Comparison of short-term efficacy of transanal total mesorectal excision and laparoscopic total mesorectal excision in low rectal cancer

Background/objectiveThe transanal total mesorectal excision(TaTME) of rectal malignancies is largely referred to as treatment of mid to low, especially low rectal cancer. This study was to compare the short-term efficacy of TaTME and laparoscopic total mesorectal excision (LaTME) for low rectal cancer.MethodsA prospective study of patients with low rectal cancer who underwent laparoscopic radical surgery at the General Surgery of Guangzhou Red Cross Hospital from January 2017 to December 2019 was performed. The general information, perioperative results and pathological results of the two groups were compared.ResultsA total of 64 patients were included in the study, 32 in the TaTME group and 32 in the LaTME group. The clinical characteristics of the two groups was comparable (P > 0.05). The operation time in the TaTME group was longer than that in the LaTME group (212.59 ± 28.71min vs 187.66 ± 27.15min, P = 0.001), no significant differences were seen in the conversion rate, intraoperative complications, morbidity, serious morbidity, anastomotic leak, unplanned reoperation and hospital stay(P > 0.05). The circumferential resection margin (CRM) distance in the TaTME group was longer than that in the LaTME group (6.81 ± 2.99 mm vs 5.21 ± 3.06 mm, P = 0.039). The inter-group difference in terms of harvested lymph nodes, mesorectum integrity, CRM involvement, DRM distance, R1 resection, complete remission, pathological T stage, pathological N stage and pathological TNM stage was not significant (P > 0.05).ConclusionsTaTME is a promising surgical technique and maybe offers a safe and feasible alternative to LaTME in managing low rectal cancer.     

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目的　探讨腹腔镜全直肠系膜切除 (TME)治疗低位直肠癌的临床应用价值。方法　回顾性分析2 0 0 1～ 2 0 0 3年 2 7例腹腔镜低位直肠癌手术 ,其中Dixon术式 18例 ,Miles手术 9例。结果　 2 7例手术成功 ,无中转开腹。平均手术时间 (16 0± 2 0 )min ,术中平均失血 (15 0± 15 )mL ,术后平均住院 7d。无术后出血、吻合口瘘 ,术后排尿障碍 1例 ,明显性功能障碍 2例。随访 1～ 2 7个月 ,随访率为 10 0 % ,1例腹腔转移 ,1例肝脏转移 ,无穿刺口及切口转移。结论　TME治疗低位直肠癌安全可行 ,且创伤小 ,疼痛轻 ,恢复快。掌握手术适应证及良好的腹腔镜手术技术和开腹直肠手术经验是手术成功的保证。     

腹腔镜下全直肠系膜切除治疗低位直肠癌的体会

【摘要】〓目的〓总结腹腔镜下全直肠系膜切除治疗低位直肠癌的手术体会。方法〓选择我院2007年3月至2012年6月收治的低位直肠癌患者,根据手术方法不同,选择腹腔镜下全直肠系膜切除术50例(腹腔镜组)和开腹下实施直肠癌全直肠系膜切除术50例(开腹组),对两组病人术中出血量、手术时间、术后肛门排气时间、住院时间、切除淋巴结总数、住院总费用、随访结果等资料进行对比及临床分析。 结果〓腹腔镜组术中出血量、手术时间、术后肛门排气时间、住院时间均较开腹组少(P均<0.05);术中淋巴结清扫、直肠远切端距癌灶最下缘距离与开腹组没有明显差异(P>0.05);腔镜组的术后并发症及术后复发均较开腹组少(P<0.05)。结论〓腹腔镜下全直肠系膜切除治疗低位直肠癌与开腹组相比,腹腔镜组在减少损伤及术后恢复方面优于开腹组。而且腹腹镜组术后复发率低于开腹组。     

腹腔镜全直肠系膜切除治疗低位直肠癌(附198例临床资料报告)

目的探讨腹腔镜全直肠系膜切除治疗低位直肠癌的可行性和安全性。方法回顾分析198例腹腔镜全直肠系膜切除治疗低位直肠癌病例资料。结果全组无手术死亡,无中转开腹。平均手术时间（211.5&#177;69.2）min,中位出血量80（50～200）mL,平均切除淋巴结数为（11.5&#177;6.4）枚,平均肛门排气时间（2.8&#177;1.4）d,平均可下地行走时间（1.6&#177;0.9）d,平均术后住院时间（11.8&#177;6.4）d。术后并发症发生率为20.71%,最常见为肠梗阻（占并发症的24.4%）。中位随访时间为26.1（13.6～45.2）个月,随访率86.9%。33例出现术后复发转移,其中吻合口复发2例,盆腔局部复发3例,腹腔广泛转移4例,远处转移24例。死亡共37例,其中死于肿瘤相关因素28例,死于非肿瘤相关因素9例。5例带瘤生存。结论腹腔镜全直肠系膜切除治疗低位直肠癌不仅具有疼痛轻、恢复快等优点,在技术上也是安全可行的,而最终的结果仍有待于大量的、长期的前瞻性随机对照研究。     

腹腔镜直肠全系膜切除术治疗中、低位直肠癌的临床安全性对比研究

目的：探讨腹腔镜直肠全系膜切除治疗中、低位直肠癌手术的安全性。方法：回顾性对比分析我院2002年12月～2005年12月开腹直肠癌全系膜切除的病例（开腹组52例），以及2003年1月～2006年6月腹腔镜直肠癌全系膜切除的病例（腹腔镜组49例）。结果：腹腔镜组与开腹组一般资料差异无显著性。与开腹组比较，腹腔镜组术中出血量少[直肠癌前切除术（160±106）ml（n=37）vs（298±186）ml（n=36），t=-3．908，P=0．000；腹会阴联合直肠癌根治术（180±153）ml（n=10）vs（356±170）ml（n=14），t=-2．604，P=0．016]。腹腔镜组肠道功能恢复时间早于开腹手术组[（2．4±1．8）dVS（3．6±1．5）d，t=-3．648，P=0．000]。腹腔镜组总并发症的发生率低于开腹组[14．3％（7／49）g844．2％（23／52），x^2=10．834，P=0．001]。两组清扫淋巴结的数目无差异（12．7±6．5VS13．6±7．0，t=-0．668，P=0．505），下切缘均为阴性。腹腔镜组45例（91．8％）随访2～42个月，开腹组47例（90．4％）随访6～42个月，局部复发率分别4．4％（2／45）、4．3％（2／47）。结论：腹腔镜直肠全系膜切除治疗中、低位直肠癌安全、可行。     

Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer

Background The Laparoscopic approach has been applied to colorectal surgery for many years; however, there are only a few reports on laparoscopic low and ultralow anterior resection with construction of coloanal anastomosis. This study compares open versus laparoscopic low and ultralow anterior resections, assesses the feasibility and efficacy of the laparoscopic approach of total mesorectal excision (TME) with anal sphincter preservation (ASP), and analyzes the short-term results of patients with low rectal cancer.Methods We analyzed our experience via a prospective, randomized control trail. From June 2001 to September 2002, 171 patients with low rectal cancer underwent TME with ASP, 82 by the laparoscopic procedure and 89 by the open technique. The lowest margin of tumors was below peritoneal reflection and 1.5–8 cm above the dentate line (1.5–4.9 cm in 104 cases and 5–8 cm in 67 cases). The grouping was randomized.Results Results of operation, postoperative recovery, and short-term oncological follow-up were compared between 82 laparoscopic procedures and 89 controls who underwent open surgery during the same period. In the laparoscopic group, 30 patients in whom low anterior resection was performed had the anastomosis below peritoneal reflection and more than 2 cm above the dentate line, 27 patients in whom ultralow anterior resection was performed had anastomotic height within 2 cm of the dentate line, and 25 patients in whom coloanal anastomosis was performed had the anastomosis at or below the dentate line. In the open group, the numbers were 35, 27, and 27, respectively. There was no statistical difference in operation time, administration of parenteral analgesics, start of food intake, and mortality rate between the two groups. However, blood loss was less, bowel function recovered earlier, and hospitalization time was shorter in the laparoscopic group.Conclusion Totally laparoscopic TME with ASP is feasible, and it is a minimally invasive technique with the benefits of much less blood loss during operation, earlier return of bowel function, and shorter hospitalization.     

Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer

Aim The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic total mesorectal excision (TME) with coloanal anastomosis for mid and low rectal cancer. Methods During a 2‐year period, 50 patients underwent laparoscopic TME with coloanal anastomosis for rectal carcinoma located at a median of 4.5 (range 2–11) cm from the anal verge. Pre‐operative radiotherapy was used in 46 patients. Intersphincteric dissection was combined with the laparoscopic procedure to achieve sphincter preservation. Results Conversion to a laparotomy was necessary in six patients. Postoperative mortality and morbidity were 2% and 28%, respectively. Morbidity was lower in patients operated on during the second part of the study, who had extraction of the rectal specimen through a small laparotomy incision, than in those operated on during the first part of the study when removal of the specimen was by transanal extraction. Oncological quality of excision was safe in 44 patients with intact or almost intact rectal fascia in 88% and R0 resection in 90%. At a median follow‐up of 18 months, there was no local or port‐site recurrence. Conclusion This study confirms our preliminary results of oncological feasibility of laparoscopic TME with sphincter preservation for mid and low rectal cancer, and showed that morbidity can be decreased by using a standardized surgical procedure.     

腹腔镜全直肠系膜联合经肛门内括约肌切除治疗低位直肠癌的疗效探讨

目的探讨腹腔镜全直肠系膜（TME）联合经肛门内括约肌切除（ISR）治疗低位直肠癌的疗效,评估手术的安全性。方法回顾性分析2009年1月至2012年12月采用腹腔镜TME联合ISR术治疗的42例低位直肠肿瘤患者（腹腔镜组）,同时选取2006年1月至2012年12月开腹行TME联合ISR术治疗的44例低位直肠肿瘤患者（开腹组）。比较分析两组患者的一般资料、手术情况、临床病理特点、术后并发症和术后生活质量。结果两组患者的一般情况和术后临床病理特点相近。腹腔镜组患者均顺利完成手术,总体手术时间（min）明显小于开腹组（181.2±65.4 vs 216.6±82.9,t=2.192,P=0.031）,出血量（ml）亦明显小于开腹组（83.2±37.5 vs 117.4±33.0,t=4.495,P〈0.01）。4例低位直肠癌患者发生吻合口瘘,经保守治疗治愈,并发症发生率与开腹组相比差异无统计学意义。两组患者肛门功能自我评价以及KIRWAN分级差异均无统计学意义。结论对于术前评估早中期低位甚至超低位直肠癌,特别是肿瘤没有侵犯肛门内括约肌的患者,采用腹腔镜TME联合ISR术是安全可行的,提高了保肛成功率,保留患者术后肛门括约肌功能,改善生活质量。     

Evolution of transanal total mesorectal excision for rectal cancer:From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision(TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life(QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision(TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending.As evidence for safety and feasibility accumulates,structured training programs to standardize teaching,training, and safe expansion will aid the safe spread of the TaTME.     

Laparoscopic sphincter‐preserving total mesorectal excision: 10‐year report

Aim Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long‐term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long‐term oncological outcome after laparoscopic sphincter‐preserving TME with a median follow up of about 4 years. Method Patients with mid or low rectal cancer who underwent laparoscopic sphincter‐preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis. Results During the 10‐year study period, 177 patients underwent laparoscopic sphincter‐preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow‐up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5‐year survival and 5‐year disease‐free survival in the present study were 74% and 71%, respectively. Conclusion The results of this study show that laparoscopic sphincter‐preserving TME is safe with long‐term oncological outcomes comparable to those of open surgery.     

腹腔镜全直肠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

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术（ISR）对超低位直肠癌的治疗效果。方法对接受腹腔镜TME联合经肛ISR手术的35例超低位直肠癌患者的临床和随访资料进行回顾性分析。结果35例患者肿瘤下缘距肛门2～5（平均3．4）cm;高、中分化腺癌32例,绒毛状腺瘤癌变3例;pTNMⅠ期16例,ⅡA期15例,ⅢA期3例,ⅢB期1例。术后末端回肠造口狭窄1例,吻合口瘘3例（均为未行末端回肠造E1者）。经4～49（中位时间16）个月的随访．1例患者出现吻合口复发．1例死于肝转移。随访满1年的19例患者术后1年排粪次数为1～4次／d．控便时间5min以上。结论腹腔镜TME联合经肛ISR治疗超低位直肠癌具有根治、保肛和微创的优点!侣廊进行严格的病例选择．     

Total mesorectal excision – 40 years of standard of rectal cancer surgery

Abstract

Total mesorectal excision (TME) was first described 40?years ago by Richard Heald. The purpose of this article is to point out importance of this surgical procedure. Starting from first attempts to surgically cure rectal carcinoma in the nineteenth century through Miles’ operation at the beginning of the twentieth century results were not satisfactory due to high number of local recurrences after resections for rectal cancer. Progress in surgical technique and knowledge of anatomy and embryology of the rectum led to development of TME. Principle of TME is surprisingly simple: removal of the rectum with complete embryonic space containing lymph nodes which are site of primary dissemination of the disease. Main advantages and drawbacks of TME as well as focus on newer procedures developed from the concept of TME are presented in the form of a review.     

腹腔镜辅助经肛全直肠系膜切除手术

男性,50岁,体重质量指数(BMI)26.7 kg/m~2,初始诊断为低位直肠癌,肿瘤分期为cT_3CN_1M_0;经过术前新辅助放疗后的肿瘤分期为ycT_2N_0M_0,肿瘤下缘距离肛缘的距离为4.5 cm。患者在放疗后6周接受了腹腔镜辅助经肛全直肠系膜切除术,我们采用经腹和经肛两组手术医生团队同时实施手术,经下腹部小切口取出全直肠系膜切除的标本,在腹腔镜辅助下完成消化道重建,并采用荧光腹腔镜吲哚菁绿显像的方法检测吻合口血运。     

Robotic total mesorectal excision for the treatment of rectal cancer

Robotic techniques have been developed to facilitate endoscopic surgery and to overcome its disadvantages. Thus, we performed robotic total mesorectal excison (TME) in a patient with rectal cancer, using the da Vinci^® Surgical System. To our knowledge, this is the first robotic low anterior resection, based on standard TME principles, with pelvic autonomic nerve preservation. In conclusion, this robotic system is an excellent instrument for performing the standard TME procedure in rectal cancer patients.     

腹腔镜与开腹直肠全系膜切除术治疗低位直肠癌的临床对比研究

目的探讨腹腔镜辅助直肠全系膜切除术治疗低位直肠癌的可行性、安全性及近期临床疗效。方法将2001年9月至2003年6月我院同期收治的低位或超低位直肠癌患者,分腹腔镜组和传统开腹组进行手术,对其临床资料进行比较分析。结果腹腔镜组62例,其中3例(4.8%)中转开腹;开腹手术79例。两组手术时间分别为(155.1±48.8)min和(136.1±34.9)min,差异有显著性意义(P<0.05)。术中平均出血量分别为(69.3±70.1)ml和(100.7±110.5)ml,腹腔镜组明显少于开腹组(P<0.05)。两组在肠段切除长度、肿块距下切缘距离和淋巴结清扫范围方面比较,差异无显著性意义(P>0.05)。恢复肠道功能的时间腹腔镜组为(2.0±1.4)d,开腹组(3.2±1.1)d,两组比较,差异有显著性意义(P=0.000)。术后并发症发生率分别为16.1%和38.0%,两组比较,差异有显著性意义(P=0.004)。局部复发率分别为3.4%和5.4%。结论腹腔镜直肠全系膜切除术对低位、超低位直肠癌患者能够达到TME的治疗原则,并可取得与开腹手术同样的肿瘤根治性效果。     

Total mesorectal excision for rectal cancer – what can be achieved by a national audit?

Objective The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986–88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five‐year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. Methods In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. Results The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow‐up the rate of local recurrence was 8%, and 5‐year overall survival was 71% for patients younger than 75 years. Conclusions An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.