The Use of Posterior Trans-Sphincteric Approach in Surgery of the Rectum: A Chinese 16-Year Experience

BACKGROUND: The posterior trans-sphincteric approach to treat different lesions of the rectum has been known since the last century. Although there are many advantages to this procedure, it has never been widely accepted because many surgeons fear its potential postoperative complications. The purpose of this study is to reevaluate the role of this conventional approach to surgery of the rectum from the authors' 16 years experience. METHODS: Data were collected retrospectively from clinical records of 102 patients with mid- to low-lying rectal neoplastic disease treated by a single surgeon using a posterior trans-sphincteric approach to the rectum at Peking Union Medical College Hospital, China, between August 1990 and August 2006. The Williams incontinence scale of every patient was assessed preoperatively and postoperatively and the results were analyzed. RESULTS: Forty men and 62 women with a median age of 55.5 years (range = 21-87 years) underwent this approach. Their preoperative anal continence was assessed as grade 1 in 98 and grade 2 in 4. Indications for surgery were rectal villous adenoma in 36, early rectal carcinoma in 43, advanced rectal carcinoma in 10, and rectal submucosal neoplastic disease in 13. The median operating time, blood loss, and postoperative hospital stay were 75 min (range = 40-180 min), 60 ml (range = 0-300 ml), and 8 days (range = 7-60 days), respectively. All 102 rectal neoplastic diseases achieved complete excision (partial rectectomy in 96, segmental rectectomy in 6), and the resection margins were all clear. Three patients (2.9%) developed postoperative wound infection, and 4 patients (3.9%) developed fecal fistula. Thirty-three patients (32.4%) developed postoperative initial incontinence to flatus (n = 26) or liquid stool (n = 7) within 1 week. Three months after the operation, 94 patients (92.2%) achieved grade 1 continence and only 8 patients (7.8%) had occasional episodes of flatus incontinence. No patient developed postoperative anal stricture. There was no operation-related mortality. Three patients (2.9%) developed local tumor recurrence during median follow-up of 76.8 months (range = 10-192 months). CONCLUSION: The posterior trans-sphincteric approach is suitable for mid- to low-lying rectal lesions amenable to treatment using local therapy.     

120例直肠疾病患者经肛门括约肌路径手术的临床疗效

目的探讨经肛门括约肌路径的手术（Mason手术）在直肠外科中的应用。方法回顾分析1990年8月至2005年8月同120例中下段直肠疾病患者施行Mason手术的临床资料。结果全组直肠绒毛状腺瘤61例。其中伴癌变者26例；直肠癌25例；直肠黏膜下结节17例；直肠阴道瘘13例；直肠尿道瘘1例；直肠良性狭窄3例。103例直肠肿物中行直肠部分切除术98例，直肠节段切除术5例。术后伤口感染2例（1．7％），直肠。皮肤瘘4例（3．3％）。肿瘤局部复发3例（2．9％）。全组术后无发生肛门失禁者。确诊直肠癌的51例患者术后存活逾5年者达90．2％。结论Mason手术具有手术径路直达、术野表浅和显露良好的优势。适用于可行局部手术治疗的中下段直肠良、恶性疾病。     

经肛门内镜微创手术与传统经肛门局切术治疗早期直肠肿瘤的疗效对比

目的 对比经肛门内镜微创手术(TEM)与传统经肛门局切术(TAE)治疗早期直肠肿瘤的应用指征、安全性、疗效.方法 回顾性分析上海交通大学医学院附属瑞金医院普外科2003年1月- 2006年7月完成的76例传统经肛门局切术及2006年9月- 2010年2月完成的53例经肛门内镜微创手术的临床资料.结果 两组患者性别、年龄...     

经肛手套通路联合结肠镜微创手术治疗直肠肿瘤

目的：探讨经肛手套通路联合结肠镜微创手术治疗直肠肿瘤的可行性及疗效。方法杭州市第三人民医院肛肠外科自2012年10月至2013年3月,选择经评估适合行局部切除的直肠肿瘤患者8例,使用经肛手套通路联合结肠镜微创手术治疗。经肛手套通路的建立：将手套袖口连同扩肛器缝合固定于肛周,再将手套5指经由透明肛门镜翻转出肛门,将超声刀、无损伤肠钳和肠镜镜头分别从3个指套伸入并结扎固定。结果8例患者均成功完成肿瘤切除手术,制作手套入路装置平均耗时12．5（10．0～15．0） min,平均手术时间55．6（30．0～110．0） min,平均住院时间为5．0（3．0～8．0） d,术后病理提示绒毛状腺瘤3例,管状腺瘤2瘤,管状绒毛状腺瘤2例,锯齿状腺瘤1例,其中2例伴低级别上皮内瘤变,1例高级别上皮内瘤变,所有肿瘤组织标本边缘及基底部均为阴性。术后2例患者少量便血,随访1～5（中位3．1）月,无肿瘤复发。结论采用经肛手套通路联合结肠镜微创手术治疗直肠早期肿瘤具有简单和安全的特点,具有一定的应用价值。     

经肛门括约肌手术在直肠外科中的应用

目的 探讨经肛门括约肌路径的手术(Mason手术)在直肠外科中的应用.方法 回顾性分析1990年8月至2008年12月150例中下段直肠疾病患者施行Mason手术的经验. 结果150例中直肠绒毛状腺瘤75例,早期直肠癌48例,进展期直肠癌9例.以直肠类癌为主的黏膜下结节23例,直肠肿瘤中行直肠部分切除术120例,直肠节段切除术6例.直肠阴道/尿道瘘21例,其中一次修补成功者17例(81%).术后伤口积液感染6例(4%),直肠-皮肤瘘5例.获随访的46例早期直肠癌中2例肿瘤局部复发(2/46).其中存活超过5年者39例,占84.5%(39/46).150例术后均未发生肛门失禁.结论 Mason手术具有手术进路直达,术野表浅和显露良好的特点,适用于可行局部手术治疗的中下段直肠良恶性疾病.     

直肠癌术后局部复发的再手术治病（附25例报告）

目的 探讨直肠癌术后局部复发的相关因素及再手术的价值。方法 对25例直肠癌术后局部复发的临床资料作一回顾性分析。结果 首次手术时DukdesB期10例,C期15例;行Miles术4例,Dixon术16例,Hartman术2例,结肠肛门拖出术3例。粘液腺癌12例,低分化腺癌8例,腺癌2例,绒毛状腺瘤癌变3例。肿瘤距远切缘＜3cm者16例,＞3cm者9例。再次手术时,12例行根治术,9例行姑息性手术,4例未能切除。根治术组和姑息性手术组中位生存期分别为30个月和12个月,未能切除组2．3个月。再手术5年生存率21．7％。结论 直肠癌术后局部复发与肿瘤Dckes分期、组织学类型、术后选择、术前术中“无瘤术”实施有密切关系。对直肠癌局部复发仍应积极手术,可提高病人的生存期。     

Treatment of rectal prolapse. A clinical study of 50 consecutive patients

The results of surgical treatment of rectal prolapse in 50 consecutive adult patients were evaluated. The mean age of the patients was 51.8 +/- 15.9 years. 8 of the patients were males. 13 of the patients had recurrent prolapse after operations performed earlier elsewhere. There were 4 types of operations: Delorme's mucosal sleeve resection (n = 21), perineal rectosigmoidectomy (n = 7), low anterior resection (n = 12) and abdominal rectopexy (n = 10). There was no operative mortality. The main postoperative complications were perforation or stricture of the rectum in the Delorme group and ileus and anastomotic complications in the low anterior resection group. The frequency of postoperative complications was clearly highest in the low anterior resection group (67%). Follow-up examination was performed 5.2 +/- 3.9 years postoperatively. The recurrence rate of prolapse was highest after perineal operations. Fecal incontinence was almost always associated with recurrence of prolapse and its incidence increased with reoperation. In conclusion, abdominal rectopexy was superior to other forms of operation in the treatment of rectal prolapse. Successfull correction of rectal prolapse does not necessarily rule out the need for later surgery for faecal incontinence.     

经肛门内镜显微手术治疗直肠绒毛状腺瘤和早期直肠癌31例

目的探讨经肛门内镜显微手术（transanal endoscopicmic rosurgery，TEM）治疗直肠绒毛状腺瘤和早期直肠癌的疗效。方法1995年11月～2003年12月，我院行TEM治疗直肠肿瘤31例。全麻下根据肿瘤位置选择合适的体位，经肛门插入特殊的手术直肠镜，保持CO2充气状态，在立体视镜和腔镜系统下，采用针形电刀或5mm超声刀将直肠肿瘤完整切除（黏膜下或全层切除），手术创口在腔内连续缝合。结果31例直肠肿瘤均获完整切除，切缘均阴性。手术时间45～220min，平均95min；术中出血量0～180ml，平均40ml。手术并发症：暂时性排气失控2例，急性尿潴留1例，慢性阻塞性气道疾病急性发作1例，因服用阿斯匹林而出现继发性出血1例。术后病理分期：pT0期16例，pTis期2例，pT1期7例，pT2和pT3期各3例。31例随访2～92个月，平均23个月，肿瘤无原位复发。结论TEM是治疗直肠绒毛状腺瘤和早期直肠癌的一种安全、有效的微创手术方法。     

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery

OBJECTIVE: Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS: Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS: Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION: TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.     

Surgical technique and outcome of gasless video endoscopic transanal rectal tumour excision

BACKGROUND: Transanal endoscopic microsurgery (TEM) is unpopular because of its high cost and most surgeons' unfamiliarity with microscopic surgery. This report describes an experience with a modification of TEM, gasless video endoscopic transanal rectal tumour excision (gasless VTEM), which incorporates a standard laparoscopic video camera and requires no carbon dioxide insufflation system. METHODS: One hundred and one patients with 105 rectal tumours underwent gasless VTEM between 1993 and 2000.RESULTS: Histological examination revealed 18 adenomas, 75 carcinomas (Tis, 47; T1, 23; T2, five), 11 carcinoid tumours and one lymphoma. The median height above the dentate line and maximum tumour diameter was 5.0 (range 2-14) cm and 2.0 (range 0.4-8.0) cm respectively. The peritoneal cavity was opened intraoperatively in two patients. The median operating time was 53 (range 15-202) min. Bleeding, suture dehiscence and transient incontinence developed after operation in four patients. There was no operative death. Median hospital stay was 5 (range 1-21) days. Eleven patients with T1/T2 staging underwent subsequent radical resection. The median duration of follow-up was 52.3 months. One patient with a carcinoma developed a recurrence. CONCLUSION: Gasless VTEM is a feasible, safe and minimally invasive procedure for the treatment of selected rectal adenomas and early carcinomas. The suggested modifications may make the procedure more widely available.     

经肛门内镜显微手术局部切除早期直肠癌后续治疗策略对临床结局影响研究

目的 探讨经肛门内镜显微手术（TEM）局部切除早期直肠癌后续治疗方式的选择。方法 回顾性分析北京协和医院于2013-2019年间收治的105例经TEM切除直肠癌病人资料,所有病人均在知情同意后接受TEM。结果 105例病人经术前检查［直肠腔内超声和（或）直肠MRI］评估为cT1期且除外淋巴结转移,经病理学活检报告为腺瘤局部癌变或者直肠腺癌,均通过TEM完成直肠癌的局部扩大切除。105例病人术后36例行补救性根治性手术,29例行补救性放化疗,40例仅随访观察。105病人术后接受平均40（12～69）个月随访。随访期间,13例（12.4%）局部复发,2例（1.9%）远处转移,3例（2.9%）死亡。单因素分析结果显示,T分期（P=0.003）、是否R0切除（P＜0.01）和术后处理策略（P=0.036）是复发及死亡预测因子。在多因素分析中,T分期（HR 7.36,95%CI 1.82~29.85,P=0.005）、是否R0切除（HR 20.82,95%CI 2.71~159.64,P=0.003）及术后处理策略（HR 0.57,95%CI 0.08~0.38,P=0.003）与复发及死亡密切相关。结论 TEM局部切除pT1期直肠癌安全、有效。而对于pT2期或未达R0切除直肠癌病人术后复发风险高,后续积极采取根治术或辅助放化疗的补救性治疗可提高病人预后。     

直肠癌根治术后局部复发83例临床分析

目的总结直肠癌根治术后局部复发的原因及疗效。方法回顾性分析83例直肠癌根治术后局部复发患者的临床资料,根据对局部复发的治疗方法,分为根治手术组（A组）34例,姑息手术加放疗组（B组）28例,单纯放疗组（C组）21例。结果中位生存期A、B、C组分别为28、18和10个月。A、B、C组3、5年生存率分别为58.8%、28.5%、19.0%和35.3%、3.6%、0%。结论直肠癌术后应密切随访,以便早期诊断局部复发,及时给予以手术为主的综合治疗。     

Local excision of rectal tumours by transanal endoscopic microsurgery

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM. METHODS: Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm. RESULTS: Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively. CONCLUSION: TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.     

直肠绒毛状腺瘤癌变的外科治疗

目的探讨直肠绒毛状腺瘤癌变的外科治疗方式。方法对62例手术治疗的直肠绒毛状腺瘤癌变的临床资料进行回顾性分析。结果62例中局部切除28例，其中经肛切除(transanal excision，TE)20例，经骶切除(Kraske)8例；扩大切除34例，其中腹会阴联合切除(Miles)11例，直肠前切除(Dixon)21例，其他手术2例。62例中82％(51／62)为早期癌变，68％(42／62)为高分化癌，26％(16／62)为中分化癌。局部切除与扩大切除术后各有6例出现复发、转移，5年生存率分别为79％和76％。结论直肠绒毛状腺瘤癌变恶性程度低，合理选择治疗方式能有效治疗肿瘤，减轻患者痛苦，提高生存质量。     

Who should be followed up after transanal endoscopic resection of rectal tumours?

Objective To determine follow‐up requirements following transanal endoscopic microsurgery (TEM) for rectal tumours based on clinical and histopathological assessment of resection specimens. Method A consecutive series of 117 patients undergoing TEM between 1997 and 2005 was studied. The excised specimens were classified as intact with clear surgical resection margins, macroscopically intact specimens with microscopically involved resection margins or piecemeal. Recurrence rates were determined for the three groups. Results Of the 117 procedures performed, 80 were for benign disease and 37 for malignancy. Within the benign group 39 (49%) resections were intact with clear surgical resection margins and yielded zero recurrences; 22 (27%) resections were macroscopically intact with microscopically involved surgical resection margin and yielded two recurrences; and 19 (24%) resections were piecemeal and yielded eight recurrences. Within the malignant group all 37 patients had resection specimens which were intact with clear surgical resection margins. Two patients had immediate salvage surgery. Of the 35 who went on to long‐term follow‐up post‐TEM (0.6–8.1 years, median 4) four developed recurrent cancer (two local with submucosal disease and two liver metastases). Conclusion For benign rectal neoplasms, resection of an intact specimen with histologically clear surgical resection margins was associated with no observed mucosal recurrence. Local recurrence after TEM is significantly more frequent when histological examination reveals involved margins or when resection is piecemeal. Early endoscopic follow up is required for the latter two groups. Local recurrence for malignant cases was submucosal and detected by palpation.     

Factors predicting early recurrence after transanal endoscopic microsurgery excision for rectal adenoma

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is an accepted way of excising rectal adenomas with low morbidity and mortality, avoiding major resectional surgery. However, there are no agreed criteria for surveillance following TEM. The purpose of this study was to identify criteria to guide surveillance programmes, thus reducing the surveillance burden for those patients at low risk of recurrence. PATIENTS AND METHODS: Patients who had undergone TEM for rectal adenomas were identified, and a retrospective review of patient, pathological and histological parameters was performed. RESULTS: Seventy-five (40 male) patients were identified; median age 70 years (39-85). There were seven tubular, 33 tubulo-villous and 35 villous adenomas. All were considered completely excised by the operating surgeon. Forty-seven (62.7%) were reported as being completely excised histologically. There was no significant association between recurrence at 6 months and sex, age, type or position of adenoma, height above the anal verge, or degree of dysplasia. Recurrence rates at six months were 0% for the completely excised adenomas and 21.4% for the incompletely excised ones; this was statistically significant (Pearson chi(2), P < 0.001). In all there were 12 recurrences, 10 in the incompletely excised group at a median follow up of 31 (6-80) months (P < 0.001). In addition, a significant association for large adenomas to recur was noted at median follow up (Armitage Trend test, P = 0.019). CONCLUSIONS: Histological assessment of completeness of excision of rectal adenoma and size of adenoma are important predictors of early recurrence and have potential to guide follow-up strategies after TEM.     

经骶尾入路手术在低位直肠肿瘤局部切除中的应用

目的：探讨经骶尾入路手术在低位直肠良性病变及早期直肠癌局部切除中的应用价值。方法：对我院1997～2002年问，应用经骶尾人路手术治疗的24例低位直肠肿瘤患者进行随访及疗效判断。结果：直肠绒毛状腺瘤14例，绒毛状腺瘤癌变7例，直肠类癌3例，经5个月～6年的随访，所有患者均无瘤存活。结论：骶尾入路手术具有简单易行、手术创伤小、术野宽敞等优点，是治疗低位直肠肿瘤的较好方法。     

Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision

Anterior resection and abdomino-perineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. Local recurrence rates of 10% to 14% are described after these conventional procedures. Preoperative neoadjuvant radiotherapy reduces local failure. Because local excision techniques can be applied to treat early rectal cancer in selected patients, we evaluated the results of preoperative high-dose radiotherapy and transanal endoscopic microsurgical excision (TEM) in patients with T2 rectal cancer. All patients underwent preoperative irradiation with 5,040 cGy, divided over 5 weeks. Forty days after completion of radiotherapy, the patients underwent complete full-thickness local excision of the rectal lesion including adjacent perirectal fat by TEM. The patients were followed for up to 8 years. Thirty-five patients, with pT2 rectal cancer as determined by pathological examination of the surgical specimen were enrolled in the present study. The tumors were responsive to preoperative radiotherapy in 82.8% of cases. No intraoperative complications and no conversion to open surgery were observed. No major complications and no mortality occurred during the 60-day postoperative period. Minor postoperative complications were observed in 5 patients (14.3%). The median follow-up of the patients was 38 months (range 24 to 96 months). One local recurrence (2.85%) was noted. The probability of surviving at 96 months after completion of treatment was 83%. Local excision by TEM combined with preoperative high-dose radiotherapy can achieve results similar to those observed after conventional surgery in patients with pT2 rectal cancer.     

The role of colonoscopic endoanal ultrasound scanning (EUS) in selecting patients suitable for resection by transanal endoscopic microsurgery (TEM)

OBJECTIVE: This study was performed to assess the accuracy of colonoscopic endoanal ultrasound scanning (EUS) in the selection of patients with rectal neoplasia suitable for local excision by transanal endoscopic microsurgery (TEM). Our policy is to offer TEM to patients with premalignant (T0) lesions or with T1 tumours that have early disease. PATIENTS AND METHODS: Data were collected prospectively on all patients undergoing EUS for the assessment of rectal neoplasia at our institution over a six-year period. A colonoscopic EUS probe was used to determine whether the tumour breached the muscularis propria (the interface between T1 and T2 disease). Subsequently patients underwent surgical resection, including TEM for those with T0/1 disease. The preoperative stage predicted by EUS (uT stage) was compared to the postoperative histopathological stage of the resected specimens (pT stage). RESULTS: One hundred and fifty-six EUS examinations were evaluated. Sixty-two patients went on to have TEM whilst the remaining 94 had another form of surgery. Of the 62 patients undergoing TEM, 3 were overstaged on EUS. No patients were understaged, giving an accuracy of 95%. Of the 94 patients undergoing an alternative procedure, 5 were overstaged on EUS as having T2 tumours when in fact their histology was T1. Accuracy of EUS at predicting more advanced disease fell to 89%, giving an overall accuracy of 92%. CONCLUSIONS: EUS is accurate at predicting T0/1 vs T2 disease in our institution, and we believe that it is a useful modality in assessing patient suitability for local excision.