Low anterior resection.

A personal series of 93 patients treated by low anterior resection for carcinoma (87) and benign disease (6) is reviewed to highlight the technical problems and complications of the operation. The series comprises two groups for comparison of (i) technique of anstomosis; (ii) the use of protective stoma; and (iii) methods of drainage.     

Hand-assisted laparoscopic low anterior resection

Background: Laparoscopic low anterior resection for rectal cancer has never gained wide acceptance among general surgeons, mainly due to the technical difficulties encountered during pelvic dissection. It has therefore been stated that these patients should undergo open rather than laparoscopic surgery. Hand-assisted laparoscopic surgery (HALS) is a new technique that has the potential to overcome many of the existing limitations of pure laparoscopy. In the treatment of rectal cancer, HALS could reproduce an operative setting similar to that of the open approach. Methods: To assess the technical feasibility of hand-assisted laparoscopic low anterior resection for rectal cancer and evaluate potential benefits and drawbacks of this new procedure, a pilot study was conducted at a university hospital on 16 consecutive patients during a 12-month period. Only patients with extraperitoneal rectal cancer were included in this series. Patients' clinical data, operative time, conversion rate, complications, and early outcome measures were prospectively examined. Results: There were 9 men and 7 women. The average ± SD operation time was 238 ± 38 min. Conversion to open surgery was never required. Ten of 16 patients were off pain medication on the third postoperative day. Eight were able to walk the day after surgery. Three minor postoperative complications were recorded. Mean postoperative stay for patients without complications was 5.6 ± 1.4 days. Conclusion: From a technical standpoint, the reported hand-assisted procedure makes pelvic dissection during laparoscopic low anterior resection almost equivalent to the laparotomic operation. The incision for hand access that is needed with this technique does not seem to compromise the quick recovery of patients undergoing purely laparoscopic procedures.     

Anterior and low anterior resection

The various definitions of anterior and low anterior resection are outlined. The operative technique for performance of both and their perioperative management are described. Operative mortality in 157 patients operated on from 1973 to March 31, 1982, was 4.5% (7 of 157 patients) and had decreased to 1.9% (2 of 107 patients) within the last 5 years. The rate of anastomotic leakage also decreased concomitantly. Five-year survival rates are similar to those reported in the literature; there was no difference between anterior and low anterior resection for tumors of Dukes' stage A-C.

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Résumé Les définitions respectives de la résection antérieure classique et de la résection antérieure basse du rectum sont précisés dans cet article. La technique opératoire et le traitement pré et post opératoire de chacune des méthodes sont décrites. La mortalité opératoire d'une série de 157 malades opérés de 1973 à mars 1982 fut de 4,5% (7 morts pour 157 malades) 2 morts seulement furent à déplorer chez les 107 derniers opérés (lors des 5 dernières années). Le taux des déhiscences anastomotiques s'abaissa parall'èlement.Le taux de survie à cinq ans fut identique à celui des autres séries de la littérature. Il ne fut constaté aucune différence entre le taux de survie après résection antérieure classique ou résection antérieure basse dès lors que la résection s'appliquait aux tumeurs de A à C selon la classification de Dukes.

     

前入路肝切除术

由于临床和解剖学研究的不断进步和手术器械的更新,肝脏外科手术技术取得了较大的发展.近年来,前入路肝切除技术以其相较于传统肝切除术的诸多优点,日益受到肝脏外科医师的重视.     

腹腔镜辅助下直肠癌前切除67例临床治疗体会

目的探讨腹腔镜手术治疗直肠癌的临床应用价值。方法回顾分析腹腔镜辅助下直肠癌前切除67例患者与开腹行直肠癌前切除82例患者之间临床资料,比较两组患者手术时间、术中估计出血量、远切缘距离、淋巴结清扫数量、排气时间、进食时间、住院时间及术后并发症情况。统计分析用SPSS20．0软件,计量资料采用方差分析或非参数检验;计数资料采用Pearsonr检验。结果腹腔镜组和开腹组手术平均时间[（195±54．5）min与（148±52．1）rain],平均出血量[（30．0±10．1）ml与（200±40．0）ml],平均排气时间[（3．0±1．0）d与（6．0±1．0）d],平均进流食时间[（4．0±1．0）d与（6．0±2.0）d],平均住院时间[（7．0±1．0）d与（12．0±1．2）d],腹腔镜手术组优于开腹手术组（t值分别为：5．34、37．07、18．22、7．92、27．74,P〈0．05）,两组差异有统计学意义。两组淋巴结清除数、术后并发症发生率及3年生存率差异无统计学意义（检验值分别为：t=1．77、r=0．17、χ^2=0．76,P〉0．05）。结论腹腔镜直肠癌前切除技术上是安全可行的,能满足肿瘤根治的要求,切口小、创伤小、出血少、胃肠道功能恢复快等优点已经逐渐被大家所公认。     

直肠脱出技术在腹腔镜低位直肠前切除术中的应用

目的探讨直肠脱出技术在腹腔镜低位直肠前切除术中应用可行性与治疗效果。方法回顾性分析2005年10月至2007年3月上海微创外科临床医学中心为9例低位直肠肿瘤病人运用直肠脱出技术行腹腔镜低位直肠前切除术的临床资料，研究其手术操作、术后恢复、肿瘤根治性效果及随访结果。结果男6例，女3例，平均年龄58（40～75）岁。腺瘤2例，Ⅰ期病例6例，Ⅱ期1例。所有病例无术中严重并发症和手术死亡，无中转开腹手术；平均手术时间195（150～232）min、平均术中出血55（25～100）ml，病人术后排气时间、留置导尿管时间和术后住院天数分别为2（1～4）d，7（5—10）d和11（7～20）d。清扫淋巴结总数12（9～20）枚，肿瘤距下切缘距离为1．6（1．0～3．8）cm。无严重术后并发症。随访12（4—21）个月，无局部复发和远处转移，排便功能恢复较满意。结论直肠脱出技术运用于腹腔镜低位直肠前切除术安全有效，符合肿瘤根治原则，且能获得较满意的排便功能恢复。     

Comparison of single‐incision laparoscopic high anterior resection with standard laparoscopic high anterior resection

Aim Single‐incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS). Method Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS. Results Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three‐port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2–24) h for SILS vs 18 (2–96) h for StdLS] and were discharged faster [1 (1–8) days for SILS vs 3 (1–24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30‐day mortality. Conclusion SILS for high anterior resection is feasible, safe and quicker to perform than standard three‐port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.     

Abdominoperineal resection for locally recurrent rectal cancers following anterior resection

STUDY AIM: The aim of this retrospective study was to evaluate the short and long term results of abdominoperineal resection for local recurrence following low anterior resection of a rectal adenocarcinoma and to determine the prognostic factors. PATIENTS AND METHODS: From January 1978 to December 1996, 35 patients (17 women, 18 men) with a mean age of 59.4 years, underwent an abdominoperineal resection for local recurrence after low anterior resection of a rectal adenocarcinoma. The primary tumor was below the peritoneum in 29 cases, and the mean security margin was 3 cm under the tumor. Tumor staging at the time of primary surgery included 23 Dukes B, 11 Dukes C, and 1 Dukes D. The mean time elapsed between low anterior resection and local recurrence was 16.4 months. The histological diagnosis of recurrence was obtained preoperatively in 29 cases (82.8%). RESULTS: Resection was curative in 12 patients and palliative only in 23 patients. The recurrence was intramural in 3 cases, extramural in 10 cases, and mixed in 22 cases. Ten patients had an extended "en bloc" resection including one or several adjacent organs, and a synchronous metastasis was resected in 2 cases. The mortality rate was 2.8% (n = 1) and the morbidity rate was 23% (n = 8). The 1-year and 5-year survival rates were respectively 77 and 30.2% with the univariate analysis of prognosis factors of survival, there were four pretherapeutic factors (age, staging of the primary tumor, delay of the recurrence, CEA rate) and four therapeutic factors (curative resection, extramural recurrence, staging of the recurrence, postoperative radiotherapy). The curative or not curative type of resection was the only independent predictor of survival with multivariate analysis. CONCLUSION: The results of this study seem to justify an abdominoperineal resection for local recurrence after low anterior resection whenever possible. Long-term results may possibly be improved by using adjuvant treatment.     

Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis

Objective:

To compare laparoscopic anterior discoid resection (ADR) with low anterior resection (LAR).

Methods:

This is a retrospective review of a cohort (Canadian Task Force classification II-2) of patients undergoing laparoscopic ADR or LAR at a university hospital. Chart review and telephone questionnaires were conducted to examine long-term outcomes. Preoperative and operative findings, short- and long-term outcomes were compared. SF-12 quality of life scores, need for further interventions, and overall satisfaction were also compared.

Results:

Twenty-two patients underwent laparoscopic ADR (n=8) or LAR (n=14) for rectosigmoid endometriosis between January 2001 and December 2009. Mean follow-up time was 41.26 months (range, 14 to 70). Patients undergoing laparoscopic ADR had significantly less blood loss and shorter operative time and hospital stay. Patients who required LAR had a significantly higher rate of mucosal involvement (61.5% v. 0%). No statistically significant difference was found in the size, depth of invasion, location of lesions, or operative complications. Fifty percent of the LAR group had several lesions as opposed to 12.5% of the ADR group. Median age was significantly higher in patients who required LAR (39) than in patients who required ADR (32). Three patients in the LAR group (21.4%) had anastomotic strictures; 2 required dilation. The ADR group had consistently higher increments of improvement in bowel symptoms and dyspareunia. Overall satisfaction rate with the procedures was 93.3%. SF-12 scores were comparable between the 2 groups.

Conclusion:

ADR compared with LAR is associated with decreased operative time, blood loss, and hospital stay and a lower rate of anastomotic strictures. Other outcomes and satisfaction rates are comparable between the 2 procedures.     

Anorectal function following low anterior resection

Introduction Rectal function following rectal resection for carcinoma was studied in 43 patients. Methods Sixteen women and 27 men with a median age of 66 years (range 41–79 years) were included. Twenty‐three patients had a diverting ileostomy at the time of resection. Eight patients had a 6‐cm colonic J‐pouch. Ten patients had anastomotic leakage including two patients without diverting ileostomy. One patient had pre‐operative radiation with 25 Gy. The patients were studied at a median 12 months (range 3–30) after rectal resection. Distance from anal verge to the anastomosis was a median 7 cm (range 3–12 cm). Clinical data, anal manometry and rectal compliance were analysed. Results Stool frequency was 3 per day (range 1–10). Twenty‐two (51%) patients were continent, 11 (26%) were incontinent for flatus, and 10 (23%) were incontinent for faeces (three for liquid and seven for solid stool). Fourteen (33%) patients had constipation, two of whom also had incontinence for solid or liquid stool. The level of the anastomosis for patients with postoperative constipation was 5 cm (range 3–12 cm), while it was 7 cm (range 3–10 cm) for nonconstipated patients (NS). Anal manometry was normal. Rectal compliance was lower in patients with incontinence for liquid or solid faeces than in patients with flatus incontinence only (P < 0.01), and rectal volume tolerability was lower in incontinent patients compared with continent patients (P < 0.05). The rectoanal reflex was present in 31 (72%) patients. There was a negative correlation between maximal rectal volume and stool frequency and between level of the anastomosis and degree of incontinence. Age did not affect functional outcome. Conclusion Many patients had a poor functional result following low anterior resection. One in four suffered from incontinence to liquid or solid faeces and one third of the patients experienced constipation. A low level of anastomosis tended to increase stool frequency and carried a higher risk of incontinence. Patients with faecal incontinence tended to have lower rectal compliance and volume tolerability than patients who were continent, while there was no difference in anal pressures.     

Anorectal function after low anterior resection

Most patients with rectal carcinoma can now be treated with sphincter-sparing procedures. The quality of life after sphincter-sparing procedures is better than after abdominoperineal excision. However, morphology and physiology of the neorectum/sphincter complex are challenged and enthusians towards restorative surgery in rectal cancer was tempered by concerns over functional deficits: after low anterior resection a substantial portion of patients experience impaired anorectal function, in particular fecal leakage and urgency of defecation and report disturbed sexual function. The aim of our work was to investigate functional outcome and anorectal physiologic function as measured by manometry after the three most commonly used reconstructions of intestinal continuity: anterior rectal resection, low anterior rectal, and intersphincteric rectal resection.     

Low anterior resection using stapling instrument

Twenty-one patients, eighteen with carcinoma of the rectum and three with diverticulosis of the colon, have been treated with anterior resection. The anastomoses were made with the stapling instrument, EEA, allowing very low anastomoses. All patients had temporary colostomy. Seventeen patients had a postoperative uneventful course. In three patients, major but tractable complications were seen. One patient died of pulmonary embolism. All survivors were completely continent for air and faeces, even with anastomoses only 4 cm above the anus. Two cases of recurrency have been noticed, one after two months and one after thirteen months. The result of making low anterior resection with the aid of the stapling machine EEA are so far promising.     

腹腔镜直肠癌前切除术

基于COLOR II等研究结果,腹腔镜直肠癌手术的地位得以逐步确立。手术切除是直肠癌最重要的治疗方法,对于上段直肠癌,前切除术是标准术式;对于中下段直肠癌,需遵循全直肠系膜切除(TME)的原则,选择低位前切除术或者腹会阴联合切除术。R0切除是手术治疗的核心要素,这包括两层含义:其一是淋巴结清扫范围需要达到D2水平,其二是标本的远、近端切缘以及环周切缘均需为阴性。准确地解剖出肠系膜下动脉、左结肠动脉以及直肠上动脉,是保证淋巴清扫范围的基础,循"神圣平面"解剖分离直肠系膜是环周切缘阴性和标本完整的保证。     

腹腔镜下直肠前切除术的吻合方式

直肠前切除术是外科治疗直肠肿瘤的主要术式.传统的手术是在大切口、直视下,将肿瘤所在肠段、系膜及其所属区域淋巴组织分离切除,再行肠道重建吻合.近十余年,随着微创外科技术的广泛应用,腹腔镜下直肠肿瘤切除手术的安全性和可行性得到了大量临床研究的证实[1-4],这一创伤小、出血少、恢复快的微创外科技术也逐渐得到了同道们的认可.     

Aspects of low anterior rectum resection

Results analysis of 162 low anterior rectum resections, carried out in the hospital during 1999-2006 years on account of upper and medial rectal ampulla adenocarcinoma is presented in the article. Method of marking rectum resection distal border with use of optical coherent tomography was worked out and put into practice. Comparative evaluation of operation results with total and partial mesorectal cellular tissue removal was carried out. It is established that local recurrence has been indexed in 14.28% of patients undergoing anterior resection with maintenance of mesorectum part in 7.89% of patients undergoing mesorectumectomy. Indications for mobilization of left bend colon and one or another type of discharge ostomy were formulated. Measures for prediction and prophylaxis of anal incontinence after rectum resection and also the new method of small pelvis cavity intraoperative drainage were offered.