内镜黏膜下剥离术治疗直肠类癌

目的探讨内镜黏膜下剥离术（ESD）治疗直肠类癌的应用价值。方法肠镜发现直肠黏膜下肿块后进行微探头超声检查，对诊断为类癌者应用头端弯曲的针形切开刀进行内镜黏膜下剥离术治疗：（1）黏膜下注射生理盐水抬高病灶，使病灶与肌层分离；（2）预切开病灶周围黏膜；（3）剥离病变下方黏膜下层结缔组织，完整切除病灶。结果5例直肠类癌患者，肿瘤直径0.4～1.2（平均1．1）cm，均成功完成ESD治疗。ESD手术时间（自黏膜下注射至完整剥离病变）20-45（平均35）min；术中创面少量出血，均经电凝、氩离子血浆凝固和止血夹成功止血。不需再次肠镜下止血。1例剥离深至肌层，出现皮下气肿，保守治疗好转。术后全部经病理确诊。基底和切缘未见病变累及。1个月后肠镜复查，创面基本愈合。结论ESD是治疗直肠类癌的新方法．以往需要外科手术切除的肿瘤通过ESD可以达到同样的治疗效果。     

Endoscopic submucosal dissection for rectal carcinoid tumors

Background

Endoscopic submucosal dissection (ESD) has an advantage over endoscopic mucosa resection (EMR) by enabling removal of gastrointestinal neoplasms en bloc. The ESD procedure is the treatment of choice for rectal carcinoids that have classic histologic architecture with minimal cellular pleomorphism and sparse mitoses, but it has not been applied for such tumors.

Methods

The ESD procedure was performed for patients with colorectal tumors that fulfilled the inclusion criteria specifying tumor with a diameter of 10 mm or less, no muscular layer invasion, and no metastases to the lymph nodes or distal organs. The ESD procedure was performed for patients with rectal carcinoids but no node or distal metastasis.

Results

This study enrolled 20 rectal carcinoid tumors from 20 consecutive patients. The mean tumor size was 7.6 mm (range, 3–16 mm). En bloc removal was achieved for all the tumors, and the complete resection (en bloc with tumor-free lateral/basal margins) rate was 90% (18/20). The two cases in which the margins were not evaluable due to burn effects still are free of recurrence and metastasis at this writing. Perforation was seen in one case, which was managed nonsurgically.

Conclusions

Precise histolopathogic assessment of the specimens resected en bloc by ESD may reduce tumor recurrence and metastasis after ESD. As the treatment of choice for small rectal carcinoids, ESD is associated with nominal risks of metastatic disease.     

Ilio-pelvic lymphatic dissection in the rectal cancer

The method of iliopelvic lymphodissection was used in 61 patients aged from 42 to 72 years having histologically verified rectum cancer. The results of treatment by this method have shown that in 83.6% of the patients the tumor spread corresponded to pT3-T4, the metastatic involvement of regional lymph nodes was found in 52.5% of the patients. The most justified reason for a radical surgery and lymphodissection was a combination of the endoscopic signs of a considerable extension of the tumor around the circumference of the rectum with the CT signs of enlargement of the regional lymph nodes or the ingrowth of the tumor in the pararectal fat. In cases with the lymphogenic metastasing the cumulative 5 year survival was 43.6 +/- 8.7%, in cases without it it was 55.3 +/- 11.8%. A thorough preoperative evaluation of the extension of the tumor process allows to optimize indications for iliopelvic lymphodissection.     

Lateral pelvic lymph node dissection for advanced lower rectal cancer

BACKGROUND: The oncological outcome of patients who underwent curative surgery for lower rectal cancer was investigated to clarify whether lateral pelvic lymph node dissection (LPLD) conferred any benefit. METHODS: A total of 246 patients who underwent curative surgery for stage II and III lower rectal cancer (below the peritoneal reflection) between 1985 and 1998 was reviewed. Forty-two of these patients did not undergo LPLD. RESULTS: Patients who did not undergo LPLD were older, more likely to have anterior resection and pelvic nerve preservation, and had smaller tumours and lymph node metastasis at an earlier stage than those who underwent LPLD. There was no difference in survival among patients with stage II and III disease between the two groups. However, in patients with pathological N1 lymph node metastasis, the 5-year disease-free survival rate was 73.3 per cent in patients who had LPLD compared with 35.3 per cent among those who did not (P = 0.013). Multivariate analysis showed that LPLD was a significant prognostic factor. CONCLUSION: LPLD improved the prognosis of patients with stage III disease and a small number of lymph node metastases. A randomized clinical trial is needed to verify the benefit of LPLD.     

Laparoscopic and robotic lateral lymph node dissection for rectal cancer

Surgery Today - In the era of neoadjuvant chemoradiotherapy/radiotherapy and total mesorectal excision, overall oncological outcomes after curative resection of rectal cancer are excellent, with...     

Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer

OBJECTIVE: The authors have performed per anum intersphincteric rectal dissection. With direct coloanal anastomosis for cases of lower rectal cancer in which the distal surgical margin is difficult to secure by the double stapling technique. The aim of this study was to evaluate the long-term outcome and to clarify the surgical indications for this operation. PATIENTS AND METHODS: Between 1993 and 2002, 31 patients underwent per anum intersphincteric rectal dissection with direct coloanal anastomosis. Of these, two patients (one stage 0 and one stage IV) were excluded from the analysis of oncological outcome. The remaining 29 patients formed the basis of this study. The median follow-up was 57 months (range 6-106 months). RESULTS: Local recurrence and distant metastasis developed in 9 and 3 patients, respectively. Local recurrence rate for pT1 was significantly lower than that for pT2/T3 disease. The local recurrence rate cases with tumours less than 3 cm was significantly lower than that for tumours sized 3 cm or more. The distant metastasis rate for cases with lymph node metastasis was significantly higher than that for cases without lymph node metastasis. There was an association between distant metastasis and TNM or pT stage. The overall survival rates for stage I, II and III were 85%, 80% and 89%, respectively. No significant difference was seen in total Cleveland Clinic incontinence score between per anum intersphincteric rectal dissection with direct coloanal anastomosis and the double stapling technique. CONCLUSION: The surgical indications of this operation should be limited to patients with T1 rectal cancer or tumours less than 3 cm.     

直肠癌侧方淋巴结清扫意义的meta分析

目的评价直肠癌侧方淋巴结清扫（lateral lymph node dissection,LLND）对患者术后5年生存率和局部复发率的影响,为直肠癌根治性手术中是否应常规进行侧方淋巴结清扫提供临床依据。方法利用meta分析的方法综合评价国内外公开发表的所有关于直肠癌侧方淋巴结清扫与局部复发率、5年生存率关系的文献。结果筛选出符合入选和排除标准的文献8篇,共4648例,其中LLND组2249例,LLND组5年生存率与非LLND组比较,合并值ORs为1.07（95%CI=0.80~1.42,P=0.67）,局部复发率合并值ORs为0.85（95%CI=0.51~1.39,P=0.51）。结论直肠癌侧方淋巴结清扫并不能提高患者的5年生存率,亦不能降低局部复发率。     

内镜黏膜下剥离术在中低位直肠肿瘤中的应用

早期直肠癌的内镜下切除存在一定的争议,文章就内镜下切除技术的发展、适应证、操作方法及在中低位直肠肿瘤中的应用做一综述。重点介绍了内镜黏膜下剥离术（ESD）的器械、技术要点、术后处理和疗效评价。     

Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer

Background

Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.

Objective

The aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.

Methods

Between July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.

Results

En bloc resection rates with free margins were achieved in 81.8 % of patients in the ESD group and 84.6 % of patients in the TEM group (p = 0.40). Mean tumor size was 64.6 ± 57.9 mm in the ESD group and 43.9 ± 30.7 mm in the TEM group (p = 0.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133 ± 94.8 min in the ESD group and 150 ± 66.3 min in the TEM group (p = 0.69). Mean hospital stay was 3.8 ± 3.3 days in the ESD group and 4.08 ± 1.7 days in the TEM group (p = 0.81).

Limitations

This was a non-randomized clinical trial with a small sample size and selection bias in treatment options.

Conclusion

ESD and TEM are both safe and effective for the treatment of early rectal cancer.     

直肠癌根治术后营养相关并发症与干预

直肠癌根治术后营养相关并发症包括营养不良导致的相关并发症和营养支持治疗相关并发症。快速康复外科在结直肠癌手术患者中开展较广泛,临床上仅那些存在营养不良和营养不良风险患者需营养治疗。营养支持治疗会产生一些并发症,分为肠外营养相关并发症和肠内营养相关并发症。这些并发症如果处理不好,营养治疗反而会适得其反,对患者的预后造成不良影响。肠外营养和肠内营养相关并发症具有不同的特点,本文总结了直肠癌根治术后患者肠外和肠内营养的常见并发症,并对相应的预防和治疗措施进行了探讨。     

腹腔镜直肠癌根治术侧方淋巴结清扫术

对腹膜反折以下cT3或N＋的直肠癌行侧方淋巴结清扫术可减少局部复发率及提高生存率。该术式采用五孔法完成,按日本学组提出的三间隙原则进行清扫：①分离保护输尿管及下腹神经,清扫下腹神经丛及下腹神经与髂总动脉、髂内动脉之间的第二间隙淋巴结;②清扫髂内外动脉间及闭孔内的第三间隙淋巴脂肪组织;③切除髂内血管及盆丛神经。应视肿瘤部位、浸润深度以及侧方淋巴结肿大情况,选择性行单或双侧清扫。腹腔镜下完成侧方淋巴结清扫具有视野好、狭小间隙操作方便、出血少等优势,是一种安全可行的手术方式。     

Distal dissection in total mesorectal excision,and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4–5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.