LAPAROSCOPIC RESECTION IN COLORECTAL CANCER

1 IntroductionThe feasibility of colon resection usingthelaparoscope was demonstrated as early as 1991[1~3].It wasshown one year later that it is also possible to use the laparoscope in abdominoperineal resection of the rec-tumfor rectal carcinoma[4,5].One year after this,thefirst study was reportedin whichthe results of ante-rior resection with thelaparoscope were compared withthe conventional operationin a small number of pa-tients with carcinoma of the rectum[6].The first reports on the fea…     

经直肠双平面超声在直肠癌手术方式选择中的应用

目的评价经直肠双平面超声在直肠癌手术方式选择中的作用。方法47例经活检证实的直肠癌患者应用双平面腔内探头行经直肠超声检查,并根据超声检查结果拟定手术方式,与实际采取的手术方式进行比较。结果34例直肠癌获得正确诊断,符合率为72.3%。7例中上段直肠癌均行保肛术,40例下段直肠癌中34例拟定术式与实际术式一致,符合率为85.0%。对于距肛缘6cm内的35例直肠癌,拟定术式与实际术式的差异无统计学意义(P>0.05)。结论经直肠双平面超声能为临床医师术前选择合适的直肠癌手术方式提供依据。     

直肠间质瘤的临床分析

目的探讨直肠间质瘤的诊断及治疗。方法对1998年1月至2010年12月间收治的15例直肠间质瘤患者的临床资料进行回顾性分析。结果 15例患者中经肛门肿物切除术4例,经腹会阴联合切除术（Miles术）5例,经腹直肠前切除术（Dixon术）6例,所有患者最后均经病理和免疫组化证实。CD117、CD34的阳性率分别为93.3%、73.3%。15例患者获6～72个月的随访,其中2例患者分别术后12、26个月局部复发再次行手术切除,术后口服伊马替尼400mg.d^-1辅助治疗;5例经腹前切除或经肛局部切除患者出现腹腔复发并肝多发转移,其中3例死亡;2例服用伊马替尼治疗后肿瘤缩小,带瘤生存;其余6例患者无复发、转移。结论直肠间质瘤的治疗以手术为主、分子靶向治疗为辅的综合治疗。伊马替尼对中高危患者的复发、转移的治疗有效。     

Anorectal melanoma: report of three cases with extended follow-up

Primary anorectal melanoma is rare. There is controversy regarding the best surgical treatment because of its poor prognosis. Three cases with extended follow-up are reported in this article. A 53-year-old woman with rectal bleeding was diagnosed with a melanoma of the rectum and underwent an abdominoperineal resection. The patient died with distant metastases 8 months later. An 80-year-old woman with rectal bleeding was diagnosed with a melanoma of the rectum and underwent a transanal local excision. She remains alive 4 years later but with locally recurrent disease. A 78-year-old man with rectal bleeding was diagnosed with a melanoma of the rectum and underwent an abdominoperineal resection. He died with local and metastatic disease 25 months later. Recent trends favor local excision when technically feasible, although some patients may require an abdominoperineal resection of the rectum, especially for larger tumors.     

Sialomucin at the resection margins and likelihood of local recurrence of carcinoma of the rectum after anterior resection

The histochemical changes in mucin at the postoperative resection margins in carcinoma of the upper and middle third of the rectum after anterior resection were studied retrospectively in 52 patients. The sialomucinous change was most likely to occur at the intestinal margins of those patients who had tumour recurrence (P less than 0.001). The histological types of tumour, degree of differentiation, Dukes' stages and their distance from the anal verge were virtually the same in patients with and without tumour recurrence. By using high iron diamine-alcian blue staining technique we identified patients with higher risk conditions of tumour recurrence after anterior resection. This technique should increase the likelihood of a cure for patients with recurrent carcinoma of the rectum after anterior resection.     

Congenital aganglionic megacolon in Nigerian adults: two case reports and review of the literature

Congenital aganglionic mega colon (Hirschsprung's disease) is a motor disorder in the gut, due to a defect in the craniocaudal migration of the neuroblast originating from the neural crest that occurs during the first twelve weeks of gestation, causing a functional intestinal obstruction, with its attendant complications, in infants. Despite modern pediatric practice, with emphasis on early diagnosis, Hirschsprung's disease is seen in adults in regions where perinatal care is limited. We report two cases of Nigerian adults with longstanding, recurrent constipation, getting relieved by laxatives and herbal enemata, and then presented to our Emergency Department with a history of progressive abdominal distention, colicky pain, occasional vomiting, and weight loss. Per rectal examination revealed a gripping sensation in the rectum, 10 cm from the anal verge, with rectal fecal load. Barium enema showed a grossly distended proximal large colon, with high fecal retention, with the transition zone at the middle one-third of the rectum. Due to difficulty in bowel preparation of these patients, emergency laparotomy was done. The first case had a diverting sigmoid colostomy and later had a low anterior resection. The second case had a one-stage procedure. Histology of both the cases showed aganglionosis of the stenotic segment and a normal distal rectum. Both patients had complete resolution of the symptoms, without complications, in a three-year follow-up. The related literatures were reviewed. Hirschsprung's disease should be considered in adults patient presenting with chronic constipation. Low anterior resection of the rectum would be a surgical option for the treatment of short and zonal segment of adult Hirschsprung's disease.     

腹腔镜下直肠切除术的器械应用与管理

目的探讨腹腔镜下直肠切除术的器械应用与管理特征。方法72例腹腔镜下直肠前切术和腹会阴联合直肠癌根治术患者,采用统一的临床路径治疗方案和整体护理。结果除5例中转开腹外,67例完成腹腔镜下直肠切除术,手术时间130～210min,平均155min;术中平均出血量190mL。结论手术室建立腹腔镜组,培养熟练掌握腹腔镜结直肠切除手术器械使用与维护、清洗、包装和灭菌的技术人才,能不断完善腹腔镜手术的操作规范,促进腹腔镜下结直肠手术的发展。     

Endoscopic resection of small rectal carcinoid tumours using an aspiration method with a transparent overcap

Rectal carcinoid tumours are often small and rarely metastatic. Endoscopic resection may, therefore, be the best treatment for small tumours. We diagnosed rectal carcinoid tumours in four women and three men (mean age 53 years; range, 43 - 63) between 1994 and 1999. Tumour depth was evaluated using a high-frequency ultrasonographic probe in five of the seven patients. All tumours were resected by endoscopic mucosal resection using an aspiration method with a transparent overcap. Histologically, all tumours were located within the submucosal layer. Tumour cells were found at the resected margin of the lateral side in one patient, and at the bottom of the margin in another. Both patients were followed up with frequent endoscopy, and no local recurrences have been detected at 1-year or 4-year follow-ups. Ultrasonographic examination before resection is useful to estimate tumour depth. Endoscopic resection by an aspiration method with a transparent overcap is safe and effective for the treatment of small rectal carcinoid tumours.     

Three‐dimensional laparoscopy‐assisted bowel resection for cavernous hemangioma of the rectum: Report of two cases

The safety and feasibility of 3‐D laparoscopy‐assisted bowel resection were demonstrated in the management of rectal cancer. However, this procedure’s role in the management of patients with diffuse cavernous hemangioma of the rectum has not been evaluated. Here, two patients were diagnosed with diffuse cavernous hemangioma of the rectum by colonoscopy and abdominal imaging. One case underwent pull‐through transection and coloanal anastomosis in 3‐D laparoscopy‐assisted surgery. In another patient, 3‐D laparoscopy‐assisted abdominoperineal resection was performed. The operations were safely performed in both cases. The two patients recovered uneventfully, and satisfactory postoperative outcomes were demonstrated. This report shows that 3‐D laparoscopy‐assisted bowel resection may be safe and feasible for patients with diffuse cavernous hemangioma of the rectum.     

Safe anastomosis in laparoscopic low anterior resection for rectal cancer

Introduction: In laparoscopic rectal surgery, there are some limitations on a surgeon's ability to maneuver, especially in transection of the lower rectum. To achieve minimally invasive surgery, safe anastomosis, including proper rectal transaction, is necessary. Methods: To overcome the difficulty in lower rectal resection, we followed a series of steps. First, we completely mobilized the rectum to the pelvic bottom, just above the anal canal, making the lower rectum mobile and allowing for an easy rectal transection. To secure the transaction, the mesorectum around the transection must be properly divided. We recommend placing the lower right quadrant port as caudal as possible to properly staple the rectum. We found a 60 mm compression‐type stapler most suitable for rectal transection. To wash and flatten the rectum, a detachable intestinal clip is quite useful because of its flexibility. Finally, in addition to conventional abdominal drains around the anastomotic site, we employed transanal tube to actively decompress rectal pressure inside the anastomotic site. Results: Between August 2009 and July 2010, 101 patients underwent laparoscopic low anterior resection using this technique. Most patients, 98.0% (99/101), underwent lower rectum transection using a single‐fire cartridge. The anastomotic leakage rate was only 1.0% (1/101) in total and 1.3% (1/78), when not including patients with diverting stoma. Conclusion: We have to follow up with more patients to conclude whether our technique is effective in the long term. However, this step‐by‐step technique could lead to safe anastomosis in laparoscopic low anterior resection for rectal cancer.     

Hybrid resection of massive rectal gastrointestinal stromal tumor using laparoscopic and transanal approaches

Rectal gastrointestinal stromal tumors (GISTs) are rare, and radical surgery such as abdominoperineal resection is necessary for large rectal GISTs to obtain tumor-free resection margins. Here, we describe a 77-year-old man with a locally advanced non-metastatic GIST in the left anterolateral wall of the lower rectum. Tumor size was estimated to be 73 mm, and invasion of the left seminal vesicle and prostate was suspected. Chemotherapy with imatinib mesylate reduced the tumor size, creating a slight gap between the tumor and anterior organs. Therefore, we performed sphincter-sparing partial rectal resection using a hybrid method of laparoscopic and transanal approaches. The postoperative course was uneventful, and the patient remains disease-free on adjuvant chemotherapy 12 months after surgery. This case suggests that a hybrid method of laparoscopic and transanal surgery allows oncological and function-preserving excision of large rectal GISTs.     

经直肠超声术前评估直肠癌累及直肠系膜筋膜

目的 探讨经直肠超声（ERUS）术前评估直肠癌累及直肠系膜筋膜（MRF）的价值。方法 44例直肠癌患者术前均接受ERUS检查,其中18例接受新辅助放化疗,26例未接受;所有患者于接受ERUS检查后1周内行全直肠系膜切除手术（TME）。以术后病理诊断环周切缘（CRM）的结果为金标准,判断ERUS术前评估直肠癌累及MRF的诊断效能。结果 44例患者中,术后病理诊断T1期2例,T2期17例,T3期25例;CRM阳性2例,CRM阴性42例。低位直肠癌16例,中位直肠癌28例。肿瘤位于前壁和前侧壁26例,后壁和后侧壁13例,累及肠壁全周5例。ERUS对术前接受和未接受新辅助放化疗的患者诊断准确率分别为83.33%（15/18）和92.31%（24/26）;肿物位于前壁和前侧壁时,诊断准确率为80.77%（21/26）,而肿物位于后壁和后侧壁时为100%（13/13）;对于低位和中位直肠癌,诊断准确率分别为75.00%（12/16）和96.43%（27/28）;总准确率为88.64%（39/44）。结论 ERUS是术前评估直肠癌是否累及MRF的有效辅助检查方法。     

Laparoscopic high anterior resection for rectal cancer with rare variations of the left renal vessels: A case report

We present a case of rectal cancer with rare variations of the left renal vessels. A man in his 60s underwent endoscopic mucosal resection for an Ip‐type lesion in the upper rectum. Histologically, the lesion was a well‐differentiated adenocarcinoma that had invaded the deep submucosal layer. Therefore, additional resection of the rectum with regional lymph node dissection was recommended. Preoperative CT revealed rare variations of the left renal vessels. There were two left renal arteries and veins; the caudal left renal artery and vein were located between the inferior mesenteric artery and the abdominal aorta. During the operation, these renal vessels were confirmed, and laparoscopic high anterior resection was performed safely without any injury to these renal vessels. To avoid the risk of unexpected intraoperative injuries, it is important to preoperatively check whether there are any variations in the renal vessels, even before colorectal surgery.     

内镜辅助下手术治疗上干型胸廓出口综合征的临床应用

目的 报告内镜辅助下手术治疗上干型胸廓出口综合征的方法及临床疗效。方法 16例上干型胸廓出口综合征患者局麻下通过颈外侧区作长1．5cm切口，在内镜辅助下切断部分前、中斜角肌的腱性起始纤维。结果 术后平均随访25个月（16-36个月），按WOOD等的评定标准评价：优9例，良5例，可2例。结论 在内镜辅助下经颈部微小切口切断部分前、中斜角肌的腱性起始纤维可解除斜角肌对臂丛神经的压迫，是一种治疗上干型胸廓出口综合征的有效微创手术方法。     

脊髓损伤患者直肠脱垂的手术治疗

目的评价吻合器经肛门直肠切除术(STARR)或Altemeir术治疗脊髓损伤患者直肠脱垂的疗效。方法对260例脊髓损伤患者进行肛肠疾病调查,21例非手术治疗无效的脊髓损伤直肠脱垂患者根据直肠脱出程度分别使用Altemeir或STARR术进行治疗。采用国际脊髓损伤肠功能基础及扩展数据集了解患者术前、术后12个月排便状况。结果脊髓损伤患者直肠脱垂发生率为32.7%(85/260)。接受手术治疗的21例患者均有不同程度便秘和混合痔,直肠黏膜脱垂(<7 cm)19例,直肠内套叠4例,直肠完全脱垂(7 cm)2例;Ⅰ度13例,Ⅱ度5例,Ⅲ度3例。Ⅰ、Ⅱ度直肠脱垂均使用STARR术治疗,Ⅲ度使用Altemeir手术治疗。术后无严重并发症。术后12个月,患者肠道功能障碍影响生活质量的自我报告明显改善(P<0.01),需偶尔用手掏排便的患者数明显减少(P<0.01);需要外用衬垫或塞子、使用止泻剂的患者显著减少(P<0.001);排便不尽感、腹胀、腹痛/腹部不适缓解(P<0.05)。结论STARR或Altemeir手术是治疗脊髓损伤患者直肠脱垂安全有效的方法。     

Pelvic recurrence of cancer after abdominoperineal resection of the rectum

Records of 122 patients with carcinoma of the rectum treated by abdominoperineal resection at M. D. Anderson Hospital and Tumor Institute between 1967 and 1972 were reviewed with regard to local pelvic recurrence and survival. Local recurrence rates for men were: stage IB, 14%; II, 23%; and III, 21%; and for women: IB, 6%; II, 15%; and III, 35%. Forty-one percent of the male patients and 54% of female patients had nodal metastasis at the time of their initial operation. The high pelvic recurrence rates in women may lend support to consideration of a posterior exenteration in all female patients with advanced carcinoma of the rectum.     

直肠癌改良术74例观察

目的探讨改良结肠肛管吻合术在低位直肠癌治疗中的价值。方法回顾分析74例低位直肠癌的术后并发症及疗效。结果术后发生吻合口瘘4例，吻合口狭窄18例，无手术死亡和肛门失禁；盆腔复发10例。结论改良结肠肛管吻合术在保留肛门功能的同时，避免了预防性横结肠造口，其局部复发率与低位前切除和经腹会阴切除相似。     

阴道超声结合肠灌注液体诊断女性直肠癌的临床价值

目的 开辟女性直肠癌检查的新途径,探索阴道超声结合直肠灌注液体诊断女性直肠癌的临床价值,方法 对临床拟诊为直肠癌者２１例,卵巢癌侵犯直肠前壁７例患者,先向直肠内灌注无菌生理盐水１５０ml左右,再经阴道超声检查。结果 经阴道超声结合直肠灌注液体能清晰显示直肠解剖及毗邻,检查成功率、病灶显示率和定位正确率为１００％,贫苦诊断准确率为85.71%。结论 经阴道超声结合小剂量直肠灌注诊断女性直肠癌的检查成功率、定位准确率、病灶显示率、分期诊断准确率可以与直肠超声媲美。有一定的临床价值。     

盆静脉浸润对直肠癌预后的意义

目的：探讨直肠癌盆静脉浸润对预后的影响。方法：484例中低位直肠癌经腹会阴联合切除术（APR）（共356例）、低位前切除术（LAR）（共128例）后，对肿瘤因素进行分类，依据复发与五年生成的随访结果，就盆静脉浸润进行多因素回顾性统计分析。结果：总的复发率为14．5％，累积的五年生存率为71．1％，其中盆静脉浸润者分别为：44．4％（52／117）、29％（34／117）。Cox风险比例模型多因素回归分析显示：盆静脉浸润对五年生存的影响具有独立特性。结论：直肠癌盆静脉浸润是影响五年生存具有独立特性的高危因素，是准确预测患者的预后、指导术后系统的辅助治疗及随访的重要指标，也是临床病理分期方案的基准。     

直肠癌手术并发症的处理

目的 :探讨直肠癌手术并发症发生的原因、预防措施及处理方法。方法 :回顾性总结分析 1983～ 2 0 0 2年间 9例直肠癌手术并发症的临床资料。Miles手术并发症 7例 ,直肠前切除 2例 ;并发症包括吻合口漏 1例 ,人工肛门狭窄 2例 ,尿道损伤 2例 ,盆底腹膜裂孔疝 3例 ,骶前静脉丛出血 1例。结果 :盆底腹膜裂孔疝、吻合口漏、1例人工肛门狭窄经再次手术痊愈 ,尿道损伤修补后发生尿瘘 ,骶前静脉丛出血用ZT胶粘堵控制出血。结论 :直肠癌手术并发症重在预防 ,及时有效地处理这些并发症也很关键。