低位直肠癌全直肠系膜切除术86例分析

全直肠系膜切除术(total mesorectal excision, TME)自1982年由英国学者Heald等[1]提出到现在已经20余年,其临床效果已得到国际公认.对比传统的直肠癌根治术,在无辅助放化疗的情况下,单独应用TME技术能降低直肠癌术后局部复发率并提高术后生存率,越来越多的国家和地区把TME作为低位直肠癌根治术的金标准[2-3].我院自1998-01对86例低位直肠癌患者施行了直肠癌根治术,结果总结报道如下.     

直肠癌直肠系膜解剖及其临床意义

目的 研究直肠癌直肠系膜的结构及其在直肠癌手术中的意义。方法 解剖本院近2年来72例直肠癌术后的新鲜标本，测量肠系膜下动脉的长度；观察直肠系膜结构、肠系膜下动脉分支及肿大淋巴结情况；病理检查送检淋巴结、系膜边缘及肠残端。结果 直肠系膜内的淋巴结主要集中于直肠肿瘤周围2cm区域，直肠上动脉分又处，肠系膜下动脉根部3个区域，各区域淋巴结阳性率为78．6％、34．3％、8．9％，而直肠反折上肿瘤各区淋巴结阳性率79．8％、40．5％、23．7％。但左结肠动脉到直肠上动脉分又处的较长沿途中，淋巴结肿大、转移极少，直肠系膜呈中厚侧薄的结构，直肠下端近隔膜处的裸区实质上就是直肠下端直肠系膜与直肠之间通过疏松结缔组织相连的区域，并不是真正的裸区。结论 直肠癌D3手术高位结扎肠系膜下动脉是完全必要的，手术时最下一支的乙状结肠动脉及其所供血的结肠可作为直肠癌切除的上切缘，“裸区”存在对低位及超低位直肠癌保肛手术有重要意义。     

全直肠系膜切除与直肠癌根治术

目的 探讨直肠癌根治性切除的手术范围。方法 对56例采用全直肠系膜切除术直肠癌患者进行术后病理分析。结果 吻合口瘘发生率为3.6%。56例中有22例直肠系膜内有淋巴结转移,14例直肠系膜内发现癌结节,直系膜转移率50.0%(28/56),5例直肠和纱膜转移位于肿瘤远端2cm以下。结论 直肠癌根治性手术应施行全直系膜切除。     

全直肠系膜切除术对低位直肠癌患者局部复发率及生活质量的影响

目的探讨全直肠系膜切除手术(total mesorectal excision,TME)对直肠癌患者近远期疗效及生存质量的影响。方法选取2008年1月至2011年12月期间徐州市贾汪区人民医院收治的低位直肠癌患者为研究对象,根据术式分为TME组60例及传统手术组66例。随访5年,对比分析两组患者近远期疗效及生存质量。结果两组手术时间差异无统计学意义(P0.05),TEM组术中出血量住院时间、总并发症发生率均低于传统手术组,差异有统计学意义(均P0.05)。两组1、3年复发率及1、3年生存率相比差异均无统计学意义(均P0.05),而5年局部复发率及5年生存率相比,差异均有统计学意义(均P0.05)。结论 TME手术能提高直肠癌患者治疗效果,降低患者局部复发率,提高患者生存率及生存质量。     

直肠癌全直肠系膜切除术临床应用(附27例报告)

目的研究直肠癌患者行全直肠系膜切除术(TME)的临床疗效。方法对27例行TME术式的直肠癌患者的临床资料进行分析。结果27例均获根治性切除，15例行吻合器吻合，术后发生吻合口瘘2例。术后辅助化疗及放疗，近期无局部复发病例。结论TME是降低直肠癌术后局部复发率，提高生活质量的有效措施。直肠癌根治性手术中采用TME手术方法是非常重要的。     

直肠系膜全切除在直肠癌低位前切除的应用

[目的]探讨直肠系膜全切除在直肠癌低位前切除的应用。[方法]对1995年-2000年收治的进行低位前切除的直肠癌病例共67例进行回顾性分析。[结果]全组共发生吻合口瘘5例,发生率为7%。均行转流性造口而治愈,无手术相关死亡。[结论]直肠系膜全切除在直肠癌低位前切除的应用是安全的。     

腹腔镜全直肠系膜切除术49例低位、超低位直肠癌保肛手术应用分析

[目的]比较腹腔镜全直肠系膜切除术(TME)与传统开腹直肠癌根治术在直肠癌保肛治疗中的应用效果。[方法]选取2009年6月至2011年2月在宁波市第二医院确诊为直肠癌的患者101例,分为腹腔镜组(49例)和开腹组(52例)。[结果]腹腔镜组的手术时间、术后肛门排气时间、留置导尿时间、术后住院时间分别为150.4±30.2min、2.6±0.2d、2.8±0.7d及9.5±2.6d,开腹组分别为168.1±41.3min、3.8±0.7d、4.9±0.6d及15.4±3.7d,腹腔镜组均短于开腹组P<0.05。术中出血量腹腔镜组(92.7±24.1ml)少于开腹组(144.8±23.6ml)(P<0.05)。肿瘤大小、切除标本长度、清扫淋巴结数目及肿瘤远端切缘长度方面与开腹组比较差异无统计学意义(P>0.05)。但是腹腔镜组手术费用、住院总费用要高于开腹组(P<0.05)。腹腔镜组术后切口感染(2.0%)、肠黏连(2.0%)、术后尿潴留(4.0%)明显少于开腹组(P<0.05)。吻合口瘘发生率两者差异无统计学意义(P>0.05)。[结论]腹腔镜TME技术应用于低位、超低位直肠癌保肛手术中疗效确切,具有手术时间短、出血量少、肛门恢复排气时间快、术后并发症发生率低等优点,值得临床推广。     

直肠癌侧方淋巴结清扫和全直肠系膜切除

目前全直肠系膜切除（TME）原则已经是直肠癌手术的基本原则之一。很多学者把TME作为金标准,但不可将TME和侧方淋巴结清扫混为一谈。不可以因为TME而废除淋巴结清扫,也不可以因行淋巴结清扫而不行TME,只有二者同时进行才可达到根治肿瘤的目的。     

术前同步放化疗联合全直肠系膜切除术治疗中低位局部晚期直肠癌的疗效

目的探讨术前同步放化疗联合全直肠系膜切除术(TME)治疗中低位局部晚期直肠癌的疗效。方法给予75例中低位局部晚期直肠癌患者(T3~4N0M0期或T1~2N1~2M0期)进行新辅助同步放化疗,放化疗结束后行全直肠系膜切除术(TME),观察治疗效果。结果 75例患者均完成术前同步放化疗,其中完全缓解(CR)13例,部分缓解(PR)50例,疾病稳定(SD)12例,84.0%(63/75)的患者临床分期下降。75例患者均接受了手术治疗,总保肛率为66.7%(50/75),无一例发生围手术期死亡,术后并发症发生率为20.0%(15/75)。结论术前同步放化疗联合TME治疗中低位局部晚期直肠癌安全、有效,可以降低肿瘤分期,提高保肛率,提高患者生活质量。     

同步新辅助放化疗联合全直肠系膜切除术治疗中低位局部进展期直肠癌的临床研究

目的:探讨同步新辅助放化疗联合全直肠系膜切除术(total mesorectal excision,TME)治疗中低位局部进展期直肠癌的疗效及安全性。方法:2009年9月-2011年2月30例中低位局部进展期直肠癌患者[Ⅱ期(T3-4N0M0)14例,Ⅲ期(T1-4N1-2M0)16例]接受了术前同步新辅助放化疗(术前放疗总剂量为45～50Gy,1.8Gy/次;化疗方案为FOLFOX4,化疗2个周期)。同步新辅助放化疗结束后4～6周行手术治疗,遵循TME原则。结果:全部患者均完成同步新辅助放化疗,CR5例、PR18例、SD7例,有23例(76.7%)患者的临床TNM分期下降。同步新辅助放化疗结束后4～6周,除1例CR患者拒绝手术外,29例患者均行手术治疗,其中23例行低位或超低位前切除术(Dixon术),6例行腹会阴联合切除术(Miles术),保肛率为80.0%(24/30)。无一例发生围手术期死亡,术后并发症的总发生率为20.7%(6/29)。结论:同步新辅助放化疗联合TME治疗中低位局部进展期直肠癌安全而有效,可以降低肿瘤分期、提高肿瘤切除率和保肛率,改善患者的生活质量。     

Distribution of metastases in mesorectum is unpredictable: Metastases do not respect tumor localization even in small non-circumferential rectal cancers

Introduction

Low anterior resection with total mesorectal excision (TME) is the gold standard for surgical treatment of rectal carcinoma. The radicality of this procedure is negatively counterbalanced by morbidity, lethality, and numerous other complications. Local excision would appear to be an attractive alternative, but its radicality is disputable due to risk of undetected metastasis to the mesorectum. The study aimed to determine the location of mesorectal metastases with respect to circumferentially – located tumors in patients with tumors involving less than one-third of the rectal circumference.

Regional micrometastasis of low rectal cancer in mesorectum: a study utilizing HE stain on whole-mount section and ISH analyses on tissue microarray

Aim: To investigate the regional spread of microscopic tumor nodules in the mesorectum of patients with low rectal cancer, and to provide further pathological evidence for optimal procedure selection of radical resection for rectal cancer. Methods: Sixty-two patients with low rectal cancer underwent low anterior resection and total mesorectal excision (TME). Surgical specimens were sliced transversely on serial embedded blocks at 2.5-mm intervals, and stained with hematoxylin and eosin (HE). On whole-mount sections the mesorectum was divided into 3 regions: the outer region of the mesorectum (ORM), the middle region of the mesorectum (MRM), and the inner region of the mesorectum (IRM). Microscopic metastatic foci were investigated for metastatic mesorectal region, frequency, types, involvement of the lymphatic system, and correlation with the primary tumor. Tumor-suspect nodules previously considered disease free by HE stain on whole-mount section were examined by in situ hybridization (ISH) on tissue microarray (TMA) through detecting mRNAs of CEA and CK20 with non radioactive biotin-tagged oligonucleotide probes. Results: Microscopic spread of the tumor was observed in 50.0 percent of patients (31 out of 62, 24 by HE stain on whole-mount section and 7 by ISH on TMA) and that in the ORM was observed in 38.7 percent of the patients (24 out of 62, 16 observed by HE stain on whole-mount section and 8 by ISH on TMA). Microscopic tumor foci spread in the circumferential resection margin (CRM) occurred in 8.1 percent of the patients (5 out of 62, 4 observed by HE stain on whole-mount section and one by ISH on TMA), and distal mesorectum (DMR) involvement was detected in 6.5 percent (4 out of 62, all observed by HE stain on whole-mount section), with the spread extending to within 3 cm from the lower margin of the tumor. Most (26 of 31) of the patients with microscopic spread in mesorectum had TNM Stage III diseases. Conclusions: The results of the present study support the theory that complete excision of the mesorectum without destruction of the ORM is essential for surgical management of low rectal cancer, and an optimal DMR clearance resection margin of no less than 4 cm was referenced. Five patients with microscopic tumor nodule spread in the CRM observed in the study suggested that microscopic metastases exist in pelvic lateral areas and in the mesorectum simultaneously, indicating the significance of preoperative and/or postoperative radiochemotherapy.     

Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

Background

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.

直肠系膜全切除术的合理实施

目的 从直肠癌术后局部复发形式探讨直肠系膜全切除(TME)的合理实施及临床意义。方法 分析207例局部复发直肠癌患者的复发形式、治疗情况及治疗效果。结果 吻合口复发71例,直肠系膜复发65例,会阴部复发50例,淋巴结复发59例,多部位复发89例,其他部位少见。第1次行前切除术(AR)的8l例患者中,改行腹会阴联合切除术(APR)者58例;第1次行APR者102例,改行会阴部肿块切除者38例;行全盆及后盆器官切除者15例,补充行淋巴结清除者18例。手术切除率为66．2％(137／207),其中根治性切除率为46．0％(63／137)。172例有完整随访资料的患者中,病灶切除者的5年生存率为23．4％(32／137)．根治切除者的5年生存率为34．9％(22／63)。结论 从局部复发形式来看,TME是中低位直肠癌手术必须遵循的原则,复发患者只要全身条件允许,应再行手术治疗。     

Quality of life outcomes following laparoscopic total mesorectal excision for low rectal cancers: a clinical control study.

AIMS: To evaluate the health-related quality of life (HRQoL) outcomes in patients undergoing laparoscopic total mesorectal excision (LTME) with anal sphincter preservation (ASP) for low rectal cancers. METHODS: Patients undergoing LTME with ASP or open procedures (OTME) for low rectal cancers were prospectively followed up. All patients were treated in curative attempt and were free of local recurrence during the study. HRQoL was assessed by questionnaires during 3-6 months, 12-18 months, and 2-5 years after surgery. RESULTS: From June 2001 to March 2006, 125 patients undergoing LTME and 103 undergoing OTME were included in this study. In contrast to OTME patients, the LTME ones showed significantly better physical function during 3-6 months after surgery, less micturition problems within 12-18 months, less male sexual problems and better sexual function during 12-18 months after surgery, with better sexual enjoyment after 24 months postoperatively. Both groups showed significant improvement in most subscales from the first to the second assessment, and an improvement in sexual enjoyment from the second to the third assessment. The sexual function, micturition problems and male sexual problems in the LTME group significantly improved from the first to the second assessment, whereas the sexual function in the OTME group improved from the second to the third assessment. CONCLUSIONS: Patients undergoing LTME for low rectal cancers can achieve superior postoperative HRQoL than patients undergoing OTME, with superior physical function, micturition function, overall sexual and male sexual functions in the short term, and better sexual enjoyment in the long term. The HRQoL of both LTME and OTME patients may be expected to improve over time, particularly over the first postoperative year.     

Outcomes of laparoscopic Miles' operation in very low rectal adenocarcinoma. Analysis of 32 cases.

AIMS: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. METHODS: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. RESULTS: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. CONCLUSIONS: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.     

Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer

Introduction

The need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer.

低位直肠癌前切除术中吻合器的应用价值(附420例病例报告)

背景与目的：中同直肠癌的发病率逐年上升，如何提高患者的生存率及术中保肌是目前探讨的热点话题本研究旨在探讨直肠系膜全切除术（TME）及吻合器在低位直肠癌保肌手术中的作用、方法：回顾性分析邯郸市中心医院2000--2006年间420例低位直肠癌患者用吻合器行直肠癌前切除术的临床资料结果：全组手术进行顺利，无手术相关死亡，术后局部复发17例．占手术病例总数的4％。1年生存率为100％，5年生存率为63.1％。结论：低位直肠痛保肛手术中行TME及应用吻合器可明显降低局部复发率及提高患者生存率.