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目的 评价经肛门局部切除治疗低位直助癌的效果。方法 回顾性分析1991—2000年间经肛门局部切除治疗24例低位直肠癌的临床资料。结果 (1)24例均为直肠腺癌。(2)24例直肠癌T0期2例，T1期8例，T2期14例。(3)围手术期病死率为0。(4)术后特异性并发症仅有1例，占4．2％。(5)有4例局部复发。其中1例经局部切除治愈；另外3例行经腹会阴联合切除术，其中1例于术后3．5年固多发转移死亡。(6)本组直肠癌病人经肛门局部切除术后，随访均超过2年，5年生存率为93．10％。结论 低位直肠癌采用经肛门局部切除手术结合放疗的方法可以达到很好的疗效且并发症少，但应严格掌握适应证，慎重选择病例。     

经腹及肛门内括约肌切除保肛术治疗低位直肠癌的临床研究

目的 探讨经腹及肛门切除肛门内括约肌的直肠癌根治保肛术治疗低位直肠癌的临床疗效。方法 对34例癌灶下缘距齿状线不足2cm或距肛缘不足4—5cm的低位直肠癌经腹及肛门切除肛门内括约肌保肛术进行回顾性分析。结果 34例中男23例，女11例。年龄28—76岁，平均为56．4岁。癌灶下缘距肛缘4cm12例（腺瘤癌变5例），癌灶下缘距肛缘5cm22例，病理诊断直肠腺癌29例，其中高分化者18例，中分化者11例，腺瘤癌变5例。Dukes分期：A期18例，B期16例。34例术后随访率为97％（33／34），中位随访时间为4．9年。术后发生吻合口瘘1例（2．9％），吻合口狭窄1例（2．9％）；术后6—12个月时排便功能基本恢复正常。术后局部复发率为2.9％，术后5年生存率为69．6％。结论 经腹及肛门切除肛门内括约肌的直肠癌根治保肛术式，既能保存良好的肛门排便功能，又不降低5年生存率，是一种安全有效的低位直肠癌保肛术式。     

48例早期低位直肠癌经肛门局部切除手术的临床疗效

低位直肠癌原则上需采用经腹会阴联合切除术。但对于尚处于早期的病变，能否采取经肛门局部切除是一值得探讨的问题。早期低位直肠癌经肛门局部切除术。具手术野显露好、创伤小、风险低等优点，且保全排便和泌尿生殖功能．然而由于其不能切除引流淋巴，在病理分期和手术彻底性上存在缺陷，因此必须严格掌握指征。现就我院1999年8月至2001年8月的48例低位直肠癌病人经肛门局部切除疗效进行分析。同期我院直肠癌病人共163例，局部切除术占29．4％。     

低位直肠癌经肛门局部切除40例疗效分析

目的 探讨低位直肠癌经肛门局部切除的适应证和疗效.方法 回顾性分析1997年1月至2006年12月间广东省人民医院普通外科40例低位直肠癌患者经肛门局部切除的临床资料.结果 本组患者平均手术时间50(30～85)min,术中出血量40(10～100)ml,平均住院时间5(2～10)d.全组患者平均随访时间40(6～120)个月.术后局部复发率为20.0%(8/40),5年生存率为90.0%.T1期患者术后局部复发率为17.9%(5/28),低于T2期患者的25.0%(3/12),但两组差异无统计学意义(x2=0.268,P=0.61);高分化腺癌患者术后局部复发率为12.9%(4/31),明显低于中分化腺癌的4/9,两组差异有统计学意义(x2=4.337,P=0.04);肿瘤直径小于3 cm者术后局部复发率为10.7%(3/28),明显低于大于或等于3 cm者的41.7%(5/12),两组差异有统计学意义(x2=5.030,P=0.03).经肛门局部切除术后局部复发率与肿瘤部位(x2=0.139,P=0.93)、分型(x2=1.290,P=0.53)和手术切除方式(x2=0.667,P=0.41)无关.结论 低位直肠癌经肛门局部切除适应证为肿瘤直径小于3 cm和高分化的T1、T2期患者.只要严格掌握手术适应证,经肛门局部切除治疗低位直肠癌可获取良好的疗效.     

低位直肠癌拖出型结肠肛管吻合术的临床应用

目的：探讨拖出型结肠肛管吻合术治疗低位直肠癌的安全性及效果。方法：对98例低位直肠癌应用拖出型结肠肛管吻合术，即肿瘤切除后将直肠远端外翻，近端结肠经外翻的直肠拖出，于肛门外行结肠肛管一期吻合，并立即送回盆腔。结果：术后吻合口瘘7．15％，局部复发率13．27％，5年生存率69．39％，术后3～6个月肛门功能接近正常人，无1例大便失禁。结论：应用拖出型结肠肛管吻合术治疗低位直肠癌应选择合适的病例，可获得较高的生存率及生活质量。     

臀大肌瓣加弹性金属环行肛门成形术

目的：探讨直肠癌根治性切除后用臀大肌瓣与弹性金属环行肛门成形的疗效及其在肿瘤局部治疗中的意义。方法：对34例中下段直肠癌在根治性切除后，利用白体臀大肌瓣加弹性金属环行会阴肛门成形，以代替切除的括约肌，使患者仍保持术后由会阴部排便。结果：手术成功30例，失败4例。按患者术后排便感觉、排便次数及排便预感等主观感觉划分，术后效果优者10例(33．3％)，良者16例(53．3％)，差者4例(13．3％)。术后随访6个月～6年，其控制大便优良率为76．7％(23／30)，术后1年生存率为100％，3年为82．4％(28／34)，5年为58．8％(20／34)。结论：臀大肌瓣加弹性金属环行肛门成形术术式对部分患者，特别是不愿意行腹壁人工肛门的直肠癌患者具有一定实用价值，值得推广应用。     

低位直肠癌的保肛手术:附320例报告

目的 探讨低位直肠癌保肛手术的适应证，术式选择及疗效。方法 回顾性分析手术后≥5年的320例低位直肠癌行保肛手术治疗患者的临床资料，比较各种术式的5年生存率、局部复发率及死亡率。结果低位直肠癌保肛率为58．5％(320／547)。术后发生吻合口漏为4例(1．25％)，1年内吻合口狭窄发生26例(8．13％)，术后排便情况以加做结肠末端粪袋成形术者为佳。5年生存率及吻合口局部复发率：Dixon手术组为63．24％，10．27％；Park手术组为66．67％，5．13％；局部切除手术组为89．46％，10．7l％。5年盆腔软组织复发ll例(3．44％)。全组手术死亡2例(0．6％)。结论 低位或超低位结肠一直肠吻合术是低位直肠癌保肛手术的主要术式。在严格掌握适应证的情况下，可考虑施行低位直肠癌的局部切除术。低位直肠癌保肛手术并不影响5年生存率和局部复发率，术后并发症的发生与术式选择无关，辅助性的结肠末端粪袋成形术，有利于改善低位直肠癌保肛术后的排便功能。     

超低位前切除经肛门吻合术在低位直肠癌保肛术中的应用

目的 探讨低位直肠癌保肛术的手术方法、可行性及一些相关问题。方法 作者自1992年10月至2000年1月，对63例低位直肠癌施行超低位切除经肛门吻合术进行回顾性分析。结果 全组病例均顺利切除，吻合成功。术后发生吻合口漏11．1％（7／63），吻合口狭窄15．9％（10／63）。局部复发率12．6％（8／63），5年生存率81％（51／63）。结论 超低位前切除经肛门吻合保肛术是治疗低位直肠癌的一种易行、安全、经济的术式，并可提高生活质量。     

经肛门括约肌直肠肿瘤切除术97例临床疗效

目的探讨经肛门括约肌手术在中低位直肠肿瘤局部切除术中的作用和疗效。方法对1990年3月至2007年3月采用经肛门括约肌手术的97例中低位直肠肿瘤病例进行回顾性分析。结果全组行直肠部分切除术91例,直肠节段切除术6例。术后并发伤口感染5例（5．2％）,直肠皮肤瘘4例（4．2％）。术后病理结果为：直肠绒毛状腺瘤35例,直肠癌50例,直肠类癌等12例。直肠癌中Tis期17例,T1期21例,T2期7例,T3期2例,T4期3例。术后平均随访6．4年（2个月～16年）。术后肿瘤局部复发3例（6．2％）。术后3年和5年生存率分别为93．7％和87．5％。本组无手术死亡,无术后肛门失禁。结论经肛门括约肌直肠肿瘤局部切除术具有手术创伤小、风险低和易于保留肛门等优点,适用于中低位直肠肿瘤的治疗。     

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。     

Local excision of stratified T1 rectal cancer

BACKGROUND: Local excision has been accepted therapy for T1 rectal cancers. A recent study demonstrated that primary tumors with deeper submucosal invasion were associated with a higher rate of lymph node metastases than those with shallow invasion. Our aim was to determine the effect of the depth of submucosal penetration on recurrence and mortality rates following transrectal excision of T1 tumors. METHODS: This was a 34-year retrospective review of patients who had transrectal excision with clear margins for T1 rectal cancer. Tumors were stratified into submucosal (SM) levels, and recurrence and mortality rates were determined. RESULTS: Of 101 patients with T1 rectal cancer undergoing local excision, 31 had a full-thickness transrectal excision. Eight (26%) of the 31 patients developed a local recurrence, 2 of whom had both a local and distant recurrence. Four patients (13%) died from metastatic rectal cancer. CONCLUSIONS: The recurrence rate for transrectal excision of T1 rectal cancer is high. It may be beneficial for patients with early rectal cancer to have postoperative chemoradiation therapy or a more radical surgical procedure.     

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规范化的病理诊断对直肠癌的预后判断十分重要。回顾当前我国直肠癌的诊治过程,可以发现对标准化规范化的病理学评估仍然存在着问题,包括:(1)术前的病理学评估。(2)早期癌的局部切除适应证。(3)环周切缘问题。(4)侧方淋巴结清扫。(5)全直肠系膜切除淋巴结清扫的数量问题。     

Local excision of rectal cancer without adjuvant therapy: a word of caution

OBJECTIVE: To evaluate the results of local excision alone for the treatment of rectal cancer, applying strict selection criteria. BACKGROUND DATA: Several retrospective studies have demonstrated that tumor control in properly selected patients with rectal cancer treated locally is comparable to that observed after radical surgery. Although there is a consensus regarding the need for patient selection for local excision, the specific criteria vary among centers. METHODS: The authors reviewed 82 patients with T1 (n = 55) and T2 (n = 27) rectal cancer treated with transanal excision only during a 10-year period. At pathologic examination, all tumors were localized to the rectal wall, had negative excision margins, were well or moderately differentiated, and had no blood or lymphatic vessel invasion, nor a mucinous component. End points were local and distant tumor recurrence and patient survival. RESULTS: Ten of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had recurrence at 54 months of follow-up. Average time to recurrence was 18 months in both groups. Seventeen of the 20 patients with local recurrence underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. Preoperative staging by endorectal ultrasound did not influence local recurrence or tumor-specific survival. CONCLUSION: Local excision of early rectal cancer, even in the ideal candidate, is followed by a much higher recurrence rate than previously reported. Although most patients in whom local recurrence develops can be salvaged by radical resection, the long-term outcome remains unknown.     

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??Sphincter-preserving surgery in mid-low rectal cancer??Integrative consideration and problems GU Jin. Department of Colorectal Cancer Surgery, Peking University Cancer Hospital??Beijing100142??China
Abstract Low rectal cancer is common cancer in China. About 70% of rectal cancer is located mid-low rectum. Low anterior resection (LAR) is firstly adopted by surgeons as low-third rectal cancer. The following knowledge need to be paid attention to (1) Preoperative staging of rectal cancer is so important that surgeons should adopt based on AJCC TNM staging system.(2) Neoadjuvant therapy should be used for cT3 or N+ rectal cancer. (3) Doctors should carefully select patients to perform sphincter-preserving surgery. (4) Some problems regarding local excision for early staging cancer.     

Local recurrence and survival after laparoscopic mesorectal resection for rectal adenocarcinoma

Background: Laparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined. Methods: A prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery. Results: The median follow-up period was 31 months for patients with stages I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer. Conclusions: The survival and local recurrence rates for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.     

低位直肠癌经肛门局部切除40例疗效分析

目的 探讨低位直肠癌经肛门局部切除的适应证和疗效.方法 回顾性分析1997年1月至2006年12月间广东省人民医院普通外科40例低位直肠癌患者经肛门局部切除的临床资料.结果 本组患者平均手术时间50（30～85）min,术中出血量40（10～100）ml,平均住院时间5（2～10）d.全组患者平均随访时间40（6～120）个月.术后局部复发率为20.0%（8/40）,5年生存率为90.0%.T1期患者术后局部复发率为17.9%（5/28）,低于T2期患者的25.0%（3/12）,但两组差异无统计学意义（x2=0.268,P=0.61） 高分化腺癌患者术后局部复发率为12.9%（4/31）,明显低于中分化腺癌的4/9,两组差异有统计学意义（x2=4.337,P=0.04） 肿瘤直径小于3 cm者术后局部复发率为10.7%（3/28）,明显低于大于或等于3 cm者的41.7%（5/12）,两组差异有统计学意义（x2=5.030,P=0.03）.经肛门局部切除术后局部复发率与肿瘤部位（x2=0.139,P=0.93）、分型（x2=1.290,P=0.53）和手术切除方式（x2=0.667,P=0.41）无关.结论 低位直肠癌经肛门局部切除适应证为肿瘤直径小于3 cm和高分化的T1、T2期患者.只要严格掌握手术适应证,经肛门局部切除治疗低位直肠癌可获取良好的疗效.     

Should locally excised T1 rectal cancer receive adjuvant chemoradiation?

BACKGROUND: Local excision of low-lying adenocarcinoma of the rectum is increasingly utilized, but the benefit of adjuvant treatment in T1 lesions with otherwise favorable pathology remains controversial. METHODS: A retrospective review was performed on patients who underwent local excision of invasive rectal cancer with curative intent from 1991 to 1999. RESULTS: Forty-eight patients were treated with local surgical excision. Twenty-seven T1 lesions were identified, 10 received postoperative chemoradiation, and no local recurrences were identified. Seventeen T1 patients did not receive adjuvant treatment and local recurrence occurred in 4 patients (24%). In all cases of local recurrence, the lesions had been excised to negative margins, none were poorly differentiated, and none exhibited vascular or lymphatic invasion. CONCLUSION: These data suggest a trend toward improved local control with adjuvant therapy after local excision of T1 rectal cancer. This is an important consideration in patients with negative surgical margins and favorable pathology who are traditionally not treated.     

Local excision for ypT2 rectal cancer--much ado about something.

BACKGROUND: The role of local excision for pT2 distal rectal cancer has been challenged because of the observation of high rates of lymph node metastases and local failure. However, neoadjuvant chemoradiation therapy (CRT) has led to increased local disease control and significant tumor downstaging, possibly decreasing rates of lymph node metastases. In this setting, a possible role for local excision of ypT2 has been suggested. METHODS: A total of 401 patients with distal rectal cancer underwent neoadjuvant CRT. Tumor response assessment was performed after at least 8 weeks from CRT completion. One hundred and twelve patients with complete clinical response were not immediately operated on and were excluded from the study, and 289 patients with incomplete clinical response were managed by radical surgery. Patients with final pathological stage ypT2 were analyzed to determine the risk of unfavorable pathological features that could represent unacceptable risk for local failure after local excision. RESULTS: Eighty-eight (30%) patients had ypT2 rectal cancer. Final ypT status was not associated with pretreatment radiological staging (p = 0.62). ypT status was significantly associated with the risk of lymph node metastases, risk of perineural and vascular invasion, and recurrence (p = 0.001). Lymph node metastases were present in 19% of patients with ypT2 rectal cancer. The risk of lymph node metastases in ypT2 was associated with the presence of perineural invasion (47% vs 4%; p = <0.001), vascular invasion (59% vs 6%; p < 0.001), and decreased mean interval CRT surgery (12 vs 18 weeks; p < 0.001), but not with mean tumor size (3.2 vs 3.1 cm; p = 0.8). Disease-free and overall survival rates were significantly better for patients with ypT2N0 (p = 0.02 and 0.006, respectively). Fifty-five (63%) patients with ypT2 had at least one unfavorable pathological feature for local excision (lymph node metastases, vascular or perineural invasion, mucinous type or tumor size >3 cm). CONCLUSION: Lymph node metastases were present in 19% of patients with ypT2 and were significantly associated with poor overall and disease-free survival rates. The risk of lymph node metastases could not be predicted by radiological staging or tumor size. Radical surgery should be considered the standard treatment option for ypT2 rectal cancer after CRT.