系膜切除(Total Mesoreetal Exeision, TME)原则的前提下, 探讨应用腹腔镜辅助直肠外翻技术完成低位直肠癌骶前切除及吻合的新方法。  方法  选择性地对2007年6月到2009年7月间收治的27例低位及超低位直肠癌患者实施腹腔镜辅助直肠癌根治术, 术中将远端直肠经肛门外翻来确定肿瘤远端切缘, 完成低位保肛术。  结果  所有27例患者手术顺利, 切缘病检阴性, 术后恢复顺利, 无吻合口漏, 随访6~31个月, 26例无瘤生存。  结论  将直肠肿物经肛门外翻确定肿瘤远端切割线的方法可以弥补腹腔镜下术者手感不足的缺点, 能够准确地确定直肠远端安全切缘, 同时还可以节省手术费用, 让更多的患者受益于腹腔镜直肠癌手术。