低位直肠癌括约肌间切除超低位吻合的疗效评估

目的评价超低位直肠癌行括约肌间切除手术（ISR）后的舡肠动力学变化、肛门功能及肿瘤根治效果。方法总结分析2004年1月至2007年8月间施行ISR手术的30例超低位直肠癌患者的临床资料。结果30例患者肿瘤距肛缘2．5～4．0（平均3．4）cm。与术前比较．术后肛管静息压、肛门最大收缩压和直肠最大耐受容积明显降低（P〈0．01）．有27例（90．0％）患者术后肛门直肠抑制反射消失,且随着时间推移无明显恢复。按Williams的排便自制标准．术后3、6、12个月分别有86．7％、93．3％和96．7％的患者达到功能良好效果。全组患者随访1年至3年8个月．无死亡病例;未出现盆腔或吻合口局部复发、远处转移和吻合口瘘。10例术后出现肛周粪渍性湿疹,2例结肠黏膜脱出,1例肛管狭窄。结论ISR超低位吻合保肛手术治疗低位直肠癌可以达到良好的根治性．并能较好地保留肛门功能。     

低位直肠癌保留肛门内括约肌捆扎套入法超低位结肠-肛管吻合术

目的介绍用支撑捆扎套入法完整保留齿状线和肛门内括约肌的超低位结肠肛管吻合术。方法87例低位直肠癌在完成全直肠系膜切除后,保留距离齿状线≤1cm的直肠,剥离直肠黏膜,保留齿状线。近端结肠内置入肛门支撑吻合管,经肛门拖出与直肠残端吻合。结果87例保留内括约肌的超低位结肠肛管吻合术无手术死亡及吻合口漏,随访2～60个月,随访率89%,无吻合口复发;盆腔内软组织肿瘤复发3例,闭孔淋巴结复发2例,异时肝转移6例。术后12个月吻合口狭窄6例。术后6个月对79例排便功能进行评价,平均每日排便2～3次,可以区分排气和排便,可以控制半成形便,排便不规律52例。结论低位直肠癌根治术后,支撑捆扎套入法可以完成保留肛门内括约肌的超低位结肠肛管吻合术。     

经肛管括约肌间平面切除低位直肠癌保肛手术疗效分析

目的探讨经肛门内外括约肌间切除术用于超低位直肠癌保肛手术的安全性、可行性、肿瘤根治效果及肛门功能状况。方法回顾性分析我院2000年4月～2004年8月经选择的超低位直肠癌病人接受经肛门内外括约肌间切除直肠癌保肛手术37例的临床资料。腹部手术遵循TME原则,肛门手术在直视下距病灶下缘2cm全层切断直肠或肛门内括约肌,经括约肌间隙向上游离达肛管外括约肌环与腹部手术会师,近端结肠与肛管完成端端吻合。前瞻性随访术后病人肿瘤复发与肛门排便功能状况。结果全部病人均完成手术。术后发生急性肺栓塞死亡1例,盆底肌肉出血1例,吻合口漏3例。本组有36例获得随访,平均随访时间为40个月。吻合口复发3例,其中,死亡1例。同时肺、腹膜转移于术后24个月死亡1例,因肝转移分别于术后16、24个月死亡2例,因腹腔内淋巴结、腹股沟淋巴结转移于术后16个月死亡1例。术后6个月,病人肛门括约肌功能已比较满意。结论经肛门内外括约肌间切除治疗超低位直肠癌的手术方法是一种可供选择的安全性高、根治效果好的保肛术式。     

经肛管括约肌间径路切除低位直肠癌保肛手术临床研究

目的探讨经肛门内外括约肌间径路切除超低位直肠癌保肛手术的安全可行性,并评价肿瘤根治效果及术后肛门功能。方法分析2000-2004年华中科技大学同济医学院附属协和医院经选择的经肛门内外括约肌间径路切除超低位直肠癌保肛手术病人42例的临床资料。结果腹部手术遵循TME原则,肛门手术在直视下距病灶下缘2cm切断直肠黏膜和肛门内括约肌,经括约肌间隙向上游离达肛管外括约肌环上方与腹部手术会合,近端结肠与肛管完成端端吻合。前瞻性随访术后病人肿瘤复发与肛门排便功能状况。37例病人完成手术,并发症包括发生急性肺栓塞并死亡1例,盆底肌肉出血1例,吻合口漏3例。36例病人获得随访,平均随访时间为40(24~60)个月。3例(8.33%)吻合口复发,其中1例死亡;1例同时肺、腹膜转移于术后24个月死亡;2例因肝转移分别于术后16、24个月死亡;1例腹腔内淋巴结、腹股沟淋巴结转移于术后16个月死亡。术后6个月肛门括约肌功能已比较满意。结论经肛门内外括约肌间径路切除术治疗超低位直肠癌的手术方法是一种可选择的安全性高、根治效果好的保肛术式。     

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。     

全直肠系膜切除+经肛门内括约肌切除术治疗超低位直肠癌和直肠肛管癌的近期疗效

目的探讨全直肠系膜切除(TME)+经肛门内括约肌切除术(ISR)治疗超低位直肠癌和直肠肛管癌保肛手术的安全性及可行性,并评价近期肿瘤根治效果及术后肛门功能。方法回顾性分析2009年1月至2010年12月期间四川大学华西医院胃肠外科中心行TME+ISR治疗的超低位直肠癌和直肠肛管癌86例患者的临床及随访资料。结果 86例患者均成功完成手术,肿瘤下缘距肛门1～5 cm(平均1.63 cm);肿瘤直径2～7 cm,平均3.4 cm。肿瘤系高分化4例,中分化60例,低分化22例;pTNM分期为Ⅰ期12例,ⅡA期11例,ⅡB期15例,ⅢA期2例,ⅢB期23例,ⅢC期16例,Ⅳ期7例。术后发生吻合口漏3例,肛周感染2例(其中1例因肛周严重感染引起盆腔、腹膜感染再次手术行永久性造口),吻合口出血及吻合口狭窄各2例,直肠阴道瘘、炎性肠梗阻、尿潴留和腹腔感染各1例。86例患者均获随访,平均随访时间为18个月(12～24个月)。1例于术后7个月发现肝转移,2例分别于术后7个月和12个月因肿瘤广泛浸润、转移死亡;术后1年局部复发3例(3.5%),1年生存率为97.7%(84/86),排便次数1～5次/d,控便功能按Kirwan评分标准可达1～2级。结论 TME+ISR治疗超低位直肠癌和直肠肛管癌是一种可行的、安全的、能达到根治的保肛术式,近期疗效满意。     

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.     

套入式结肠直肠黏膜吻合术治疗低位直肠癌86例的临床研究

目的 探讨低位直肠癌保留肛门括约肌功能最理想的治疗术式。方法 对86例低位直肠癌切除后经肛门行套入式结肠直肠黏膜吻合术。肿瘤下缘距肛缘6－7cm 62例，8－10cm 24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8－12周时排便功能控制良好，排便次数为1－4次／d，18周时肛门排便功能基本恢复正常，排便次数为1－2次／d。术后随访3个月至8年，总的局部复发率为3．7％（3／81），总的5年生存率为66．7％（14／21）。结论 套入式结肠直肠黏膜吻合术可避免腹部结肠造口，并防止吻合口瘘的发生，作为低位直肠癌保肛手术，是一种安全的术式。     

超低位直肠癌保肛术22例临床分析

目的　探讨和研究超低位直肠癌保留肛门括约肌功能的最佳治疗术式。方法　经腹和肛门齿状线切除直肠下段癌 ,行乙状结肠与肛管齿状线吻合 2 2例。结果　全组无手术死亡、无发生吻合口漏和吻合口狭窄 ,术后 10 - 12周对排气和排便控制良好 ,无一例发生大便失禁。随访 11个月 - 8年 ,平均随访时间 3年 3个月。一、三、五年生存率分别为 13.6 % (3 2 2 )、5 9.1% (13 2 2 )、2 7.3% (6 2 2 )。 3例DukesC1期于术后 14、18个月和 2 3个月死于远处转移 ,无一例局部复发。结论　根据直肠肿瘤临床分期和肿瘤生物学行为选择手术适应证 ;经腹、肛门齿线联合切除根治下段直肠癌 ,行乙状结肠与肛管齿状线吻合是一种良好的保肛术式     

全直肠系膜切除支撑捆扎法低位或超低位结肠-直肠(肛管)吻合术

目的介绍在全直肠系膜切除基础上用支撑捆扎法完成低位直肠癌低位或超低位结肠-直肠(肛管)吻合手术术式。方法对346例低位直肠癌在全直肠系膜切除和根治性清扫基础上,用支撑捆扎法进行保留肛门括约肌手术,对直肠断端距齿状线≥1cm者用改良Welch手术完成结肠-直肠吻合术;直肠断端距齿状线≤1cm者行保留肛门内括约肌的结肠-肛管吻合术。结果本组346例手术中无死亡病例,术后近期出现吻合口漏4例(1·2%),局部引流2周治愈2例、横结肠造口转流2例,无吻合口出血。吻合口距离齿状线距离:2~3cm者114例,1~2cm者145例,0~1cm者87例。术后吻合口狭窄10例,狭窄率2·9%。Lifetable法计算5年生存率和局部复发率分别为78·6%及6·3%。手术后3个月排便功能的优良率为82·6%。结论支撑捆扎法用于低位直肠癌保肛手术可以完成耻骨直肠肌上缘到肌间沟平面的吻合,吻合口漏和吻合口狭窄发生率较低。     

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.     

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.     

经肛门括约肌间直肠切除结肠肛管吻合术作为超低位直肠癌保肛术的初步报告

目的 探讨经肛门括约肌间直肠切除结肠肛管吻合术（PIDCA)联合术前后放疗和化疗对超低位直肠癌保肛手术的治疗效果。方法从2002年6月到2004年10月,对19例患者施行该手术。男性11例,女性8例,平均年龄56岁(41-74岁)。肿瘤分期T,4例、T2 10例、T14例、L1例,肿瘤距离肛缘平均4．4cm(3．5-5．0cm)。经肛门在直视下从距离肿瘤下缘2cm全层切断直肠或肛门内括约肌,通过肛门内外括约肌间隙向上方游离直肠并与经腹完成的直肠游离汇合切除直肠及其系膜,经肛门行结肠肛管吻合,全部患者均未行预防性结肠或回肠造口。结果无手术死亡,吻合口瘘2例(10．5%)。随访时间为3～29个月,平均随访16个月,1例盆腔复发,复发率5．3％。术后肛门括约肌功能比较满意。结论对经过选择的距离肛缘≤5cm的超低位直肠癌结合术前后的盆腔放疗和化疗,PIDCA术是保留肛门括约肌功能较理想、安全的术式,有较好根治性治疗效果,术后肛门括约肌功能比较满意。     

保护性造口在超低位直肠肿瘤内括约肌切除术中的价值

目的 探讨保护性造口在超低位直肠肿瘤内括约肌切除术(ISR)中的应用价值.方法 对1999年1月至2009年7月给予经肛ISR联合经腹全直肠系膜切除术结肠肛管吻合术的56例无肛门外括约肌受侵的超低位直肠肿瘤患者的临床资料进行回顾性分析,比较造口组(16例)与未造口组(40例)患者术后吻合口和肛门部并发症及肛门功能恢复情况.结果 56例患者中16例(28.6%)行保护性造口.未造口组术后吻合口和肛门部并发症分别出现14例(35.0%)和16例(40.0%),而造口组吻合口及肛门部并发症分别仅出现1例(1/16),两组差异有统计学意义(P<0.05).未造口组1例吻合口裂开肿瘤复发再手术行永久性结肠造口,另3例吻合口及肛门病变需造口及二期手术治疗,再手术率为10.0%.两组患者术后肛门控便能力均下降,造口组患者造口回纳术后3、6、12个月肛门功能Kirwan评分达Ⅰ级者分别为11/16、13/15、11/13,未造口组患者术后3、6、12个月达Ⅰ级比例分别为30.0%、37.5%、45.0%,术后同期造口组患者肛门功能均明显优于未造口组患者(P<0.05).结论 保护性肠造口可减少超低位直肠肿瘤ISR后吻合口瘘,消除术后早期肛门失禁给患者带来的痛苦,且有利于肛门功能的恢复.     

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.     

Functional results after “high” coloanal anastomosis and “low” coloanal anastomosis with a colonic J-pouch for rectal carcinoma

The aim of this study was to determine the postoperative function of neorectoanal components using two different types of very low coloanal reconstruction. The two groups of patients assessed were 22 who underwent abdominal rectal resection and stapled “high” coloanal anastomosis without a pouch, being the HCAA-P group; and 34 who underwent anoabdominal rectal resection and “low” coloanal anastomosis with a colonic J-pouch, being the LCAA+P group. Manometric metric examination was performed 1, 3, 6, and 12 months postoperatively, and the patients were also assessed by a questionnaire. The LCAA+P group had remarkably less daily stool frequency and urgency, but there were no significant differences in the other functional parameters. Maximum resting pressure (MRP) was significantly less, while threshold volume (TV) and maximum tolerable volume (MTV) were greater in the LCAA+P group than in the HCAA-P group. The colonic J-pouch compensated for decreased MRP. Thus, when HCAA-P is performed, 3.0 cm of residual rectum with internal anal sphincter may be required, and construction of the pelvic pouch is desirable in low coloanal anastomosis.     

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。