经括约肌或尾骨入路的直肠肿瘤局部切除术

本文报道９例低恶性或良性的直肠肿瘤行局部切除术的结果。其中广基无蒂绒毛状腺瘤６例，距肛缘４～９ｃｍ，肿瘤直径２．０～３．５ｃｍ；类癌２例．肿瘤距肛缘７ｃｍ，直径０．５～０．８ｃｍ；血管瘤１例，肿瘤距肛缘４ｃｍ，大小为２．５ｃｍ×５ｃｍ。经肛门前括约肌局部切除４例，经尾骨局部切除４例，经尾骨及括约肌局部切除１例。术后无肛门失禁及复发。作者认为经肛门括约肌或尾骨入路的肿瘤局部切除术对于距肛缘１０ｃｍ以下的直肠低恶性或良性肿瘤是较理想的手术方式。     

内括约肌切除保肛术治疗超低位直肠癌52例临床研究

目的 探讨经腹肛门切除肛门内括约肌的直肠癌根治保肛术治疗超低位直肠癌的临床疗效.方法 对52例癌灶下缘距肛缘4～5 cm的超低位直肠癌经腹肛门切除肛门内括约肌加结肠套叠重建内括约肌保肛术进行临床分析.52例中男29例,女23例.年龄28～76岁,平均为56.3岁.癌灶下缘距肛缘4 cm 18例,癌灶下缘距肛口5 cm 34例.病理诊断直肠腺癌52例,其中高分化者21例,中分化者29例,低分化者2例,腺瘤癌变6例.Dukes分期:A期28例,B期24例.结果 52例术后随访率为88%(46/52),术后随访时间2个月至12年,中位随访时间为5.9年.术后发生吻合口瘘2例(3.8%),吻合口狭窄3例(5.7%),术后6～12个月时肛门排便控制功能基本恢复到正常.术后局部复发3例,术后5年生存牢为24/33例(73%).结论 切除肛门内括约肌的直肠癌根治保肛术能保留良好的肛门排便控制功能,不增加局部复发率,是一种安全有效的超低位直肠癌保肛术式.     

经腹经肛门切除低位直肠癌经肛门行结肠直肠粘膜吻合术32 …

目的 探讨直肠中下段癌保留肛门括约肌功能最佳治疗术式。方法 对采用经腹经肛门切除中下段直肠癌以经肛门行结肠直肠粘膜吻合术３２例，癌灶下缘距肛缘６～７ｃｍ２０，８～１０ｃｍ１２例。结果 全组无手术死亡，无吻合口瘘和吻合口狭窄发生。术后随访３２例６～５２个月，平均２９个月。于术后１９个月局部癌复发１例（３．１％），现仍无癌生存３１例。本组术后８～１２周时排便功能控制良好，为１～３次／ｄ，１８周时肛门排     

直肠类癌的诊断及手术治疗体会(附58例报告)

目的 探索直肠类癌的诊断和手术治疗.方法 结合文献回顾性分析经病理证实的58例直肠类癌的临床资料.结果 54例直径<2 cm经肛门局部切除术后经 6个月至7年随访无1例复发或转移,3例直径>2 cm者行根治性手术,2例发现直肠类癌时已有肝转移灶,1例随访2年半无复发或转移.1例直肠多发类癌行根治性手术随诊2年无复发或转移.结论 直肠类癌应早期诊断,早期治疗,对于<2 cm类癌可采用局部切除,是一种简单安全有效的治疗方法.     

直肠神经内分泌肿瘤的分布特征与治疗

目的 总结直肠神经内分泌肿瘤(NET)的临床分布特征和外科治疗方法.方法 分析2004年1月至2009年6月南京中医药大学第三附属医院11例经治疗的直肠NET患者的临床资料.结果 11例直肠NET占同期直肠恶性肿瘤的1.49%,男性6例,女性5例,肿瘤距肛缘3～7cm,无转移.其中4例在距肛缘4cm以内,占36.4%.所有患者均行外科治疗,4例经肛门行局部扩大切除;6例行内镜下黏膜切除,其中5例术后病理基底部无肿瘤,进行常规随访,1例术后病理提示基底见癌细胞,进行经肛局部扩大切除.另外1例患者肿瘤距肛缘7cm,直径1.5cm,行直肠前切除术.11例患者均得到随访,时间1～78个月(中位随访时间36个月),无复发. 结论 直肠NET临床少见,发生于直肠远端较多,其外科手术原则与直肠腺癌相似.     

保肛手术的术式选择及其评价

本文总结了我院1980年至1997年直肠癌保肛手术1059例经验,并对各种保肛手术适应证选择、优缺点进行讨论和评价。 资料和方法 本组病例共1059例。(1)局部切除139例,其中粘膜下层(SM)癌56例,固有肌层(MP)癌69例,转移癌(M1)14例,经肛切除124例,经骶切除15例,均为高、中分化直肠中下段癌。肿瘤直径<4cm,周径<1/3,活动良好。(2)前切除791例,其中高位前切除(返折上)288例,低位(腹膜返折下)和超低位(距齿线3cm内)前切除503例,均为距肛缘5cm以上高、中分化腺癌,肿瘤活动好,体型偏瘦。(3)拖出吻合术129例,均为肿瘤下缘距肛缘4cm以上高、中分化腺癌,活动好,体型肥胖。局部切除方法是距肿瘤1cm以上全层盘状切除,横形缝合。前切除和拖出吻合术必须切除肿瘤下缘3～5cm以上距离。拖出吻合术是将肿瘤切除,远段直肠翻出肛门外,保留1cm以上直肠与拖出肛门外的近段结肠行全层一期吻合后再返纳回盆腔。术后补加放疗4000rad。     

根治性局部切除治疗直肠癌

早期侵入性直肠癌作根治性局部切除为一行之有效的手术,但选择标准尚不明确.本文报告16例直肠癌经肛管作根治性局部切除,并与Dukes A期肿瘤病人作广泛性切除后,长期随访作比较.病人和方法:1950～1980年作1338例直肠癌手术.16例(1.2%)侵入性癌(穿透粘膜肌层)行根治性局部切除.平均年龄60.9岁.直肠上段癌4例(距肛缘11～18cm),直肠中段癌6例(距肛缘6～11cm),直肠下段癌6例(距肛缘6cm内).268例Dukes A期直肠癌行根治性切除(腹会阴联合切除、前切除或拖出术).平均年龄59.9岁.     

超低位直肠癌切除经肛吻合术

目的:探讨超低位直肠癌根治性切除的保肛手术方法.方法:1998年1月至2005年12月,采用根治性手术治疗距肛门3～4 cm的超低位直肠癌56例.在不影响根治的前提下,选择35例实施根治性切除保肛并经肛吻合手术,另21例实施了Miles手术.结果:保肛手术组:3年以上无瘤生存25例(71.4%);控便情况:全部患者在术后半年内不满意;28例(80%)在术后6～12个月仍不满意,12个月以后基本满意;5例(14.3%)在术后6～12个月基本满意,12个月以后满意.Miles手术组:3年以上无瘤生存15例(71.4%).结论:对距肛门3～4 cm的部分超低位直肠癌患者,在不影响根治的前提下,能完成保肛超低位切除经肛吻合手术;虽控便能力减低,但在生活质量和心理状态等方面与Miles手术相比仍体现出显著的优越性.两种手术方法对患者的预后影响无差异.     

经肛门切割缝合法处理远端肠管在腹腔镜超低位直肠癌保肛术中的应用

目的探讨经肛门切割缝合法处理肿瘤远端肠管在腹腔镜超低位直肠癌保肛手术中的应用价值。方法2005年5月~2007年5月,对施行腹腔镜直肠癌保肛手术的11例超低位直肠癌,经肛门直视在距癌灶最下缘1cm处对肿瘤远端肠管进行缝合-切割-缝合关闭远端肠管,术中冰冻病理检查确认远端切缘无癌细胞残留,再经肛门置入管状吻合器进行肠管端端吻合。结果11例手术均获成功。手术时间115~320min,平均150min;术中出血15~75ml,平均25ml。术中无直肠破裂穿孔、输尿管及邻近器官损伤。吻合口距齿状线0.5~1cm。术后排便次数3~5次/d。术后无吻合口漏及吻合口狭窄等并发症。11例术后3个月肛门测压均正常。11例随访6~31个月,平均18.4月,未发现吻合口复发及穿刺孔、辅助小切口种植转移。结论经肛门切割缝合法处理肿瘤远端肠管在腹腔镜超低位直肠癌保肛手术中既能保证肿瘤远端肠管有足够的切除范围,又能较好地保护肛门括约肌功能。     

经腹腔镜经肛门括约肌间直肠切除结肠肛管吻合术治疗超低位直肠癌13例

目的 探讨经腹腔镜经肛门括约肌间直肠切除结肠肛管吻合术对超低位直肠癌保肛手术的治疗效果.方法 从2005年6月到2007年12月期间对13例患者施行该手术.其中男8例,女5例,平均年龄53岁(41～69岁).肿瘤距离肛缘均小于5 cm.结果 13例手术全部成功,无手术死亡,无吻合口漏发生.随访时间为1～30个月,平均随访17个月,1例盆腔复发,1例肝转移;无戳孔种植转移,术后6个月肛门括约肌功能达优良者9例.结论 经腹腔镜经肛门括约肌间直肠切除结肠肛管吻合术是治疗超低位直肠癌的一种微创、安全、疗效可靠、肛门括约肌功能满意的较理想保肛手术.     

Curative resection of rectal carcinoid tumors with transanal endoscopic microsurgery

Background: Transanal endoscopic microsurgery is a minimally invasive technique for local resection of rectal tumors. Its place needs to be defined for resection of carcinoid tumors of the rectum. Materials and Methods: From 1998 to 2004, rectal carcinoid tumors were diagnosed in 5 patients. The diagnosis was suggested at biopsy in all patients. All tumors were resected full thickness with transanal endoscopic microsurgery. Data were obtained retrospectively from a review of hospital charts. Results: At the time of operation all tumors were small without clinical or biochemical signs of metastasis. All resected tumors were highly differentiated and had free margins without invasion into the submucosa. Operative times ranged from 15 to 35 minutes. Hospital stays ranged from 2 to 4 days. No morbidity or mortality was observed. Follow-up ranged from 3 to 75 months. No recurrences were observed. Conclusion: Transanal endoscopic microsurgery is an excellent technique for removal of carcinoid tumors of the rectum and even the distal part of the sigmoid, if the diameter is <1 cm without invasion of the rectal wall.     

Transanal endoscopic microsurgery for rectal tumors: experience at Korea’s National Cancer Center

Background

Transanal endoscopic microsurgery (TEM) is a minimally invasive alternative to transanal excision, enabling complete local excision of selected benign or malignant rectal tumors. This study aimed to determine the surgical and oncologic results for rectal tumors excised by TEM.

Methods

From November 2001 to October 2007, 45 patients underwent TEM for excision of adenoma (13 patients), carcinoid tumor (6 patients), and carcinoma (26 patients). The patients included 27 men and 18 women with a median age of 52 years (range, 22–72 years).

Results

The median tumor distance from the anal verge was 7 cm (range, 3–15 cm), and the median tumor size was 17 mm (range, 2–60 mm). There was no procedure-related morbidity or mortality. However, one patient with rectal carcinoma died of lung cancer during the follow-up period. Of 13 patients with adenomas, 1 patient (7.7%, 1/13) experienced local recurrence 5 months after surgery. No recurrence occurred for six patients with carcinoid tumors. Histologic examination of the carcinomas showed pathologic tumor (pT) stage 0 (ypT0) in 2 patients, pT1 in 17 patients (including ypT1 in 1 patient), pT2 in 6 patients, and pT3 in 1 patient. Immediate salvage surgery was performed for five patients (19%, 5/26). During a median follow-up period of 37 months (range, 5–72 months), one patient (3.8%, 1/26) experienced local recurrence. The overall and disease-free 5-year survival rates for patients with carcinoma were 96.2% and 88.5%, respectively.

Conclusions

The TEM procedure is a safe and appropriate surgical treatment option for benign rectal tumors. With strict patient selection, it is oncologically safe for early-stage rectal carcinomas.     

Anorectal carcinoid tumors. Is aggressive surgery warranted?

The management of large carcinoid tumors of the anorectum is controversial. Most carcinoid tumors of the rectum and anus are early lesions, adequately treated by local excision. However, because of their relative rarity, the number of advanced cases seen at most institutions is small. Forty-three patients with anorectal carcinoid tumors were treated at our institution between 1960 and 1988 with complete follow-up. The median age of onset was 56 years. Eleven patients had no symptoms and the tumor was detected incidentally in eight additional patients with other diseases. Twenty tumors were larger than 2 cm in diameter and all patients had symptoms. Eight patients had another malignancy and three patients had ulcerative colitis. An association between ulcerative colitis and rectal carcinoid tumors is not widely appreciated. Eighteen tumors were treated by local excision, 16 by radical surgery, and nine underwent only biopsy. With complete resection of the primary lesion, local recurrence was never a problem. The median survival from diagnosis was 38 months in this series and 23 patients died of disease. After detection of metastases, the median survival time was 10 months. Tumors more advanced that T2 or larger than 2 cm in diameter were always fatal. All 13 patients with involved lymph nodes died of metastatic disease, with a median survival of 10 months, although one lived 9 years. Advanced rectal carcinoid tumors are aggressive malignancies. Adequate local excision controls regional disease but rectal carcinoid tumors are cured only when they are discovered before the T3 stage, measure less than 2 cm in diameter, and when lymph nodes are not involved. Consequently if a local excision permits complete resection, radical extirpative surgery will provide little benefit.     

The policy of surgery for small carcinoid tumors of the rectum

In this report, we discuss the current policy of surgery for small carcinoid tumors of the rectum, with reference to our own cases and also to those reported in the literature. Ten cases of rectal carcinoid tumors were surgically treated at the National Kyushu Cancer Center over a period of sixteen years and three months. The tumors ranged in size from 0.2 to 1.0 cm, with an average of 0.5 cm, and all were confined to the submucosa. The lesions were treated by local excision in eight patients and by low anterior resection in the other two cases, where transanal or transsacral excision was considered difficult. No lymph node involvement was found in these two cases. All patients are alive and well without recurrence, after a average follow-up time of three years and six months. According to the literature, the incidence of metastasis from rectal carcinoid tumors smaller than 1 cm is very low, ranging between 1.7 to 3.4 per cent, and it therefore seems that most such lesions can be treated by local excision alone. If, however, any muscle invasion or lymphatic vessel invasion is demonstrated, then radical surgery is recommended.     

The policy of surgery for small carcinoid tumors of the rectum

In this report, we discuss the current policy of surgery for small carcinoid tumors of the rectum, with reference to our own cases and also to those reported in the literature. Ten cases of rectal carcinoid tumors were surgically treated at the National Kyushu Cancer Center over a period of sixteen years and three months. The tumors ranged in size from 0.2 to 1.0 cm, with an average of 0.5 cm, and all were confined to the submucosa. The lesions were treated by local excision in eight patients and by low anterior resection in the other two cases, where transanal or transsacral excision was considered difficult. No lymph node involvement was found in these two cases. All patients are alive and well without recurrence, after an average follow-up time of three years and six months. According to the literature, the incidence of metastasis from rectal carcinoid tumors smaller than 1 cm is very low, ranging between 1.7 to 3.4 per cent, and it therefore seems that most such lesions can be treated by local excision alone. If, however, any muscle invasion or lymphatic vessel invasion is demonstrated, then radical surgery is recommended.     

Transanal endoscopic microsurgery in the treatment of rectal carcinoid tumor

Background This study aimed to assess the efficacy of transanal endoscopic microsurgery (TEM) in the treatment of rectal carcinoid tumor. Methods Between May 1994 and April 2006, 27 patients with rectal carcinoid tumor underwent TEM, and their clinical data were reviewed retrospectively. Results The TEM procedure was performed as a primary excision (n = 14) or as completion surgery after incomplete resection by endoscopic polypectomy (n = 13). The average size of a primary tumor was 9.1 mm (range, 5–13 mm), and the average distance of the tumor from the anal verge was 8.5 cm. The mean duration of the operation was 51.6 min. Minor morbidities, transient soilage, and mild dehiscence occurred in two cases (7.4%). Histopathologically, all tumors were localized within the submucosal layer showing typical histology without lymphatic or vessel infiltration, and both deep and lateral surgical margins were completely free of tumors. Among 13 cases of completion surgery after endoscopic polypectomy, 4 (30.8%) were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. The mean follow-up period was 70.6 months, and no recurrence was noted. Conclusion The results indicate that TEM is a safe, minimally invasive procedure for the local excision of rectal carcinoid tumors, particularly those in the proximal rectum. Furthermore, for patients with microscopic positive margins after endoscopic polypectomy, TEM can be an effective surgical option for complete removal of residual tumors.     

经肛门内镜微创手术治疗直肠上皮内瘤变和早期直肠癌

目的探讨经肛门内镜微创手术（TEM）治疗直肠上皮内瘤变（IN）和早期直肠癌的临床价值。方法选择15例直肠肿瘤患者采用TEM行局部切除术。根据活检病理结合直肠腔内超声检查（EUS）术前诊断低级别IN8例，高级别IN4例，早期直肠癌3例。肿瘤距肛缘的距离4—15（平均7．2）cm，肿瘤直径1—4（平均1．8）cm，肿瘤占据肠腔周径比例10％～40％（平均20％）。结果15例直肠肿瘤均获完整切除（黏膜下切除5例，全层切除10例），各切缘均阴性。手术时间为40．90（平均57）min；术中出血量为10-60（平均35）ml。术后住院时间为2-9（平均4．5）d。术后病理确诊：直肠低级别IN5例，高级别IN6例，早期黏膜下浸润癌（pT1期）和进展期癌（pT2期）各2例。术前EUS评估肿瘤浸润肠壁深度的准确率为86．7％（13／15）。15例术后随访2．10（平均6）个月，肿瘤无局部复发。结论TEM微创、显露良好、切除精确、能获取高质量的肿瘤标本用于准确的病理分期，是治疗直肠IN和早期直肠癌的理想术式。术前EUS检查对TEM病例的选择十分重要。     

经肛门微创系统治疗45例直肠肿瘤的临床分析以及经肛门内镜微创手术的进展

目的探讨经肛门内镜微创手术(TEM)治疗直肠肿瘤的安全性、疗效及预后,评价其临床应用价值及文献复习。方法回顾性分析2014年8月至2017年2月期间于佛山市第一人民医院行TEM治疗的45例直肠肿瘤患者的临床资料,总结其临床效果。结果所有患者的肿瘤病灶均完整切除,肿物直径为1.8±0.8 cm(1.0~4.0 cm),肿瘤距离肛缘为7.6±2.8 cm(6~17 cm);切缘行病理学检查均为阴性,其中全层切除18例,粘膜下及肌层部分切除27例;手术时间为72.7±18.1 min(40~120min),术中失血量的中位数为16.6 m L(5~200 m L);术后住院时间为4.9±1.7 d(4~7 d)。术后病理学检查示单纯直肠腺瘤13例,绒毛管状腺瘤13例,腺瘤伴低级别上皮内瘤变5例,腺瘤伴高级别上皮内瘤变7例,腺瘤癌变5例,均为Tis~T1期;另直肠类癌2例。术后发生创面大出血3例,均经保守治疗治愈;5例肛管及内痔损伤出血术中需加缝肛管创面;无大便失禁及肠穿孔情况。39例患者包括5例癌变患者术后常规随访,随访时间的中位数为15个月(2~30个月),随访期间均未出现肿瘤局部复发,未发生大便失禁和排便功能障碍。结论我们的结果与文献报道结果相近。TEM具有直视下操作、术野暴露清晰、切除范围准确、手术创伤小、复发率低等优点,是一种可用于治疗直肠肿瘤有效的、安全的微创手术方法,应在有条件的医院开展。     

内镜治疗直肠类癌的长期疗效

目的探讨内镜下治疗直肠类癌的长期疗效。方法总结分析2000年1月至2007年7月间采用内镜治疗的91例直肠类癌患者的临床资料。结果本组患者肿瘤病理结果均为典型类癌，均未突破黏膜下层，均未侵及周围淋巴结及血管。有80例（87．9％）患者获随访，随访时间6～96（32．5±24．1）个月。肿瘤直径小于1．0cm的65例患者，术后无1例复发；1．0-2．0cm的25例患者，术后有3例（12％）复发，复发时间分别为3个月、2年和6个月，其中1例再行Dixon术后3个月又出现肝脏转移（4％）：肿瘤直径大于2．0cm的1例患者术后未见复发。本组1、3、5年累计生存率分别为100％、98．0％和91．4％。结论肿瘤直径小于1cm、未侵犯肌层的直肠类癌患者内镜下治疗长期疗效较为理想。     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

探讨经肛门内镜显微手术(TEM)在治疗局限性直肠肿瘤中的应用效果.方法 总结分析2006年4月至2008年12月接受TEM的75例直肠肿瘤患者的临床资料,分析TEM在直肠肿瘤治疗中的应用效果.结果 患者病灶平均直径为(1.6±0.8)cm(0.5～5.0 cm).病灶距肛缘平均(7.6±2.8)cm(5～20 cm).病灶在直肠内的部位:前壁25例,后壁24例,左侧壁14例,右侧壁12例.手术方式包括:肠壁全层切除64例,黏膜下及肌层部分切除11例.平均手术时间(73.7±32.1)min(30～180 min),术中平均失血(9.8±7.7)ml(3～50 ml).术后病理检查:直肠腺瘤28例,直肠腺瘤癌变和直肠癌25例(其中Tis期14例,T1期5例,T2期6例),直肠类癌7例,炎性息肉等15例.所有标本切缘均为阴性.全组术后4例(5.3%)发生并发症,其中并发肛门出血2例,肺部和泌尿系感染各1例.术后平均住院(3.4±1.2)d(2～7 d).术后平均随访8.4个月(3～26个月),未发现疾病或肿瘤有复发转移.结论 TEM治疗直肠肿瘤具有手术损伤小,出血少、疗效好、恢复快等优点,是目前直肠肿瘤局部切除的较佳方法.