完全经肛门全直肠系膜切除——腹腔镜直肠癌手术未来的方向?

全直肠系膜切除(TME)显著改善了直肠癌的外科治疗效果。随着腹腔镜技术发展,腹腔镜TME手术亦得到广泛开展。经过20余年的发展和循证医学证据的积累,腹腔镜TME手术虽然在微创效果方面显示出一定的优势,但在术后严重并发症发生率及术后住院时间方面并未显示出显著的优势。因此,结合经自然孔道内镜外科手术(NOTES)、经肛门内镜显微手术(TEM)及单孔腹腔镜手术(SILS)衍生发展出的经肛门全直肠系膜切除(ta TME)成为新的关注热点。进一步提出的完全经肛门TME手术(pure ta TME)更是凝聚了直肠癌微创外科技术的精华。在确保直肠癌手术根治性效果的基础上,不断探索最大程度降低手术创伤或将成为TME手术未来发展方向。     

经肛门直肠全系膜切除术现状及研究进展

全直肠系膜切除理念的提出是直肠癌外科治疗一项重要的变革,伴随腹腔镜技术的应用,使得腹腔镜下经肛门全直肠系膜切除术越来越被外科医师关注。对于肿瘤较大、骨盆狭小的男性肥胖患者,中低位直肠的暴露和分离仍然是个问题,而腹腔镜下完全经肛门全直肠系膜切除术可能是一种潜在的解决途径,在达到直肠癌根治切除要求的同时又尽可能保留肛门、避免腹部切口,患者不仅术后生活质量得到提高,而且美观。随着操作器械、手术平台的不断完善及经验总结后,该术式将有望在中低位直肠癌治疗中占重要地位。     

从TaTME发展看直肠癌微创外科治疗进步

随着科学技术的进步和对疾病本身认识的深入，直肠癌的外科治疗从局部切除到全直肠系膜切除（TME），从开放手术到腹腔镜手术，再从腹腔镜手术到机器人手术，目前已经进入微创时代。在此时代背景下，经肛门全直肠系膜切除（TaTME） 应运而生。正如TME的提出者Heald所言：“TaTME是近30年直肠癌外科治疗技术的集大成者”，其发展的每一个阶段都有很强的代表性，已成为直肠癌微创外科治疗技术进步发展的一个缩影。     

直肠癌机器人手术与腹腔镜手术的肿瘤学和功能学结果比较

直肠癌腹腔镜手术的环周切缘阳性率较高,近年来发展起来的机器人手术有望改善患者的预后。为比较机器人手术与腹腔镜手术的治疗效果,D’Annibale A等遵循全直肠系膜切除（TME）原则对100例直肠癌患者施行了微创前切除术,其中50例患者行机器人全直肠系膜切除术（R—TME）,另50例行腹腔镜全直肠系膜切除术（L—TME）。     

腹腔镜下直肠癌根治术14例

目的探讨经腹腔镜全直肠系膜切除术(TME)+经直肠肌鞘结肠拖出术(Soave)治疗直肠癌的可行性。方法经腹腔镜对14例直肠癌病人实施TME,并行Soave手术。结果14例手术顺利。手术时间150～260min,平均205min;术中出血50～200ml,平均125ml;术后1～2d恢复胃肠功能并下床活动;住院3～12d,平均7d。术后2例应用镇痛剂,无并发症发生,无死亡。结论经腹腔镜TME+Soave治疗直肠癌安全可行,能更好地保护自主神经,术后肛门括约肌功能良好。     

经自然腔道取标本在腹腔镜直肠癌根治术中的应用进展

直肠癌根治手术从最初提出全直肠系膜切除(TME)理念到腹腔镜广泛应用于直肠癌根治,经过30多年的迅猛发展,腹腔镜直肠癌TME手术现已成为直肠癌患者的首选术式,但是该手术用于取出肿瘤标本的腹壁辅助切口与当今微创手术理念相悖,避免腹壁切口成为胃肠外科医生和直肠癌患者共同诉求。经自然腔道取标本手术(NOSES)在全腔镜下完成直肠癌根治及消化道的重建,标本经自然腔道(直肠或者阴道)取出,无腹壁辅助切口,更符合微创实际,操作更简便。研究NOSES腹腔镜直肠癌根治术的手术进展,旨在为该术式提供一定的参考。     

直肠癌经肛门全直肠系膜切除术的临床应用

经肛门全直肠系膜切除术(Ta TME)自出现以来即受到广泛关注。Ta TME手术能够避免腹腔镜直肠癌根治术的部分缺陷,达到理想的环周切缘和远端切缘。Ta TME手术过程中要注意患者的术前评估,选择适宜的病例,沿明确的组织筋膜间隙进行游离,注意解剖结构的辨识,避免神经及输尿管的损伤。新设备新器械有助于Ta TME手术的开展,其安全性及有效性需临床研究的进一步支持。     

腹腔镜辅助经肛门全直肠系膜切除术治疗中低位直肠癌的临床体会

目的:探讨腹腔镜辅助经肛门全直肠系膜切除术治疗中低位直肠癌的临床价值.方法:选取2018年5月至2019年3月为5例中低位直肠癌患者行腹腔镜辅助经肛门全直肠系膜切除术的相关临床资料.结果:5例均顺利完成手术,无中转开腹,2例行预防性回肠外置,手术时间平均(302.20±51.72)min,术中出血量(102.35±20...     

腹腔镜全直肠系膜切除术治疗直肠癌短期疗效及并发症的临床研究(附32例报告)

目的:探讨腹腔镜全直肠系膜切除术(TME)治疗直肠癌的短期临床疗效及并发症的预防。方法:回顾分析2001年至2004年行腹腔镜全直肠系膜切除术的直肠癌32例临床资料。结果:除1例外均在腹腔镜下完成手术,保肛率为90.6％,总并发症发生率为21.8％,局部复发率为6.2％,无手术死亡、术后肝转移及远处转移。平均术后胃肠功能恢复时间1.5d,平均住院时间12.4d。结论:腹腔镜全直肠系膜切除术治疗直肠癌的短期临床疗效可靠。严格掌握手术适应证、中转开腹指征及TME手术原则,提高腹腔镜技术水平是降低并发症发生率,提高短期手术疗效的关键。     

直肠癌根治-腔镜下TME:现状与评价

迄今 ,手术切除仍然是治疗直肠癌的主要手段。近年大宗病例研究表明 ,在诸多根治术式中 ,全直肠系膜切除术(totalmesorectalexcision ,TME)在降低局部复发率、提高 5年生存率、增加保肛率以及改善病人生活质量等方面正在起着划时代的推动作用 ,已为越来越多的结直肠外科医生作为直肠癌治疗的金标准。随着TME理念的深入和腹腔镜技术的发展 ,腹腔镜全直肠系膜切除术 (laparoscopictotalmesorectalexcision ,LTME)、低位、超低位、结肠 肛管吻合术等直肠癌微创术式正在兴起 ,前瞻性临床研究的初步结果已显示出该术式具有良好的应用前景 ,…     

腹腔镜下全直肠系膜加经内外括约肌间切除用于超低位直肠癌保肛手术

目的:探讨腹腔镜下全直肠系膜加经内外括约肌间切除术治疗超低位直肠癌的可行性及优势。方法:回顾分析2004年11月至2005年11月7例腹腔镜下全直肠系膜加经内外括约肌间切除治疗超低位直肠癌的临床资料。结果:本组7例术中出血量30~80m l,手术时间3.5~5h,无术中死亡病例,术后持续胃肠减压24h,术后24~48h开始饮食,术后3d拔除尿管下床活动,术后1~2d开始排便。术后住院7~10d。随访3~6个月,无局部复发。结论:腹腔镜下按全直肠系膜切除术(TME)要求游离直肠至盆底耻骨直肠肌水平,经肛门于齿状线水平切断直肠,再经肛门手工行结肠-肛管吻合的方法治疗超低位直肠癌,能够保证完整切除直肠系膜,术中减少出血,住院天数缩短,在降低手术难度、提高保肛率等方面有其优势。患者对本术式的耐受性较好。     

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??Pure transanal total mesorectal excision: the future development direction of laparoscopic rectal cancer surgery? ZHANG Zhong-tao.Department of General Surgery, Beijing Friendship Hospital, Capital Medical University??National Clinical Research Center or Digestive Diseases, Beijing100050,China
Abstract Total mesorectal excision (TME) significantly improved the prognosis and effect of surgical treatment of rectal cancer. With the emergence and popularization of laparoscopic technique, the laparoscopic TME has been gaining acceptance rapidly and widely. With the gradual accumulation of medical evidence for more than 20 years, although the laparoscopic TME shows some advantages in minimally invasive effect, the postoperative serious complications and postoperative hospitalization time did not show a significant advantage. Therefore, combined with many kinds of technology including natural orifice transluminal endoscopic surgery, the transanal endoscopic microsurgery and the single incision laparoscopic surgery, the transanal total mesorectal excision (taTME) has become a new focus. Further proposed, the pure transanal total mesorectal excision (pure taTME) is a large collection of minimally invasive surgical techniques for rectal cancer.The trend of surgical treatment for rectal cancer is toward less invasive surgical techniques which should maintain the principles of oncologic resection obtained with TME.     

超声刀在腹腔镜直肠全系膜切除术中的临床应用

目的探讨超声刀在腹腔镜直肠全系膜切除术（Total mesorectal excision，TME）的临床应用价值。方法我院自2004年8月～2007年5月。应用超声刀在腹腔镜下对33例直肠癌患者实施TME术。结果33例患者手术顺利，无中转开腹，手术时间115～320min，平均155min；术中出血10～100ml，平均50ml；术后1～2d恢复胃肠功能并下床活动。住院时间5—14d，平均8d。术中及术后无并发症发生。术后随访1月至3年，无复发。结论应用超声刀行腹腔镜TME术，保肛率高，创伤小，出血少，烟雾少。术后恢复快，是一极具应用前景的微创外科新技术。     

Current state of laparoscopic rectal cancer surgery in Australasia

Background: To establish the current surgical approach to rectal cancer in a group of colorectal surgeons in Australasia and the current opinion regarding laparoscopic rectal cancer surgery. Methods: An online survey was distributed to the Colorectal Surgical Society of Australia and New Zealand members. Results: 123/177 surgeons responded. During the last year, 94.3% had performed a laparoscopic colorectal case, 77.2% a laparoscopic rectal case and 65% a laparoscopic rectal cancer case. The most common approach to high anterior resection was pure laparoscopic (52.8%). Low anterior resections were most commonly performed with a laparoscopic component (25.2% pure laparoscopic, 33.3% hybrid). Most surgeons (>50%) performed ultra‐low anterior resections or abdomino‐perineal resections via an open technique. In addition, 64.2% intended to perform laparoscopic total mesorectal excision (TME) within 2 years. Most surgeons believe that the quality of laparoscopic TME and oncological outcomes are similar, and surgical access and short‐term outcomes are superior when compared to the open procedure. The major concerns were in performing a low rectal transection, controlling haemorrhage and resource utilization/cost. Conclusion: Laparoscopic rectal surgery is now widely practiced by Australasian colorectal surgeons and projected to increase in the near future. However, only 10% of surgeons are routinely performing total laparoscopic ultra‐low anterior resections which may have implications for the generalizability of clinical trials in laparoscopic TME and the ability to credential surgeons in this technically challenging field. Quality of TME and oncological outcomes were rated similar to the open operation. Areas of concern included low rectal transection, haemorrhage control and resource utilization/cost.     

腹腔镜全系膜切除术联合经肛门内括约肌切除术治疗超低位直肠癌42例

目的探讨腹腔镜全系膜切除术（TME）联合经肛门内括约肌切除保肛术（ISR）治疗超低位直肠癌的临床疗效。方法选择2009年1月至2012年6月42例超低位直肠癌患者采用腹腔镜TME联合ISR术治疗。按TME原则完全游离切除直肠后,经肛门内括约肌切除,完成超低位直肠癌保肛手术。对患者的临床资料、术后并发症及随访结果进行分析。结果42例患者均顺利完成手术,无中转开腹或者改行Mile’s术式,13例行回肠预防性造口,2例发生吻合口瘘,经保守治疗治愈。所有患者术后肛门括约肌功能比较满意,无围手术期死亡。随访9-40个月,1例于术后15个月发生肝脏多发转移再次入院进一步治疗。结论对于术前评估早中期超低位直肠癌,特别是肿瘤没有侵犯肛门内括约肌,采用腹腔镜TME联合IRS术是安全可行的,提高了保肛成功率,提高患者术后生活质量且局部复发率低。     

Modern rectal cancer surgery—Total mesorectal excision—The standard of care

The literature has repeatedly shown the superiority of total mesorectal excision (TME) for rectal cancer in reducing the incidence of local recurrence (LR) and improving long-term survival compared to conventional blunt rectal dissection. This article reviews the history of surgery for rectal cancer, supports TME as the standard of care in obtaining a negative circumferential margin (CRM) for mid- and lower-third rectal cancers, discusses the drawbacks of TME, the role of tumor-specific mesorectal excision for upper-third rectal cancers and laparoscopic TME, and emphasizes the need for a selective role of chemoradiation with TME for rectal cancer. The need for standardizing TME in the United States with pathological specimen quality analysis and reporting of the completeness of the TME specimen is also emphasized.     

腹腔镜下直肠癌全系膜切除拖出式吻合8例报告

目的探讨腹腔镜下直肠癌全系膜切除术(total mesorectal excision,TME)的优势及拖出式吻合的使用价值。方法2005年11月~2006年12月对8例直肠癌行腹腔镜下直肠癌TME,经肛门拖出切除并手工吻合。结果8例均完全在腹腔镜下完成全系膜游离后拖出肛门外切除并手工吻合,无辅助切口。手术时间180~300min,平均220min。8例随访8~18个月,平均13个月,未发现穿刺口种植和局部复发。结论腹腔镜下完成全系膜游离,清晰完整,拖出肛门外切除、吻合直观、简便、经济。     

V6The feasibility of laparoscopic rectal resection for cancer

Introduction:  Total mesorectal excision (TME) has offered the lowest recurrence rates and best survival in rectal cancer patients. Recently several multi-centre trials have demonstrated the feasibility of laparoscopic colonic resections for cancer. However the technical difficulties and lack of supporting data has prevented surgeons from attempting laparoscopic TME for operable rectal cancer. We present a video demonstration of lap TME technique performed at our unit for rectal cancer resections.
Methods:  The surgical technique involves using two 10 mm and two 5 mm ports to perform rectal resections. Adherence to advanced oncological principles like high tie of IMA and IMV is the rule. Splenic flexure is routinely mobilised for mid to low rectal cancers. Total mesorectal excision is performed using diathermy hook. Rectal washout is performed before transection of the rectum using lap stapler device.
Results:  Between October 2006–December 2007, 30 rectal cancers have been operated laparoscopically at our institution using this technique. There were four APER and 26 anterior resections. The median age was 72 years with a median BMI of 25. Median operative time was 235 min with a median hospital stay of 7 days. There were no leaks.
Conclusions:  With proper training and experience, laparoscopic rectal cancer resection is technically feasible and safe to perform with good oncological outcomes.     

腹腔镜与开腹全直肠系膜切除术治疗中低位直肠癌的临床对照研究

目的评价腹腔镜全直肠系膜切除术(TME)治疗中低位直肠癌的可行性、安全性、根治性及近期、中期临床疗效。方法回顾性分析我院2005年10月至2008年10月期间行TME的腹腔镜Dixon术式52例和传统开腹Dixon术式46例并无预防性造口的中低位直肠癌患者的临床资料,对2组的手术学指标、术后恢复情况、肿瘤学指标和近期、中期疗效进行比较。结果 2组患者中除腹腔镜组有2例(3.8%)中转开腹外,其余患者手术均获成功,无围手术期死亡患者。腹腔镜组的术中出血量、术后肠道功能恢复时间(排气时间)和切口愈合情况均优于开腹组(P<0.05),而术后吻合口漏和肺部感染情况2组差异无统计学意义(P>0.05)。2组手术切除标本远切缘和环周切缘病理学检查均为阴性;清扫淋巴结数目和肿瘤下缘距远切缘距离比较,2组差异无统计学意义(P>0.05)。2组术后肿瘤相关死亡、局部复发、远处转移和3年生存率差异均无统计学意义(P>0.05)。结论腹腔镜TME安全、可行,具有明显的微创优势,根治效果满意,近期、中期疗效与开腹手术相近。