直肠癌全直肠系膜切除术的若干问题探讨

83例直肠癌患者在根治术中行全直肠系膜切除术（TME）和盆腔自主神经保留术（PANP），观察其疗效并了解术后泌尿和生殖功能情况。术后随访5～38个月。术后肿瘤发生盆腔内局部复发3例，肝转移2例。其中1例行肝转移瘤手术切除，1例行肝动脉介入栓塞。认为直肠癌术中行TME能有效预防和降低直肠癌术后的局部复发率；如同时行PANP，可以改善患者术后的排尿功能与性功能，提高患者的术后生存质量。TME有术后的吻合口瘘发生率增高和直肠、肛门丧失储便功能之弊。     

经肛门全直肠系膜切除术中自制气压平衡装置的使用体会

目的总结在经肛门全直肠系膜切除术中使用自制通气装置的体会。 方法在2016年11月至2017年4月完成的5例经肛门全直肠系膜切除手术中,当与腹腔贯通时使用自制的通气装置维持腹腔压力平衡,并分析5例患者的临床资料。 结果5例患者均顺利完成手术,无中转开腹,平均手术时间（206.0±9.5）min,其中1例在完全TaTME下完成,术中平均出血量（64.0±27.3）mL,切除肠管长度平均（17.4±1.3）cm,淋巴结清扫数目平均（16.8±1.2）枚,下切缘距肿瘤长度平均（2.5±0.3）cm,均符合全直肠系膜切除标准。术后肛门或造口排气时间（21.8±4.9）h,恢复进食时间（11.2±2.6）h,术后住院时间（5.2±0.7）d。未出现术后腹腔出血、肠瘘、腹腔感染或肠梗阻等并发症。 结论在经肛门全直肠系膜切除术中使用自制通气装置可获得稳定的操作空间和视野,有利于手术操作,效果切确。     

腹腔镜TME联合ISR对低位直肠癌的疗效及对患者控便功能的影响

目的探讨腹腔镜下全直肠系膜切除术（TME）联合经肛门内括约肌间切除术（ISR）对低位直肠癌的治疗效果及肛门控便功能的影响。 方法选取宜昌市第二人民医院手术治疗的低位直肠癌患者159例,收集时间为2014年1月至2017年1月,根据手术方式不同分为腹腔镜组69例（腹腔镜下TME＋ISR手术）、开腹组90例（采用传统开腹手术实施TME＋ISR手术治疗）,对比两组的手术相关指标及术后肛门控便功能。 结果腹腔镜组的手术时间、清扫淋巴结数目与开腹组比较差异均无统计学意义（t=1.209,1.585;P<0.05）;腹腔镜组患者的手术出血量、肛门排气时间及住院时间均小于开腹组,差异均有统计学意义（t=13.834,5.930,6.556;P<0.05）;腹腔镜组术后肛门控便功能显著的优于开腹组,差异具有统计学意义（Z=-2.183,P=0.029）;术前,两组患者的肛管收缩压（t=1.381,P=0.397）、肛管最大收缩时间（t=1.047,P=0.297）及肛管静息压（t=0.483,P=0.495）差异均无统计学意义;术后3个月,腹腔镜组患者的肛管收缩压、肛管最大收缩时间及肛管静息压显著高于开腹组,差异均有统计学意义（t=3.571,5.188,3.448;P<0.05）。腹腔镜组患者手术并发症率为7.25%,显著低于开腹组患者的17.78%（χ²=4.003,P=0.045）。 结论腹腔镜下TME联合ISR对低位直肠癌的治疗效果良好,并且具有创伤小、术后患者肛门功能恢复好的优点。     

腹腔镜直肠癌经肛门全直肠系膜切除术与传统腹腔镜术式疗效对比

目的研究腹腔镜直肠癌经肛门全直肠系膜切除术(TaTME)与传统腹腔镜术式的疗效。方法纳入2014年5月至2016年5月本院80例直肠癌患者作为研究对象,随机抽签分为观察组和对照组,每组各40例。观察组行腹腔镜直肠癌TaTME,对照组行传统腹腔镜直肠癌根治术。比较两组患者围术期指标、术后肛门功能及近期生存情况。结果观察组术中出血量、术后肛门首次排气时间、首次下床活动时间及术后住院时间均显著低于对照组,差异均有统计学意义(P 0. 05)。观察组术后1年无失访病例,死亡4例,总生存36例,无进展生存34例,对照组术后1例失访,死亡5例,总生存34例,无进展生存32例,两组总生存率和无进展生存率差异均无统计学意义(P 0. 05)。两组术后并发症发生率差异无统计学意义(P 0. 05)。观察组术后1个月时肛门功能恢复效果显著优于对照组,差异有统计学意义(P0. 05),术后3个月时和术后1年时两组间肛门功能恢复效果差异无统计学意义(P 0. 05)。结论腹腔镜TaTME与传统腹腔镜根治术治疗直肠癌短期生存预后相似,但TaTM E有助于术后肛门功能的早期恢复。     

老年中低位直肠癌患者手助腹腔镜与开腹直肠癌根治术的疗效比较

目的探讨手助腹腔镜全直肠系膜切除术在老年中低位直肠癌患者治疗中的疗效。方法 2012年6月至2013年12月行手助腹腔镜及开腹全直肠系膜切除术治疗的老年中低位直肠癌患者80例,应用手助腹腔镜下全直肠系膜切除术治疗41例(腹腔镜组),常规开腹全直肠系膜切除术治疗39例(开腹组);对两组患者的手术学指标进行统计分析与评价。结果两组患者均顺利完成保肛手术,且无术中死亡病例,腹腔镜组无中转开腹者。腹腔镜组患者术中出血量及术后排气时间均少于开腹组(P0.05),而手术时间、淋巴结清扫个数及术后并发症比较无明显差异(P0.05)。结论手助腹腔镜全直肠系膜切除术可以达到与传统开腹全直肠系膜切除术相同的疗效,相比传统开腹及全腹腔镜直肠癌根治术,手助腹腔镜直肠癌根治术在一定程度上更适合老年患者。     

腹腔镜辅助经肛全直肠系膜切除术后患者低位前切除综合征的发生率及影响因素的Meta分析

目的 系统评价腹腔镜辅助经肛全直肠系膜切除术(transanal total mesorectal excision, taTME)后患者低位前切除综合征(low anterior resection syndrome, LARS)的发生率及影响因素。方法 计算机检索PubMed、Cochrane Library、EmBase、Ovid、EBSCO、Web of Science、中国知网、万方数据库、中国生物医学文献数据库(CBM)、维普数据库等，检索时间为建库至2021年10月。采用RevMan 5.3软件和Stata 12.0分别进行影响因素和发生率的分析。结果 本研究最终纳入文献11篇，共730例患者。结果显示，腹腔镜辅助taTME后患者LARS发生率较高，术后12个月最高。腹腔镜辅助taTME后3个月患者LARS发生率为69.8%(P<0.001),术后6～9个月发生率为62.3%(P<0.001),术后12个月发生率为73.8%(P<0.001)。术后6个月轻度LARS发生率为22.5%(P<0.001),重度LARS发生率为45.5%(P<0....     

经肛全直肠系膜切除术结构化培训后学员学习效果的评价分析

目的通过分析接受经肛全直肠系膜切除术（taTME）结构化培训后学员所开展的临床工作,探讨结构化培训的效果及意义。 方法采用回顾性研究分析,统计分析自培训后开展的20例taTME手术的相关手术指标,术后并发症情况以及主观熟练度评价。 结果将20例患者根据时间先后进行分组比较,分为前10例（A组）和后10例（B组）。在手术出血量、是否行预防性造口、吻合口漏的发生上差异无统计学意义;在手术时间上,总手术时间两组比较差异无统计学意义,会阴部手术时间（t=2.557,P=0.05）和经肛平台摆放时间（t=4.575,P<0.01）上B组患者明显少于A组。吻合方式上后期B组手工吻合的患者要远多于前期A组的患者;手术者对于两组患者前列腺或阴道后壁辨认情况、荷包缝合情况的评价指标差异无统计学意义,但在对吻合口质量的评价上差异有统计学意义（t=8.667,P<0.05）。 结论在开展taTME手术前,通过结构化培训这种合理的教学方式,可使临床医生深入掌握盆底肛周的解剖结构,缩短学习曲线,提高手术安全性及保护患者的权益。     

直肠癌经肛全直肠系膜切除术的临床研究现状

直肠癌是常见病、多发病,微创手术是直肠癌外科的发展趋势。该文就直肠癌的外科治疗简介、经肛全直肠系膜切除术(transanal total mesorectal excision,TaTME)起源、应用现状、应用指征、疗效以及吻合重建等问题作一综述。     

直肠癌全直肠系膜切除术后局部复发因素分析

直肠癌 Dixon术后局部复发是直肠癌术后的主要死因之一。近年来 ,由于保肛手术有增多趋势 ,这也增加了局部复发的危险性。临床上多数学者主张行全直肠系膜切除 ,虽能明显降低局部复发率 ,但仍时有发生。自 1986～ 1996年 ,我院共收治直肠癌 689例 ,施行全直肠系膜切除盆腔内吻合术 160例 ,术后局部复发 8例。现报告如下。一般资料 :本组 8例术后局部复发患者中 ,男 6例 ,女 2例 ;年龄 2 8～ 73岁 ,平均 4 8岁。肿瘤远切缘距离均为 3～5 cm,病理组织学类型 :粘液腺癌 3例 ,低分化腺癌 3例 ,印戒细胞癌 2例。术后复发时间为 6～ 18个月 ,平均…     

老年直肠癌患者腹腔镜全直肠系膜切除术后吻合口瘘的相关因素

目的探讨老年直肠癌腹腔镜全直肠系膜切除术(TME)后吻合口瘘发生的原因。方法将2012年2月至2013年5月郑州大学附属肿瘤医院普外科96例行TME老年直肠癌患者,分析目前该科老年患者TME后吻合口瘘的危险因素。结果单因素分析和多因素分析年龄70岁、男性、肿瘤下缘距肛门距离5.0 cm;镜下吻合钉匣数目≥3个是老年TME后吻合口瘘发生的主要危险因素。结论年龄70岁、男性、肿瘤下缘距肛门距离5.0 cm;镜下吻合钉匣数目≥3个是老年腹腔镜全直肠系膜切除术发生的主要危险因素。     

闭合式切除术在直肠癌腹腔镜全系膜切除根治术中的应用效果研究

目的评价闭合式切除术（CE）在直肠癌腹腔镜全系膜切除（TME）根治术中的临床应用效果。 方法以潍坊医学院附属寿光市人民医院2011年2月至2014年6月收治的54例原发性直肠癌患者为研究对象,30例为实验组进行CE＋ TME腹腔镜根治术,24例为对照组进行TME腹腔镜根治术。术中均联合动脉灌注化疗。比较两组患者手术时间、术中出血量、淋巴结清扫数目、环周切缘（CRM）阳性比例、术后恢复饮食时间、肛门排气时间、尿管留置时间、住院时间、术后并发症发生比例及术后1年局部复发比例等指标。 结果术中出血量（t=11.775,P<0.001)显著低于TME组,CE＋TME组手术时间（t=2.207,P=0.035）、术后肛门排气时间（t=2.059,P=0.045）、导尿管置留时间（t=2.083,P=0.042）、术后1年内局部复发率（χ²=3.97,P=0.047）显著低于TME组;淋巴结清扫数目显著高于TME组（t=9.613,P<0.001）。 结论CE可显著降低TME术后局部复发率,具有一定的临床应用价值。     

男性患者行保留盆腔自主神经的全直肠系膜切除术后对性功能及排尿功能影响分析

目的探讨男性直肠癌患者行全直肠系膜切除(TME)并保留盆腔自主神经(PANP)根治性切除术对男性性功能及排尿功能的影响。 方法将56例直肠癌患者随机分为观察组和对照组：观察组行TME＋PANP治疗,对照组行常规TME治疗。术后1年调查患者的病死率、复发率,并评价患者的排尿功能及性功能(包括勃起功能和射精功能)。 结果两组术后1年均无死亡病例,TME＋PANP组术后1年复发2例,TME组复发l例,两组复发率比较差异无统计学意义(P>0.05)。患者术后排尿功能TME＋PANP组与TME组比较差异无统计学意义(P>0.05);射精功能优于TME组(P<0.05);术后勃起功能：TME＋PANP组得分高于TME组(P<0.05)。 结论进展期直肠癌患者实施保留盆腔自主神经(PANT)的全直肠膜切除(TME)在不增加肿瘤局部复发率的同时,可以有效降低排尿障碍、性功能障碍和射精功能障碍的发生率,值得临床推广应用。     

Total mesorectal excision: Assessment of the laparoscopic approach

PURPOSE: Total mesorectal excision offers the lowest reported rates of local recurrence for rectal cancer; however, the ability to perform total mesorectal excision laparoscopically remains unproven. The aim of this study was to assess the feasibility and adequacy of a totally laparoscopic total mesorectal excision for rectal cancer. METHODS: A prospective review of all patients undergoing laparoscopic-assisted surgery for rectal cancer by a single surgeon was undertaken. These were compared with a control group undergoing open rectal resections by another colorectal consultant in the unit (n=22). Comparison of total specimen length, longitudinal and radial excision margins, and lymph node yield was made between groups. RESULTS: Of 42 laparoscopic-assisted rectal resections attempted, 14 (33 percent) were converted to open procedures and six had their dissection completed open. One resection was considered noncurative. Twenty-one total mesorectal excisions (50 percent) were completed totally laparoscopically. No significant difference was detected between groups for specimen length, radial margin, or lymph node yield. Longitudinal margin of excision was longer in the laparoscopic group (4 (3.5–5)vs. 2.5 (1.05–3.5) cm;P=0.02, Mann-Whitney). Operating time was significantly longer in the laparoscopic group (180 (168–218)vs. 125 (104–144) minutes;P=0.003, Mann-Whitney). Data are medians (inter-quartile ranges). Four patients in the laparoscopic-assisted group had clinical anastomotic leakagevs. one in the open group (P=0.329, Fisher's exact test). At median follow-up of 38 (range, 6–53) months, one local recurrence had occurred in each group and crude mortality rates were 29 and 23 percent in the laparoscopic-assisted and open groups, respectively (P=0.736, Fisher's exact test). CONCLUSION: Totally laparoscopic excision of the mesorectum is feasible in 50 percent of patients and where possible yields histologic parameters comparable to open surgery. Early survival and recurrence figures also appear to be comparable.Drs. Hartley and Mehigan are University Research Fellows supported by Autosuture UK.Read at the meeting of The American Society of Colon and Rectal Surgeons, Washington, D.C., May 1 to 6, 1999.     

机器人和腹腔镜治疗中低位直肠癌对照研究

目的对比机器人和腹腔镜治疗中低位直肠癌的近期疗效。 方法自2017年3月18日至2017年10月25日,共有56例中低位直肠癌患者在解放军总医院普通外二科接受直肠癌根治术,患者被随机分组接受机器人或腹腔镜手术,对两组的临床资料进行了比较。 结果最终机器人组27例,腹腔镜组29例。机器人组较腹腔镜组在手术时间、术后镇痛时间、排气时间、恢复饮食时间、导尿管留置时间、住院日和淋巴结清扫数目方面差异均无统计学意义（均P>0.05）。机器人组术中失血量比腹腔镜少［（77.0±50.0）mL vs.（121.0±129.8）mL］,但差异无统计学意义（Z=-1.825,P=0.068）。机器人组术后有1例吻合口漏和1例肠梗阻,腹腔镜组术后有1例吻合口出血和1例肺部感染,术后并发症发生率方面差异无统计学意义（7.4% vs. 6.9%,χ²=0.006,P=1.000）。 结论机器人和腹腔镜直肠癌根治术围术期效果相当,远期功能学和肿瘤学效果有待进一步随访。     

Transanal total mesorectal excision:Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision(Ta TME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impactson postoperative outcomes and to discuss the future of Ta TME. METHODS: MEDLINE(Pub Med), EMBASE, and The Cochrane Library were systematically searched through the 1st of March 2015 using a predefined search strategy. RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced. CONCLUSION: Ta TME was also associated with better TME specimens and a longer distal resection margin. Ta TME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Longterm follow-up regarding anal function and oncological outcomes should be performed in the future.     

Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision(TME) with curative intent between January 2008 and December 2014(robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage?Ⅰ-Ⅲ disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME(L-TME) and 342 min for robotic TME(R-TME)(P 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. Thepatients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients(8 d for L-TME and 6 d for R-TME, P 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group(18 for R-TME, 11 for L-TME, P 0.001) and a shorter distal resection margin for laparoscopic patients(1.5 cm for L-TME, 2.5 cm for R-TME, P 0.001). The three-year overall survival and disease-free survival rates were similar between groups.CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.     

Laparoscopic total mesorectal excision with natural orifice specimen extraction

AIM:To introduce transvaginal or transanal specimen extraction in laparoscopic total mesorectal excision surgery to avoid an abdominal incision. METHODS:Between January 2009 and December 2011,21 patients with rectal cancer underwent laparoscopic radical resection and the specimen was retrieved by two different ways:transvaginal or transanal rectal removal.Transvaginal specimen extraction approach was strictly limited to elderly post-menopausal women who need hysterectomy.Patients aged between 30 and 80 years,with a body mass index of less than 30 kg/m2, underwent elective surgery.The surgical technique and the outcomes related to the specimen extraction,such as duration of surgery,length of hospital stay,and the complications were retrospectively reviewed. RESULTS:Laparoscopic resection using a natural orifice removal approach was successful in all of the 21 patients.Median operating time was 185 min(range,122-260 min)and the estimated blood loss was 48 mL. The mean length of hospital stay was 7.5 d(range,2-11 d).One patient developed postoperative ileus and had an extended hospital stay.The patient complained of minimal pain.There were no postoperative complications or surgery-associated death.The mean size of the lesion was 2.8 cm(range,1.8-6.0 cm),and the mean number of lymph nodes harvested was 18.7(range, 8-27).At a mean follow-up of 20.6 mo(range,10-37 mo),there were no functional disorders associated with the transvaginal and transanal specimen extraction. CONCLUSION:Transvaginal or transanal extraction in L-TME is a safe and effective procedure.Natural orifice specimen extraction can avoid the abdominal wall incision and its potential complications.     

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

AIM： To investigate the feasibility and safety of monopolar electrocautery shovel （ES） in laparoscopic total mesorectal excision （TME） with anal sphincter preservation for rectal cancer in order to reduce the cost of the laparoscopic operation, and to compare ES with the ultrasonically activated scalpel （US）.
METHODS： Forty patients with rectal cancer, who underwent laparoscopic TME with anal sphincter preservation from June 2005 to June 2007, were randomly divided into ultrasonic scalpel group and monopolar ES group, prospectively. White blood cells （WBC） were measured before and after operation, operative time, blood loss, pelvic volume of drainage, time of anal exhaust, visual analogue scales （VAS） and surgery-related complications were recorded. RESULTS： All the operations were successful; no one was converted to open procedure. No significant differences were observed in terms of preoperative and postoperative d I and d 3 WBC counts （P = 0.493, P = 0.375, P = 0.559）, operation time （P = 0.235）, blood loss （P = 0.296）, anal exhaust time （P = 0.431）, pelvic drainage volume and VAS in postoperative d 1 （P = 0.431, P = 0.426） and d 3 （P = 0.844, P = 0.617） between ES group and US group. The occurrence of surgery-related complications such as anastomotic leakage and wound infection was the same in the two groups.
CONCLUSION： ES is a safe and feasible tool as same as US used in laparoscopic TME with anal sphincter preservation for rectal cancer on the basis of the skillful laparoscopic technique and the complete understanding of laparoscopic pelvic anatomy. Application of ES can not only reduce the operation costs but also benefit the popularization of laparoscopic operation for rectal cancer patients.     

Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome

Background

Transanal total mesorectal excision (TaTME) has rapidly become an important component of the treatment of rectal cancer surgery. Cohort studies have shown feasibility concerning procedure, specimen quality and morbidity. However, concerns exist about quality of life and ano(neo)rectal function. The aim of this study was to prospectively evaluate quality of life in patients following TaTME for rectal cancer with anastomosis.

Methods

Consecutive patients who underwent restorative TaTME surgery for rectal adenocarcinoma in an academic teaching center with tertiary referral function were evaluated. Validated questionnaires were prospectively collected. Quality of life was assessed by the EuroQol 5D (EQ-5D), European Organization for Research and Treatment of Cancer’s QLQ-C30 and QLQ-CR29 and low anterior resection syndrome (LARS) scale. Outcomes of the questionnaires at 1 and 6 months were compared with preoperative (baseline) values.

Results

Thirty patients after restorative TaTME for rectal cancer were included. Deterioration for all domains was mainly observed at 1 month after surgery compared to baseline, but most outcomes had returned to baseline at 6 months. Social function and anal pain remained significantly worse at 6 months. Major LARS (score >30) was 33% at 6 months after ileostomy closure. No end colostomies were required.

Conclusions

TaTME is associated with acceptable quality of life and functional outcome at 6 months after surgery comparable to published results after conventional laparoscopic low anterior resection.