超声刀联合双吻合器在开放直肠癌低位前切除术中的应用

目的 探讨超声刀联合双吻合器在开放直肠癌低位前切除术中的临床应用价值.方法 40例拟行直肠癌低位前切除的患者随机分为应用超声刀联合双吻合器20例作为研究组,应用高频电刀联合单吻合器20例作为对照组.比较2组的保肛成功率,同时观察保肛成功病例2组间手术时间、术中出血量、术后第1个24h引流量、术后并发症、肠功能恢复时间及住院时间的差异.结果 研究组保肛成功19例(95％),对照组保肛成功14例(70％),2组相比P=0.037;33例保肛成功患者中,研究组手术时间(102.5±14.6m)较对照组(114.7±17.5m)明显缩短(P=0.032);研究组手术出血量(62.5±19.3)mL较对照组(91.3±26.5)mL显著减少(P=0.001);术后第1个24h引流量研究组和对照组分别为(33.6±15.0)mL、(65.7±25.9)mL(P＜0.001);术后首次排气时间分别为(2.4±0.6)d、(2.9±0.4)d(P=0.004);术后平均住院天数研究组较对照组也显著缩短(P=0.014);2组术后并发症无显著差异(P=0.674).结论 开放直肠癌低位前切除术中应用超声刀联合双吻合器是直肠癌手术向微创手术理念和快速康复外科理念发展的尝试,在开放直肠癌手术领域具有广泛的应用前景.     

超声刀联合双吻合器在开放直肠癌低位前切除术中的应用

目的探讨超声刀联合双吻合器在开放直肠癌低位前切除术中的临床应用价值。方法40例拟行直肠癌低位前切除的患者随机分为应用超声刀联合双吻合器20例作为研究组,应用高频电刀联合单吻合器20例作为对照组。比较2组的保肛成功率,同时观察保肛成功病例2组间手术时间．术中出血量,术后第1个24h~]流量．术后并发症,肠功能恢复时间及住院时问的差异。结果研究组保肛成功19倒（95％）,对照组保肛成功14倒（70％）,2组相比P=o．037;33例保肛成功患者中,研究组手术时间（102．5±14．6m）较对照组（114．7±17．5m）明显缩短（P=0．032）;研究组手术出血量（62．5±19．3）mL较对照组（91．3±26．5）mL显著减少（P=O．001）;术后第1个24hql流量研究组和对照组分别为（33．6±15．O）mL,（65．7±25．9）mL（P〈O．001）;术后首次排气时间分别为（2．4±0．6）d,（2．9±0．4）P=O．004）{术后平均住院天数研究组较对照组也显著缩短（P=0．014）;2组术后并发症无显著差异（P=0．674）。结论开放直肠癌低住前切除术中应用超声刀联合双吻合器是直肠癌手术向微创手术理念和快速康复外科理念发展的尝试,在开放直肠癌手术领域具有广泛的应用前景。     

二联式经肛外手工吻合在腹腔镜超低位直肠癌保肛术中的应用

目的 探讨二联式经肛外手工吻合在腹腔镜超低位直肠癌保肛术中的应用价值.方法 应用超声刀在腹腔镜下对12例超低位直肠癌患者实施全直肠系膜切除原则的根治性手术,用肛门部二联式手工吻合法完成结-直肠/肛管吻合.结果 12例患者手术经过均顺利,无中转开腹,术后发生吻合口瘘1例,无腹腔出血、感染、吻合口狭窄等并发症.手术时间185～310(218±10)min.术中出血160～450(232±8)ml,住院时间9～14(11±3)d.全部病例术后随访6～36(18±2)个月,术后无局部复发,远处肝转移1例.结论 超低位直肠癌行腹腔镜下超低位切除、肛门部二联式手工吻合保肛术是一种安全、经济、创伤小、疗效可靠,并具有出血少、住院时间短等优点,值得推广使用.

Abstract：

Objective To explore the values of manual anastomosis with two operations out of anus in laparoscopic anal sphincter preserving resection of ultra low rectal cancer. Methods Radical excision of ultra low rectal cancer was performed with ultrasonic scalpel in 12 patients based on the concept of total mesorectal excision (TME) and ultra low coloreclal/anal anastomosis was performed applying manual anastomosis with two operations out of anus. Results All the operations were finished successfully, without conversions to open for surgery. One case had anastomotic leakage, and there were no bleeding and infection of abdominal cavity, anastomotic stenosis and other complications. The operating time was 185-310 (218 ±10) min, the blood loss was 160-450 (232 ±8) ml,the length of hospital stay was 9-14 (11 ±3) d. All patients were followed up 6-36(18 ± 2) months, local recurrence was not found but 1 case had liver metastasis.Conclusions The manual anastomosis with two operations out of anus in laparoscopic anal sphincter preserving resection of ultra low rectal cancer is safe,economical,effective,minimally invasive, and has the benefits of less bleeding during the operation and shorter hospital stay. It should be widely used.     

中低位直肠癌保肛手术临床分析

目的探讨保肛术治疗低位直肠癌患者的临床效果。方法回顾性分析2002年5月至2009年5月期间中低位直肠癌保肛手术治疗的58例患者的临床资料,所有患者均经过手术病理确诊。手术遵循直肠癌根治切除术和直肠系膜全切除术的原则,远近切缘距肛瘤分别至少达2.5cm及8cm,应用双吻合器法于骶前行结直肠端端吻合。结果 58例全部完成保肛手术,2例术后2周内发生吻合口漏,3例发生吻合口狭窄,无手术死亡。平均随访3年,局部复发3例。结论严格掌握保肛手术指征、合理选择患者、规范手术是中低位直肠癌保肛根治手术成功的关键。     

超低位直肠癌保肛术中应用双吻合器的护理

目的探讨超低位直肠癌保肛术中应用双吻合器的护理。方法对45例应用双吻合器的超低位直肠癌病人,术前给予心理护理、肠道准备及肛门括约肌的锻炼,术后进行一般护理、吸氧及呼吸道护理、管道护理、吻合口瘘的护理、饮食护理、肛门括约肌舒缩功能恢复训练和肛周护理。结果 45例病人均未出现护理相关并发症,病人对护理结果满意。结论采用双吻合器进行超低位直肠癌前切除与吻合,术前成功的肠道准备、术后管道的护理、吻合口瘘的观察、肛门括约肌舒缩功能恢复训练和肛周护理,是手术成功、预防并发症的关键。     

腹腔镜辅Dixon术行超低直肠癌切除保肛手术的临床效果分析

目的 探讨使用腹腔镜辅助Dixo术进行超低位直肠癌切除保肛手术的临床效果.方法 将我院2009年1月至2011年7月收治的超低位直肠癌选择保肛手术患者随机分为2组,对照组患者给予Dixon术治疗,实验组患者给予腹腔镜辅Dixon术治疗,比较2组患者的治疗效果和手术后患者并发症的发生率.结果 实验组患者手术中出血量少,患者住院时间短,其尿管留置时间短,术后肠道功能恢复较早,与对照组患者比较有显著差异,P＜0.05,差异有统计学意义.结论 采用腹腔镜辅Dixon术行超低直肠癌切除保肛手术具有较好的效果,患者手术后并发症少,值得在临床应用.     

腹腔镜下全直肠系膜切除术治疗低位直肠癌临床疗效观察

目的 探究腹腔镜下全直肠系膜切除术对治疗低位直肠癌临床疗效及优越性.方法 将86例低位直肠癌患者随机分为观察组和对照组,观察组给予腹腔镜下全直肠系膜切除术,对照组给予开腹全直肠系膜切除术,观察2组患者术后复发率、死亡率及手术效果.结果 2组复发及死亡率比较无显著性差异(P＞0.05),2组手术时间、清除淋巴结数目比较无显著差异(P＞0.05);观察组术中出血量及肠功能恢复时间均明显低于对照组(P＜0.05).结论 腹腔镜下全直肠系膜切除术治疗低位直肠癌安全可行,具有创伤小、术中出血量少、胃肠功能恢复快等优点,可作为目前治疗低位直肠癌的一种较佳手术方案.     

低位直肠癌保肛手术适应症选择与评价

目的 探讨低位直肠癌保肛手术适应症选择标准，评价保存肛术后临床效果。方法 根据肛门指诊、直肠腔内超声、盆腔ＣＴ、ＭＲＩ、术前活检病理，９６例低位直肠癌用美国ＪＯＨＮＳＯＮ吻合器或／和闭合器行结肠直肠（肛管）吻合术。低位直肠保肛手术适应症选择标准：高中分化腺癌、隆起型、未浸透深肌层、环周度≤１／２周，无肠旁淋巴结肿大、距齿状线１ ｃｍ以上；高中分化腺癌、溃疡型≥１／２周，浸透肠壁深肌层、无盆腔淋巴结肿大、距齿状线３ ｃｍ以上；低分化腺癌、粘液腺癌未浸透深肌层，环周度≤１／２周，无肠旁淋巴结肿大，距齿状线４ ｃｍ以上，在完成全直肠系膜切除和淋巴结清扫的基础上保留肛门。结果 全组除发生１例直肠阴道瘘外无手术死亡及其它严重并发症。寿命表法计算３年生存率７８．１％，局部复发率５．２％。术后病人排便功能优者达８４．０％，１２～１８月排便次数和排便功能接近正常状态，无完全性排便失禁。结论 低位直肠高中分化腺癌隆起型，未浸透肠壁深肌层，环周度≤１／２周，无肠旁淋巴结肿大，距齿状线１ ｃｍ以上；高中分化腺癌溃疡型≥１／２周，浸透肠壁深肌层，无盆腔淋巴结肿大，距齿状线３ ｃｍ以上。低分化腺癌、粘液腺癌未浸透深肌层，环周度≤１／２周，无     

双吻合器在超低位直肠癌保肛手术中的应用

目的评价双吻合器技术在超低位直肠癌保肛术中的实用性。方法回顾分析本院2008年1月-2011年8月45例超低位直肠癌应用双吻合器技术保肛的临床资料。结果本组手术中45例患者均吻合顺利,术后1例吻合口瘘,无出血病例发生,吻合口狭窄2例（4.44%）,无手术死亡病例。结论应用双吻合器技术可极大提高超低位直肠癌保肛率,且并发症少,安全可行,值得推广。     

Histologic response after neoadjuvant therapy in rectal adenocarcinoma: own experience and review of the literature

BACKGROUND: Neoadjuvant therapy has improved outcomes for patients with locally advanced rectal cancer. AIM AUTHORS: We studied the degree of histopathological regression after radiotherapy regimens commonly used in their clinical practice, and its effect on the pathology of by clinically founded T3-T4 rectal cancer. PATIENT AND METHODS: A total of 57 patients were investigated who underwent neoadjuvant radiotherapy or chemoradiotherapy--commonly used at our institute--for biopsy proven primary mid or lower third rectum adenocarcinoma between January and December 2004. The standard surgical treatment was anterior resection sec Dixon, Lloyd-Davies--and Hartmann's procedure, all with total mesorectal excision. RESULTS: The surgical specimens were examined by selected pathologists and a modified pathologic staging system the Rectal Cancer Regression Grade (RCRG) was used. (I) "good" response (n=12, 21%), (II) "median" response (n=25, 44%), (III) "poor" response (n=20, 35%). Significant tumor regression (RCRG I-II.) was seen in 37 patients (65%). Six patients (10.5%) have had complete pathological regression and 6 patients (10.5%) have had only microscopic foci of adenocarcinoma. CONCLUSION: Comparing of pretreatment and pathologic staging revealed that the depth of invasion was significantly downstaged. The authors also reviewed the literature of neoadjuvant therapy, total mesorectal excision, prognostic and predictive factors of rectal cancer.     

腹腔镜与开腹全直肠系膜切除保肛术治疗低位直肠癌临床对比的研究

目的 比较腹腔镜与开腹全直肠系膜切除保肛术在低位直肠癌治疗中的临床应用.方法 将2006年1月至2008年6月收治的106例低位直肠癌患者根据意愿分别接受腹腔镜手术(腹腔镜组,51例)和传统开腹手术(开腹组,55例),对比两组的手术安全性、疗效和随访结果.结果 两组均无术中、术后严重并发症和手术死亡病例,保肛率100%.腹腔镜组排气时间、进半流食时间、住院时间分别为(2.4±0.6)、(5.4±0.6)、(9.2±3.2)d,与开腹组比较差异有统计学意义(P＜0.01或＜0.05);腹腔镜组切除标本长度为(15.4±1.4)cm,肿瘤下缘距切缘距离为(5.4±1.2)cm,清扫淋巴结数目为(8.5±2.4)个,与开腹组比较差异无统计学意义(P＞0.05).腹腔镜组35例(68.6%)和开腹组39例(70.9%)在1个月内恢复控便能力;术后随访6～36个月,两组均无腹壁切口种植、局部复发以及死亡病例.结论 腹腔镜全直肠系膜切除保肛术治疗低位直肠癌能取得与开腹手术同样的肿瘤根治性效果,并具有创伤小、出血量少、术后恢复快等优点,是切实可行的微创手术.     

同步新辅助放化疗联合全根治性切除治疗中低位局部进展期直肠癌的探索研究

目的：探讨同步新辅助放化疗联合全直肠系膜切除术（TME）治疗中低位局部进展期直肠癌的可行性及安全性。方法：选取2013年6月-2014年6月本院23例中低位局部进展期直肠癌患者,Ⅱ期（T3-4No Mo）11例,Ⅲ期（T1-4N1-2Mo）12例,均接受术前同步新辅助放化疗（术前放疗总剂量全盆腔DT 40-46Gy/20-23 Fx,瘤床区加量至50-56 Gy/25-28 Fx;化疗采用含希罗达方案2个周期）。同步新辅助放化疗结束后4-8周行手术治疗,遵循TME原则,并尽可能保肛。结果：22例患者均完成同步新辅助放化疗,放化疗期间3级毒副反应总发生率为27.3%,无4级毒副反应者。放化疗后CR 2例、PR 14例、SD 4例;16例（80%）患者的临床TNM分期下降。同步新辅助放化疗结束后4-8周,20例患者行根治性手术治疗,其中12例行低位或超低位前切除术（Dixon术）,7例行腹会阴联合切除术（Miles术）,1例行Hartmann手术,保肛率为60.0%（12/20）。无一例发生围手术期死亡,术后并发症的总发生率为20%（4/20）。结论：同步新辅助放化疗联合TME治疗中低位局部进展期直肠癌安全而有效,可以降低肿瘤分期、提高肿瘤切除率和保肛率,改善患者的生活质量。     

腹腔镜全直肠系膜切除保肛治疗直肠癌的手术技术探讨

目的探讨腹腔镜直肠癌全直肠系膜切除（Laparoseopie Total mesorectal excision，LTME）保肛术的可行性、安全性、操作要点及治疗效果。方法回顾分析51例腹腔镜直肠全系膜切除术患者的临床资料。结果51例患者手术顺利，无中转开腹，手术时间（128～280）min，平均143min；术中出血20～130ml，平均40ml；淋巴结清扫9～24枚，平均13．1枚。术后30～72h恢复胃肠功能并下床活动，住院时间5～16d，平均9d。51例术后随访1～36个月，平均17个月，均未发现吻合口肿瘤复发及远处转移。结论只要熟练地掌握腹腔镜下结肠、直肠毗邻结构的解剖，运用规范的操作和合理的手术技巧，腹腔镜直肠癌全直肠系膜切除保肛术安全可靠、创伤小、出血少、痛苦少、恢复快，是目前治疗直肠癌的一种较为理想的方法。     

Place of abdominoperineal excision in rectal cancer.

In an attempt to elucidate if and when there is a place for abdominoperineal excision in rectal cancer, we have evaluated survival, risk of local recurrence and functional results of alternative procedures. There seems to be no difference in survival rate after intended curative surgery for rectal cancer between rectal excision and sphincter-saving resection. This is also true with respect to risk of local recurrence, except in patients with poorly differentiated Dukes' C tumours, where the risk of significant distal intramural spread is increased. Functional results are satisfactory after low anterior resection with colorectal anastomosis, whereas colo-anal anastomosis is followed by less satisfactory results especially in elderly patients. In these patients rectal excision with a permanent colostomy is probably preferable.     

直肠癌前切除术后局部复发的危险因素研究及其预防

目的分析直肠癌患者前切除术后局部复发的危险因素并探讨有效的预防措施。方法选择2007年10月-2010年1月湖北省肿瘤医院行直肠癌前切除术的98例患者,统计术后局部复发比例,分析复发的危险因素。结果本组98例患者的术后局部复发率为11.2%（11/98）,其发生与性别、年龄、肿瘤距肛缘距离、全系膜切除、辅助化疗、病理分型恶性程度及Duck’s分期相关（P〈0.05）。结论临床工作者应了解直肠癌前切除术后局部复发的危险因素,注意针对危险因素采取相应的预防措施,降低患者术后局部复发率,提高患者的生活质量。     

老年低位直肠癌保肛手术与腹会阴联合切除术疗效评价

目的探讨低位直肠癌保肛术与腹会阴联合切除术对病人术后并发症和肿瘤复发影响。方法随访2009年7—12月期间我院普外科手术治疗56例低位直肠癌,对保肛手术(LAR)与经腹会阴联合切除术(APR)两组病人的临床病理指标、术后并发症和局部复发状况进行统计学分析。结果 LAR组吻合口漏发生率明显较APR组高,差异有显著性(P<0.05),两组术后局部复发率比较,差异无统计学意义(P>0.05)。结论低位直肠癌保肛术与腹会阴联合切除术并不影响低位直肠癌病人术后肿瘤复发,但LAR较易发生吻合口瘘。     

Colo-anal anastomosis, a strong competitor of preternatural anus

A colostomy after a rectum amputation has great impact on a patient's lifestyle. An alternative that can restore anal defaecation after rectum extirpation for low-seated lesions is attractive if the method does not increase mortality or morbidity, if functional results are good and if oncological principles can be maintained. In selected cases a colo-anal anastomosis after rectal excision can be an alternative to a colostomy. The technique originates from pouch-anal anastomosis techniques after total proctocolectomy for ulcerative colitis and familial polyposis coli. Based on the literature and the results of seven of our own patients the method, its complications, its functional results and the oncological consequences are discussed. The conclusion is that in selected cases of rectal carcinoma the method can prevent a colostomy without increasing morbidity or mortality, with good functional results and according to oncological principles. Especially when a lesion is located distally in the rectum, the method is often applicable when a low anterior resection is not, or technically easier than a low anterior resection.     

Local recurrences and primary surgery in rectal carcinoma

BACKGROUND: The authors analyze retrospectively a consecutive series of rectal carcinomas operated on with different surgical strategies at Third Surgical Department of "La Sapienza" University of Rome, between January 1985 and December 1997, by one expert surgeon (GDM), and report the incidence of the local recurrence correlated to the surgical technique development. METHODS: In most recent groups of patients treated for extraperitoneal neoplasm from January 1992 with curative (R0) total mesorectal excision (TME) and nerve sparing technique (NST) (Group C, n = 47) and with curative TME plus lateral pelvic lymphadenectomy (LPL) and NST (Group D, n = 7), sacrificing the pelvic autonomic nervous system only in case of neoplastic infiltration, the local recurrence was 8.5% (4 cases, with mean interval of 30.5 months) and 0 respectively at mean follow-up of 44.9 and 55 months. RESULTS: In none of the local recurrences of the Group C a re-resection (neither curative nor palliative) was possible and the survival was 50% at 14 months from the diagnosis of relapse. Instead, in local recurrences of rectal carcinoma in patients who underwent a first anterior resection with less extended dissection in other Department (Group E), a re-resection was possible for 3 cases out of 4 (R0, R1 and R2 operations); re-resected patients are now alive at mean follow-up of 33.6 months (82, 12 and 7 months, respectively). In Group A patients, treated between January 1985 and December 1988 with partial mesorectal excision (R0) also for extraperitoneal localization, the incidence of local relapses is 21.9% (9/41 cases) vs 11.2% (11/98 cases) in Group B patients, treated from January 1989 with curative TME for extraperitoneal tumors. CONCLUSIONS: The incidence of local recurrences of extraperitoneal rectal cancer can be reduced by total mesorectal excision. The total sparing of pelvic autonomic nervous system in advanced rectal carcinoma doesn't increase the incidence of local recurrences.     

直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症剖析及防治

目的探讨直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症的形成原因及防治方法。方法回顾性分析按TME原则手术的120例低位直肠癌行保肛手术的临床资料。结果术后发生吻合口漏7例,占5.8%,吻合口出血8例,占6.7%,吻合口狭窄5例,占4.2%。结论在低位直肠癌保肛手术中,严格掌握低位直肠癌行保肛手术的指征、充分的术前准备、保证吻合口的血供、正确选择和使用吻合器及引流管是降低吻合口并发症发生的关键,对术后吻合口漏视具体病情采用个体化治疗。     

直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症剖析及防治

目的探讨直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症的形成原因及防治方法。方法回顾性析按TME原则手术的120例低位直肠癌行保肛手术的临床资料。结果术后发生吻合口漏7例,占5．8％,吻合口出血8例,占6．7％,吻合口狭窄5例,占4.2％。结论在低位直肠癌保肛手术中,严格掌握低位直肠癌行保肛手术的指征、充分的术前准备、保证吻合口的血供、正确选择和使用吻合器及引流管是降低吻合口并发症发生的关键,对术后吻合口漏视具体病情采用个体化治疗。