直肠癌全直肠系膜切除术中盆腔植物神经的易损区域及保护

全直肠系膜切除术（TME）是目前国际公认的直肠癌标准术式,随着TME手术的推广和认识,盆腔植物神经保护（PANP）的理念逐渐受到重视。笔者认为,在开展直肠癌TME手术时,有六个区域容易发生盆腔植物神经损伤,需要识别和保护：肠系膜下动脉根部的肠系膜下丛、上腹下神经丛及腹下神经的近端、盆丛前丛的近端、盆丛后丛的主干、盆丛后丛的终末支及盆腔内脏神经。熟悉盆腔筋膜、植物神经解剖,开展以TME手术层面为主导,盆腔植物神经为引导的精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。     

保留盆腔自主神经对男性直肠癌术后患者排尿及性功能影响的临床分析

目的 探讨盆腔自主神经保留根治术(PANP)对男性直肠癌患者术后排尿和性功能的影响.方法 回顾性分析全直肠系膜切除术(TME)组和自主神经保留根治术组(TME + PANP)患者术后排尿和性功能指标及局部复发率.结果 TME + PANP组患者术后排尿和性功能部分指标优于TME组(P＜0.05),两组术后局部复发率比较无统计学差异(P＞0.05).结论 男性直肠癌患者施行TME + PANP,可以更好地保护患者的排尿和性功能,并且不增加局部复发率.     

Denonvilliers筋膜的微创解剖认识及其临床价值

1836年,法国外科学家Charles-Pierre Denonvilliers首次描述在男性的直肠与膀胱、精囊腺和前列腺之间存在薄层致密组织,后被称为Denonvilliers筋膜。1982年英国外科学家R.J. Heald教授提出全直肠系膜切除术（TME）理念,历经数十年的临床实践,TME已成为中低位直肠癌手术的金标准。根据TME理念,直肠后方及侧方均应在盆筋膜壁层内面与直肠固有筋膜间分离,而在直肠前方于Denonvilliers筋膜前方分离、肿瘤下方2 cm处倒U形离断并切除部分Denonvilliers筋膜。然而,资料显示,由于盆腔自主神经（PAN）的损伤,TME术后排尿及性功能障碍发生率居高不下。因此,进一步理清盆腔筋膜和自主神经解剖的认识,对于改善患者术后功能尤为重要。在国内外众多学者研究的基础上,我们从胚胎发育学、解剖学、组织学和外科手术角度对盆腔筋膜及外科层面进行深入探索,指出Denonvilliers筋膜不属于直肠固有筋膜的范畴、如非肿瘤浸润应予保留,并提出保留Denonvilliers筋膜全直肠系膜切除术（iTME）的理念;并采用多中心临床试验加以验证。在此基础上我们联合国内直肠癌外科领域专家,发布iTME中国专家共识,旨在提高从业者对神经功能保护的认识,规范手术操作,造福广大患者。     

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。     

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。     

保留盆腔自主神经对老年男性直肠癌TME术后性功能和泌尿功能的影响

目的探讨保留盆腔自主神经(PANP)的直肠全系膜切除术(TME)对老年男性直肠癌患者性功能和泌尿功能的影响。方法将36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。术后进行半年随访,评价患者性功能和泌尿功能,随访3年观察患者局部复发情况。结果观察组泌尿功能障碍、性功能障碍发生率较观察组低(P<0.05),术后3年两组患者的局部复发率分别为11.1%和16.7%,生存率为74.2%和71.4%,两组间的差异并无统计学意义(P>0.05)。结论保留盆腔自主神经的直肠癌根治术可以较好地保护老年男性患者的性功能和泌尿功能,而患者局部复发率并没有升高。     

3D腹腔镜下直肠癌根治术中植物神经保护的研究

随着腹腔镜技术的迅速发展,腹腔镜全直肠系膜切除术（TME）已成为直肠癌的标准手术。然而,低、中位直肠癌患者术后膀胱功能及性功能障碍的发生率仍较高。如何避免盆腔自主神经损伤尤为重要。与传统的二维腹腔镜手术相比,三维腹腔镜手术还原了真实的三维视野、出现了纵深感,能更清晰地显示直肠周围层,减少盆腔自主神经损伤。近两年来本中心开展了3D腹腔镜下TME手术千余例。本文将探讨三维腹腔镜手术中自主神经保护的经验和技巧,包括盆腔自主神经解剖、手术方法的选择和手术中的要点。     

男性盆丛神经的解剖定位及意义

在前列腺癌或膀胱癌根治术中,如保留海绵体神经,则部分患者保留了性功能。反之性功能丧失。故详细了解盆丛神经的分布可避免在下尿路手术中损伤该神经。本研究选用福尔马林固定过的男尸做盆腔局部解剖,观察盆丛神经与盆腔器官的解剖关系,寻找盆丛神经的解剖定位。现将结果报告如下。     

直肠癌直肠系膜中CK20的表达及临床意义

目的:通过对直肠癌直肠系膜中CK20表达的检测,探讨直肠癌区域转移及微转移的规律,为临床直肠癌术式的选择及实施提供依据.方法:应用RT-PCR方法对直肠癌TME术后50例患者的肿瘤组织、直肠系膜及盆筋膜壁层中CK20的表达进行检测,同时分析CK20的表达与病理特征的关系.结果:正常对照组织中无阳性表达,直肠癌组织中CK20高表达(78%),肿瘤平面和直肠系膜近端可表达,直肠系膜远端(20%)和盆筋膜壁层表达(6.38%)程度较低.CK20表达与肿瘤形态、TNM分期、浸润深度有关,而与肿瘤直径、肿瘤分化程度、原发部位无关.结论:直肠癌患者外科治疗时常规行TME是必要的.     

低位前切除术与经腹会阴联合切除术治疗中低位直肠癌疗效比较

直肠癌外科治疗的主要肠道重建方式为低位前切除术（EAR）和腹会阴联合切除术（APR）,全直肠系膜切除术（TME）是中低位直肠癌治疗的标准手术。为探讨在TME前提下肠道重建方式对直肠癌预后的影响,本文回顾分析了中低位直肠癌患者用LAR、APR术式治疗的相关临床资料。现报告如下。     

Definition of total mesorectal excision, including the perineal phase: technical considerations

BACKGROUND: Total mesorectal excision (TME) has contributed to a decline in local recurrence. The operation is difficult because of the complicated anatomy of the pelvis and the narrow spaces in the pelvis. We review the anatomy related to TME and we present our surgical technique. ANATOMY: The pelvis can be divided into a parietal compartment and a visceral compartment. Both compartments are covered by a fascial layer: the parietal and the visceral fascia. A space between these fascial layers can be opened by dividing loose areolar tissue. The pelvic autonomic nerves consist of the sympathetic hypogastric nerve and the parasympathetic sacral splanchnic nerve. At the pelvic sidewall these nerves join in the inferior hypogastric plexus. SURGERY: We present our surgical technique based on careful dissection under direct vision and describe our approach to abdominoperineal resection in the knee-chest position. This position enables en bloc resection of the levator ani muscle with the mesorectum, preventing positive circumferential margins in distal rectal tumor. CONCLUSION: TME is a difficult and challenging operation. Continuous attention to surgical technique and anatomy is important to keep up the high standards of contemporary rectal surgery.     

Preservation of urine voiding and sexual function after rectal cancer surgery

In order to decrease the urinary and sexual morbidity which follows radical pelvic lymphadenectomy for rectal cancer, we began selective preservation of the pelvic autonomic nerves. Between 1985 and 1987, 134 patients with rectal cancer underwent a curative resection (52 abdominoperineal resections, 82 sphincter-saving resections) with extended pelvic lymphadenectomy and selective pelvic autonomic nerve preservation (PANP). PANP was classified into five degrees depending on the extent of pelvic dissection. First-degree PANP indicates complete preservation of the nerves; second-degree PANP indicates destruction of the hypogastric plexus; thirddegree PANP indicates partial preservation of the pelvic autonomic plexus; fourth-degree PANP indicates bilateral or unilateral preservation of only the fourth pelvic parasympathetic nerve; and fifth-degree PANP indicates complete destruction of the pelvic autonomic nerves. Most patients with first-degree PANP were able to spontaneously void 7–10 days following the operation. However, 78 percent (28/36) of patients with fifth-degree PANP had not regained bladder sensation by the third postoperative week and were discharged with an indwelling catheter; 58 percent (21/36) had not regained bladder sensation by the 60th postoperative day. The cystometric data indicate a progressive decline in bladder sensation and function with increasingly extensive pelvic dissection. However, preservation of only the fourth parasympathetic nerve (fourth-degree PANP) resulted in partial sparing of bladder sensation and voiding function. Evaluation of sexual function in males under 60 years of age revealed that only 31 percent (12/39) recovered erectile function and only 19 percent (6/39) recovered normal ejaculatory function in the first postoperative year. Most of these patients had complete preservation of their pelvic autonomic plexus (i.e., first-degree PANP). Four patients with partial PANP have recovered erectile function. Complete PANP is the best way to prevent urinary and sexual morbidity after rectal resection. The opposing goals of maximizing the chance for cure and minimizing morbidity must be individualized and balanced in each patient. Our data demonstrate that it is now possible to perform radical pelvic lymphadenectomy in the majority of patients with advanced rectal cancer with a minimum of voiding dysfunction. Preservation of sexual function in males is more difficult and depends on complete PANP and, as such, should be restricted to the group of patients with Dukes' A and B carcinomas.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.Supported in part by a grant of Cancer Research of Health and Welfare Ministry of Japan.     

The Efficacy of a Nerve Stimulator (Cavermap®) to Enhance Autonomic Nerve Identification and Confirm Nerve Preservation During Total Mesorectal Excision

PURPOSE Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap?) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed. PATIENTS AND METHODS Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. Cavermap? was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeon’s ability to localize the nerves and Cavermap? to confirm this were evaluated. RESULTS Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. Cavermap? successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. Cavermap? improved the identification rate in four of the remaining five patients. After proctectomy, Cavermap? successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device. CONCLUSION Cavermap? may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, June 3 to 8, 2002, Chicago, Illinois. Poster presentation at the meeting of the Association of Coloproctology of Great Britain and Ireland, July 2 to 5, 2002, Manchester, United Kingdom. Podium presentation at the Tripartite Colorectal meeting, October 27 to 30, 2002, Melbourne, Australia. An erratum to this article is available at .     

Total mesorectal excision and preservation of autonomic nerves]

The procedure of total mesorectal excision (TME) becomes a gold standard for the treatment of rectal cancer. The reason is the marvelously low incidence of local recurrence after TME even without other adjuvant treatment, which has been reported by several independent groups. Although controversy still exists about the role of TME in upper rectal cancer, it is now widely accepted for cancers of the middle and lower third. There are number of histopathological evidences that cancer cells can spread distally several centimeters from the lower margin of cancer, and cancer bearing lymph nodes are found in the distal portion of the mesorectal tissues far from the cancer. Therefore, the distal clearance of mesorectum should be performed downwardly to the level of pelvic diaphragm (puborectalis) and the rectum is divided within a few centimeters from the pelvic floor musculature. TME defines an en-bloc procedure, along the plane between parietal and visceral pelvic fasciae. If the dissection plane is breached, the chance of visceral pelvic fascia tearing is raised and mesorectal tissue might reside in the pelvis. There are problems in auditing the procedure. As many surgeons agree, this procedure requires a learning curve. Theoretically, the autonomic nerves run between the visceral and parietal pelvic fasciae since the nerves must be preserved to make visceral fascial envelop. Any patient who become incontinent or impotent after the surgery should have received decorticating surgery other than TME. Thus, the high quality of TME should fulfill two clinical measurements: absence of impotence or incontinence and at least single digit, 5-year, cumulative recurrence rate regardless of adjuvant therapy.     

Identification of hiatal ligament for laparoscopic total mesorectal excision

Total mesorectal excision (TME) based operation is now established as a standard procedure for patients with lower or middle third rectal cancer. Laparoscopic surgery has a great advantage in colorectal surgery, with good operative views, as well as benefit to the patients owing to less invasiveness, early recovery and shorter hospitalization. From April 2001 through March 2002, we assessed the laparoscopic TME for eight consecutive patients with rectal cancer in Kobe University Hospital (median age: 65.3). The procedure included sharp mesorectal dissection with high vascular ligation and preservation of autonomic pelvic nerves. During the laparoscopic TME, the hiatal ligament that is the sequence of anococcygeal raphe body can be identified with the traction of the rectum upward, and this fixes the posterior wall of the rectum to the levator hiatus. Resection of the hiatal ligament enables us to isolate the recto-anal canal up to the level of the internal anal sphincter. We conclude that identification of the hiatus ligament is essential to achieve the appropriate laparoscopic TME.     

Technique for laparoscopic autonomic nerve preserving total mesorectal excision

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.     

Intraoperative electrostimulation objectifies the assessment of functional nerve preservation after mesorectal excision

Background To improve nerve-sparing surgery, intraoperative electrical stimulation of pelvic autonomic nerves (INS) has been proposed in urology, gynecology, and visceral surgery. The aim of this study was to assess the impact of INS while monitoring intravesical pressure on the accurate evaluation of pelvic autonomic nerve preservation (PANP) after mesorectal excision. It was sought to determine whether this confirmation is useful in the prediction of postoperative urinary function. Methods Sixty-two patients with mesorectal exzision for rectal cancer were examined prospectively. PANP was assessed visually by the surgeon and with INS. Bladder function was evaluated by post voiding residual volume measurement, rate of recatheterization, rate of long-term urinary catheterisation, and the international prostatic symptom score with quality of life index. Results INS confirmed bilateral preservation of parasympathetic nerves in 46 patients (74%), and in 10 patients (16%) in at least one side. In six patients (10%), INS failed to confirm PANP. Eleven patients (18%) developed urinary symptoms postoperatively. INS results had a higher sensitivity than visual assessment by the surgeon (82 vs 46%). Values for specificity ranged at 90 and 92%, respectively. Accuracy of INS in predicting PANP was higher (88 vs 83%). The correlation between urinary function and the findings on INS was good (kappa-value: 0.65), correlation between urinary function and visual assessment by the surgeon was fair (kappa-value: 0.40). Conclusion INS, while monitoring intravesical pressure, accurately predicts bladder function after mesorectal excision. It may provide further insight into pelvic autonomic nerve sparing techniques.     

Dis Colon Rectum, Vol. 47, No. 12, December 2004, pp. 2032–2038 (DOI: 10.1007/s10350-004-0718-5)

PURPOSE Sexual dysfunction after total mesorectal excision may be caused by injury to the autonomic nerves. During surgery, nerve identification is not always achieved, and, to date, there has been no method to objectively confirm nerve preservation. The aim of this study was to assess the efficacy of a nerve-stimulating device (CaverMap?) to assist in the intraoperative identification of the autonomic nerves during total mesorectal excision, and objectively confirm nerve preservation after proctectomy is completed. PATIENTS AND METHODS Sexually active consecutive male patients undergoing total mesorectal excision were prospectively enrolled in this study. During pelvic dissection, the surgeon attempted to localize the hypogastric and cavernous nerves. Cavermap? was used to confirm these findings and to facilitate the identification in cases of uncertainty. At the completion of proctectomy, the nerves were restimulated to ensure preservation. Factors that could affect the surgeons ability to localize the nerves and Cavermap? to confirm this were evaluated. RESULTS Twenty-nine male patients with a median age of 58 years were enrolled in this study. An attempt to visualize the hypogastric nerves during dissection was made in 26 patients; the surgeon was able to identify the nerves in 19 (73 percent) patients. Cavermap? successfully identified the nerves in six of the seven remaining patients, and failed to identify them in only one case. An attempt to localize the cavernous nerves during dissection was made in 13 patients, of which localization was successful in 8 (61.5 percent) patients. Cavermap? improved the identification rate in four of the remaining five patients. After proctectomy, Cavermap? successfully confirmed the preservation of both hypogastric and cavernous nerves in 27 of 29 (93 percent) patients. A history of previous surgery statistically correlated with failure to identify the hypogastric nerves by the surgeon (P = 0.005). There were no adverse events related to use of the device. CONCLUSION Cavermap? may be a useful tool to facilitate identification of the pelvic autonomic nerves during total mesorectal excision and to objectively confirm nerve preservation. Due to an electronic error in production, nine paragraphs of the Patients and Methods and Results section were omitted from the print and pdf versions of the article “The Efficacy of a Nerve Stimulator (Cavermap?) to Enhance Autonomic Nerve Identification and Confirm Nerve Preservation During Total Mesorectal Excision” by Giovanna M. da Silva, M.D., Oded Zmora, M.D., Lars B?rjesson, M.D., Nelly Mizhari, M.D., Norma Daniel, R.N., Farah Khandwala, M.S., Jonathan Efron, M.D., Eric G. Weiss, M.D., Juan J. Nogueras, M.D., Anthony M. Vernava III, M.D., Steven D. Wexner, M.D., published in the December 2004 issue of Diseases of the Colon & Rectum (Vol. 47, No. 12, pp 2032–2038, DOI ). The HTML version is correct. Below, the entire article is printed in its entirety with the omitted paragraphs in bold format. Springer regrets the error. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, June 3 to 8, 2002, Chicago, Illinois. Poster presentation at the meeting of the Association of Coloproctology of Great Britain and Ireland, July 2 to 5, 2002, Manchester, United Kingdom. Podium presentation at the Tripartite Colorectal meeting, October 27 to 30, 2002, Melbourne, Australia.