经腹结肠肛管吻合术治疗低位直肠癌

目的探讨经腹结肠肛管吻合术治疗低位直肠癌的临床应用价值。方法回顾性分析2001年11月至2005年12月,北京大学第一医院普外科收治的36例距肛缘4～6cm的低位直肠癌采用双吻合技术行直肠及部分外科肛管全层切除（部分内括约肌切除）,经腹结肠肛管吻合术的资料。结果吻合口距肛缘平均2.5cm。中位随访时间23个月,术后远处转移4例,无局部复发者。3年总存活率100%,无瘤存活率84.6%。术后1年,随访28例病人,根据Williams分级标准,肛门控便功能Ⅰ级（完全自制）23例,Ⅱ级（排气失禁）2例,Ⅲ级（偶尔漏稀便）3例。结论经腹结肠肛管吻合术是治疗距肛缘4～6cm低位直肠癌的较理想保肛术式;切除部分内括约肌对肛门的远期功能无明显影响。     

支撑捆扎套入法结肠-肛管吻术(Povrk)在低位或超低位直肠癌保肛手术中的应用

目的:介绍用支撑捆扎套入法结肠肛管吻合术(Povrk)在保留齿状线和肛门内括约肌的低位或超低位直肠癌中的应用方法。方法:37例低位直肠癌在术前放疗,在全直肠系膜切除基础上用支撑套入法结肠肛管吻合术完成手术,术后予希罗达口服化疗。结果:本组37例无死亡病例。近期吻合口瘘2例,均引流后治愈,直肠癌距肛门4～7cm术后排便功能恢复好。结论:支撑法结肠肛管吻合术用于低位直肠癌保肛手术可作为双吻合器保肛手术的替代或改良方法以应用。     

管扎式结肠肛管吻合术治疗低位直肠癌(附256例报告)

目的:评价管扎式结肠肛管吻合术治疗低位直肠癌的安全性和临床效果.方法:回顾性分析1991年10月至2005年12月共256例低位直肠癌行管扎式结肠肛管吻合术的临床资料.结果:无手术死亡,术后发生吻合漏1例,吻合口狭窄16例,术后肛门功能优良率96.7%,术后5年肿瘤局部复发13.1%,5年存活率为71.9%.结论:该法具有操作简单易行安全可靠,减少了吻合口漏的发生,适用于各级医院开展.     

低位直肠癌改良Parks术的应用研究（附33例报告）

目的 总结1990年1至1998年10月间经腹低位直肠癌切除、结肠肛管吻合术33例,探讨提高手术成功率,减少并发症的方法.方法 回顾性分析33例低位直肠癌经腹切除术,采用结肠肛管吻合术的方式及疗效,并对Parks进行改进研究.结果 33例采用经腹直肠癌切除、结肠肛管吻合术,其中根治切除32例,占96.97%,无手术死亡病例,吻合口瘘2例,占6.06%,无吻合口狭窄,随访6～84个月,盆腔复发2例,无吻合口复发病例,手术近期肛门控制稀便功能欠佳,3～6个月随访肛门功能良好.结论 低位直肠癌在保证根治的前提下,只要肛管直肠括约肌环完整,可采用该术式,手术安全,并发症发生率低,是一种理想的保肛术式.     

低位直肠癌保肛扩大根治手术(摘要)

低位直肠癌中选择部分病例实施保肛手术是可行的。本文报道了选择62例低位直肠癌在扩大根治术基础上,保留肛门括约肌,术式为经肛门环扎式结肠一直肠(肛管)吻合术。术后上方淋巴结转移率53.4%,侧方淋巴结转移率17.2%,下方淋巴结转移率0%,转移度9.10%。随访1~3年,未见盆腔软组织、淋巴结、吻合口复发。因肝转移死亡5例。影响低位直肠癌保肛术后生存率主要原因是血行转移,不是局部复发。低位直肠癌中合理选择手术适应证和保证根治的前提下积极实施保肛手术是可行的。     

腹膜反折以下直肠癌保肛扩大根治术

报告68例低位直肠癌中，选择54例在扩大根治术基础上采用经肛门秋扎式结肠—直肠(肛管)吻合术．保肛率占低位直肠癌的70．3％．54例保肛手术中上方淋巴结转移率52．4%，侧方转移率20.2%，下方转移率0%．转移度8.7%，吻合口漏1例．吻合口狭窄3例。术后随访1～3年，未见局部复发，术后排便功能良好率占80％，说明低位直肠癌通过实施扩大根治术，保证盆腔无复发可能的前提下，实施保肛手术是可行的．对低位直肠癌保肛手术理论、手术适应证选择，手术操作要点及远期效果加以探讨。     

吻合器在超低位直肠癌保肛手术中的应用

目的探讨在超低位直肠癌前切除术后使用吻合器行降结肠肛门吻合,以改善肛门功能、提高疗效的临床应用价值。方法2000年至今开展了超低位直肠癌前切除术后,使用吻合器的结肠肛管吻合术7例,与Parks术5例及Bacon术6例相对比。结果超低位直肠癌前切除术后使用吻合器行降结肠肛门吻合,术后无复发,肛门功能优5例,良2例。Parks术1例复发,肛门功能优1例,良3例。Bacon术无复发,肛门功能优2例,良3例。Parks术1例吻合瘘,Bacon术1例吻合口狭窄。结论超低位直肠癌在保证根治的前提下,只要肛管直肠括约肌环完整,可采用该术式,手术安全,并发症少,是一种理想的保肛术式。     

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.     

低位直肠癌经肛门直结肠外翻拉出保留肛门吻合术

目的探讨低位直肠癌保留肛门括约肌功能的手术方法和手术适应证。方法对低位直肠癌经腹经肛门直结肠外翻拉出保留肛门吻合术15例。结果全组无手术死亡，未发生吻合口漏和吻合口狭窄，局部复发1例，20周左右恢复正常排便排气功能，无大便失禁病例。随访8个月～5年，5例为远处转移，死亡4例，其中1例肝转移3年仍生存。结论根据直肠癌的临床分期和肿瘤的生物学特性选择保肛手术适应证，经腹、肛门齿线上直肠癌根治性切除，行肛门直结肠外翻拉出吻合是低位直肠癌较好的保肛术式。     

低位直肠癌保肛治疗的手术分析

目的探讨低位直肠癌保留肛门括约肌功能的手术方法和手术适应证。方法对低位直肠癌经腹经肛门直结肠外翻拉出保留肛门吻合术15例。结果全组无手术死亡,未发生吻合口漏和吻合口狭窄,局部复发1例,20周左右恢复正常排便排气功能,无大便失禁病例。随访8个月~5年,5例发生远处转移,死亡4例,其中1例肝转移3年仍生存。结论根据直肠癌的临床分期和肿瘤的生物学特性选择保肛手术适应证,经腹、肛门齿线上直肠癌根治性切除,行肛门直结肠外翻拉出吻合是低位直肠癌较好的保肛术式。     

Sphincter-saving resection for low rectal cancer

R0 resection, preservation of the anal sphincter, and local control are considered to be the most important target criteria in rectal cancer surgery. Many efforts have been made in recent years to increase the rate of sphincter preservation by performing pull-through operations, ultra-low anterior resection (U-LAR), and intersphincteric resection (ISR). U-LAR is the standard surgery for patients with lower rectal cancer to preserve anal function. Reconstruction in U-LAR is mainly performed using stapled anastomosis. Although conventional coloanal anastomosis makes it possible to preserve the anal sphincter, the mechanical methods are difficult. In that case, almost all the internal sphincter is preserved. The final options for preserving the sphincter are ISR and external sphincter resection (ESR). Although the internal sphincter is sacrificed partially, subtotally, or totally in ISR, and the external sphincter is resected partially or extensively in ESR, complete or incomplete anal function is maintained. However, the literature is not clear regarding long-term oncologic outcome and anal function after these procedures. The application of these surgical techniques can reduce the rate of abdominoperineal resection in very low rectal cancer. The indications for these procedures must be carefully determined based on tumor site and stage as well as the patient's own preference.     

肛外手工吻合在腹腔镜低位直肠癌保肛术中的应用

目的 探讨肛外手工吻合技术在腹腔镜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15例低位直肠癌患者实施全直肠系膜切除原则的根治性手术,用肛外手工吻合的方式完成超低位结肠-直肠/肛管吻合术.结果 15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125～270 min,平均156 min.术中出血30～180 ml,平均70 ml.住院时间9～14 d,平均11 d.15例术后随访2～37个月,平均14个月.术后局部无复发,远处肝转移1例.结论 低位直肠癌行腹腔镜下超低位切除、肛外手工吻合保肛术是一种安全、经济、创伤小、疗效可靠的术式.     

直肠癌根治术618例疗效分析

目的探讨Miles手术和保肛术治疗直肠癌的临床疗效。方法1984年1月至2004年12月20年间,共收治618例直肠癌患者,对其行Miles手术和保肛术式治疗。其中1984年1月至1993年12月前10年中,收治患者273例,行Miles术136例,各种保肛手术137例。1994年1月至2004年12月后10年中,收治患者345例,行Miles手术102例,各种保肛手术243例。对前后10年患者的术后并发症,复发与转移情况,术后生存率进行总结、分析。结果术后共有492例患者进行随访,时间1个月～20年,平均5年,随访率为79．6％。前10年术后局部复发率为6．9％,其中Miles术为6．7％,各种保肛术为7．1％。后10年术后局部复发率为5．1％,其中Miles术为4．8％,各种保肛术为5．2％,其中套人式结肠直肠黏膜吻合保肛术为4．9％。前10年术后5年总体生存率为64．7％,其中Miles手术为66．3％,保留肛门手术为63．4％。后10年术后5年总体生存率为68．0％,其中Miles手术为66．3％,保留肛门手术为68．7％,其中套人式结肠直肠粘膜吻合保肛术为71．3％。结论直肠癌术式应根据病变部位、生物学特性、临床分期、个体化进行选择,近10年来保肛手术逐渐增多,约占70％,保肛术后5年生存率与Miles手术基本相同,但患者生活质量得到明显提高,套人式结肠直肠黏膜吻合保肛术是一种安全有效的术式。     

括约肌间切除术在超低位直肠癌保肛手术中的应用

目的评价超低位直肠癌行括约肌间切除手术(ISR)后的肛门功能及肿瘤根治效果。方法近7年间本院为1 6例超低位直肠癌患者施行ISR手术。经腹按照TME原则游离直肠至肛提肌平面后,经肛门于括约肌间沟处切开肛管皮肤,分离内括约肌直至将直肠及内括约肌全部切除,再行结肠肛管吻合。术后7 d天开始肛门收缩功能锻炼,4周开始生物反馈训练。对Dukes B,C期患者,术后2周开始化疗,术后4周进行放疗。结果全组无术后死亡,无吻合口瘘。2例术后发生结肠黏膜脱出,2例肛管狭窄,1例切口脂肪液化。随访3个月至7年,无盆腔或吻合口局部复发;2例分别于术后1 7个月和2 1个月死于肝转移,1例术后6个月死于肺转移。按W illiams的排便自制标准,术后3,6,12个月分别有6 2.5%,8 0.0%,8 4.6%的患者达到功能良好效果。结论ISR手术并发症少,安全性高,肿瘤根治效果与排便功能的恢复满意。     

Magnetic resonance imaging predicts sphincter invasion of low rectal cancer and influences selection of operation

BACKGROUND: With the development of numerous sphincter-saving surgical techniques in the last 2 decades, the indication for abdominoperineal resection in radical-elective operations has been markedly reduced. The preoperative assessment of the extent of local tumor growth is essential for the planning of the optimal surgical procedure. Magnetic resonance imaging (MRI) proved to be a reliable method for local staging of low rectal carcinoma. The objective of this study was to determine the frequency of sphincter invasion in an unselected population with low rectal cancer. METHODS: From 1997 to 1999, 40 patients with histologically verified adenocarcinoma of the lower rectum (+/-5 cm above the linea dentata) without evidence of metastases underwent a MRI with a body coil (no anal endocoil). The MRI results were compared with the operative situs and with pathohistologic findings. RESULTS: An infiltration of the sphincter ani internus was observed in 11 cases (28%), and a combined infiltration of the sphincter ani internus and externus was found in 2 patients (5%). The median distance of the lower tumor edge to the upper border of the anal canal was 2.0 cm (range, 0-4.5 cm). No infiltration of the external sphincter was observed in patients with cancers above the anal canal. Nine patients (22%) were treated with intersphincteric resection and coloanal anastomosis, 12 (30%) with ultralow resection, and 11 (28%) with low anterior resection of the rectum in conjunction with coloanal anastomosis or a stapled anastomosis. Eight (17%) of the patients were treated with abdominoperineal resection. CONCLUSION: An infiltration of the internal sphincter occurs only in 28% of low rectal cancers; an infiltration of the external anal sphincter is extremely rare and occurred only in patients with cancers located in the anal canal. Pelvic MRI offers a precise preoperative visualization of sphincter infiltration in patients with low rectal cancers and is therefore a valuable tool for planning of rectal surgery.     

44例中下段直肠癌经腹肛拖出切除术的疗效分析

目的：探讨直肠癌经腹肛拖出切除术后排便功能恢复的程度和生存率。方法：对接受此项手术的44例病人临床病理和随访资料进行分析,并与其它保肛手术效果对比。结果：肿瘤下缘距离齿状线的平均长度为4．1cm,术后吻合口瘘发生率4．5％,72．7％的病人认为肛门功能恢复达到正常。平均随访47个月,盆底和直肠肿瘤复发率11．8％。结论：虽经腹肛拖出切除术后肛门排便功能恢复正常率低于低位前切除术（Dixon术）,但复发率低,比前切除术更适宜于中下段直肠癌的保肛治疗。     

Anal sphincter function and sphincter preserving surgery

This article reviews the methods of assessing anal sphincter function and the place of sphincter-saving surgery in patients seen in the Gatrointestinal Unit of the Birmingham General Hospital between 1976 and 1984. (The main parameters for assessing sphincter function are maximinal and pressure at rest, maximum squeeze pressure, length of the high pressure zone, electromyography and parameters of rectal sensation.) Poor functional results were observed for patients having restorative surgery for rectal cancer when there is evidence of extrarectal tumour infiltration. It has now become our policy to avoid primary resection and anastomosis for fixed rectal cancer and for cancer involving the side walls of the pelvis. We would also question the value of low sphincter-saving surgery in patients with manometric evidence of a weak anal sphincter. Assessment of rectal capacity has been of predictive value in selecting patients suitable for ileorectal anastomosis in Crohn's disease. Sphincter preserving surgery in ulcerative colitis by ileorectal anastomosis or ileoanal anastomosis with pouch is unpredictable and continence is often imperfect. Repair of a rectal prolapse alone by a posterior rectopexy restores continence to 70% of patients but if incontinence persists post anal repair is beneficial in approximately 50% of cases. Incontinence which does not improve with medical therapy can often be restored by surgical treatment. Post anal repair restores continence to approximately 70% of cases and sphincter reconstruction to 80%.     

Sphincter-preserving surgery: per anal coloanal anastomosis

Since the introduction of the stapling technique, sphincter-preserving surgery for treatment of rectosigmoid and upper rectum carcinoma has been widely performed in the view of its radicality and postoperative quality of life. Sphincter preservation is still controversial in carcinoma of the lower rectum. Since we introduced per anal coloanal anastomosis (PAA) in 1980 and per anal intersphincteric dissection and coloanal anastomosis (PIDCA) in 1993 for the treatment of lower rectal carcinoma, the sphincter has been preserved in 78.7% of patients. There was no significant difference in the 5-year survival rate between patients in whom the sphincter was preserved and those who underwent abdominoperineal resection during the same period. PAA and PIDCA are safe when anastomosis must be performed at the dentate line. They are the best sphincter-preserving techniques for lower rectal carcinoma and do not result in serious postoperative dysfunction.