腹腔镜全直肠系膜切除保肛治疗低位直肠癌

目的：探索腹腔镜全直肠系膜切除（TME）低位、超低位前切除治疗低位直肠癌的可行性。方法：按TME原则、用双钉合技术（DST）,在腹腔镜下对62例低位直肠癌患者实施TME、DST低位、超低位结肠-肛肠吻合术。结果：手术时间11-210min,平均125min;术中出血5-80ml,平均20ml;术后1-2d恢复胃肠功能并下床活动,住院时间5-14d,平均8d。1例患者因凝血障碍中转开腹,其他61例患者手术顺利。术后疼痛剂应用28例,除1例吻合口漏、1例尿潴留外,其余患者未见术中及术后并发症。结论：腹腔镜TME、低位、超低位吻合术治疗低位直肠癌,创伤小、保肛率高、术后疼痛轻、恢复快,是极具应用前景的微创新技术。     

直肠癌超低位前切除术508例临床分析

目的 探讨直肠癌超低位前切除的方法 及术后效果.方法 将1996年10月至2006年10月收治的508例能实施保存肛门功能治疗的腹膜返折附近及其以下进展期直肠癌分为两组,其中365例行超低位前切除的器械吻合术;143例行全直肠切除的结肠-肛管吻合术.分析比较两组的手术效果及预后.结果 超低位前切除组只在腹腔内操作,但撕裂远侧闭合端3例(0.9%),未完成闭合2例(0.6%),吻合器切下组织未形成2个圆圈18例(5.6%).全直肠切除组除在腹腔内分离外,还需在肛门外进行吻合.术后排便功能(排便次数、内衣污染、便意急迫)超低位前切除组明显优于全直肠切除组(P<0.01);排便困难(残便感、排便时间延长、常用泻剂)两组差异亦有统计学意义(P<0.05).超低位前切除组12例(3.5%)和全直肠切除组8例(5.6%)发生吻合口瘘(P>0.05).超低位前切除组77例(22.5%)和全直肠切除组40例(27.9%)发生吻合口狭窄(P>0.05).超低位前切除组局部复发率为11.8%,全直肠切除组为10.1%(P>0.05).超低位前切除组5年生存率为68.8%,全直肠切除组为66.8%(P>0.05).结论 两组距肿瘤下缘的切断距离不同,虽然局部复发率和5年生存率无显著差别,但排便功能与排便困难超低位前切除组则明显优于全直肠切除组.     

Long-term results of modified graciloplasty for sphincter replacement after rectal excision

Objective Restoration of the anal sphincter by means of electrically stimulated (dynamic) graciloplasty is a new therapeutic option for patients with severe faecal incontinence or those having abdomino‐perineal resection (APR) of the anorectum. The present study reviews the outcome of total anorectal reconstruction (TAR) after APR for low rectal cancer or recurrent anal cancer. Methods From 1992 to 2000, 35 of 64 patients treated with dynamic graciloplasty had a TAR performed either synchronously (n = 26) or as a secondary procedure one to five years after rectal excision (n = 9). Results The most frequent complication was injury or erosion of the neorectum (n = 9) which, was avoided with increasing surgical experience. Defaecation disorders and consequent incontinence were the most common functional problem and had to be treated with periodical enemas. Conclusion Although sphincter replacement by means of TAR after APR led to poorer functional results than those achieved in patients treated with dynamic graciloplasty for faecal incontinence, TAR remains a valid treatment option for patients who do not tolerate a permanent stoma.     

T4 rectal cancer: analysis of patient outcome after surgical excision

Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5(1/2)-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive individuals. Out of the six patients who died in this review, five (83%) received chemoradiotherapy. Operations for advanced primary rectal cancer with involvement of adjacent organs are major procedures associated with high morbidity. Patients without nodal disease may have long-term survival despite the locally advanced tumor. Interestingly, neoadjuvant therapy, adjuvant, or both, did not increase survival.     

内括约肌切除保肛手术在治疗末段直肠癌中的应用

对于末段（距肛缘4.0～5.0cm）直肠癌仍几乎无法保留肛门或同时达到保肛及根治两个目标。内括约肌切除（ISR）保肛手术用于部分符合要求的末段直肠癌患者，既可达到保留肛门功能的目的，又同时能达到根治的目的，有希望成为末段直肠癌优先选择的手术方式，然而尚有部分问题没有明确。笔者仅就ISR技术的解剖、病理生理学基础，ISR在直肠癌治疗中的适应证、禁忌证、手术技术以及患者术后的生存率、局部复发率、病死率、并发症等诸方面作一文献综述。     

Functional outcome after low anterior resection for rectal cancer using the colonic J-pouch

The functional outcome after low anterior resection (LAR) using the colonic J-pouch was compared with that after LAR using straight anastomosis. Colonic J-pouch construction was performed in 58 patients who underwent resection of tumors located 5–10 cm from the anal verge (J-pouch group). Functional assessment was performed 1 year postoperatively. Clinical function was evaluated using a scoring system, while physiologic sphincter and reservoir function were evaluated by anorectal manometry. The historical control group consisted of 20 patients who underwent LAR with straight anastomoses (straight group). The functional score of the J-pouch group was significantly better than that of the straight group. Although sphincter function was similar in the two groups, reservoir function was significantly better in the J-pouch group than in the straight group. These results demonstrated that the functional outcome following LAR for rectal cancer is improved by the colonic J-pouch construction.     

Functional treatment outcome in rectal cancer after trans-abdominal resection with endoprosthesis

Functional results of treatment of 107 patients with cancer recti, in whom the tumor had localized on the 8-12 cm distance from anus, were analyzed. Comparative estimation of sphincterometric and clinical indexes in terms up to 12 months after performance of abdominoanal resection and transabdominal resection of rectum was conducted. Application of the operation proposed had permitted to quicken and to improve trustworthy the postoperative rehabilitation of patients.     

Tumour morphology as a predictor of outcome after local excision of rectal cancer

BACKGROUND: The aim of this study was to determine whether the morphology of rectal cancer predicts outcome following treatment by local excision, and whether morphology should therefore be added to the criteria presently used for case selection. METHODS: The hospital notes and histological findings of 91 patients who had undergone a local surgical procedure for rectal cancer were reviewed retrospectively. Eight patient and tumour characteristics including morphology were analysed with respect to 5-year survival, local recurrence and cancer-specific death within 5 years. Morphology was divided into four types: polypoid, sessile, ulcerated and flat raised. RESULTS: Survival and local recurrence were significantly better for patients with exophytic (polypoid and sessile) carcinomas than for those with non-exophytic (ulcerated and flat raised) lesions. Multivariate logistic regression analysis showed that age, depth of invasion, lymphatic invasion and venous invasion were significant predictors of outcome. The exophytic group included significantly more stage T1 and fewer T2 and T3 cancers, and a significantly smaller proportion of tumours that showed venous and lymphatic invasion than the non-exophytic group. CONCLUSION: Morphology is a clinical guide to prognosis after local excision. Non-exophytic cancers are associated with high-risk histopathological features that render tumours of this type unsuitable for local excision.     

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND: Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented. METHODS: Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group. RESULTS: The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001). CONCLUSION: Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.     

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.     

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。     

Quality of life after total mesorectal excision for rectal cancer

BACKGROUND: After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo-rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo-anal J-pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease-free survivors after APR, LRA and CPA. METHODS: The charts of 301 consecutive patients who had undergone surgery for cancer in the middle or lower third of the rectum were analysed. Two hundred four patients were eligible for inclusion. The quality of life among these patients was assessed using one generic (EQ-5D) and two disease-specific questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38). RESULTS: The response rate was 82%. The median follow-up was 31 months. Overall, quality of life was good but CPA patients had better quality of life scores than APR and LRA patients. This difference was not only due to the better functional outcome but also to the lower incidence of disturbed micturition and sexual problems in the CPA group. CONCLUSION: The quality of life after colo-anal J-pouch anastomosis is better than after abdominoperineal resection (APR) and low colo-rectal anastomosis (LRA). The quality of life after APR is similar to that after LRA.     

Bladder and sexual dysfunction after mesorectal excision for rectal cancer

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced. METHODS: Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group. CONCLUSION: Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.     

腹腔镜全直肠系膜切除术治疗低位、超低位直肠癌的临床研究

目的探讨腹腔镜全直肠系膜切除在低位、超低位直肠癌手术中的安全性、肿瘤根治疗效和术后恢复情况。方法低位、超低位直肠癌患者136例行腹腔镜全直肠系膜切除64例(腹腔镜组),开腹全直肠系膜切除72例(开腹组),比较手术学指标、肿瘤根治疗效。结果腹腔镜组手术时间为(162.4±42.0)min,开腹组为(146.1±31.2)min;腹腔镜组出血量为(87.6±52.2)ml,开腹组为(199.4±95.8)ml,两组比较差异有统计学意义(P0.01)。两组保肛率、清除淋巴结数目和远切端距肿瘤的距离比较,差异无统计学意义(P0.05)。腹腔镜组直肠系膜完整性优于开腹组,两组比较差异有统计学意义(P0.05)。腹腔镜组对吗啡类镇痛药物的需要、肠功能恢复时间、住院时间均更少,差异有统计学意义[15.6%和30.6%,P0.05;(66.7±12.2)h和(99.9±19.1)h,P0.01;(7.7±1.0)d和(9.2±1.6)d,P0.01]。术后并发症发生率、随访局部复发率、总复发率、不同TNM分期的总复发率比较,差异均无统计学意义(P0.05)。结论腹腔镜全直肠系膜切除手术出血量少,更完整地直肠系膜切除,术后肠功能恢复快,镇痛的需要率低,住院时间短。     

直肠癌保肛术后吻合口瘘原因及防治分析

目的:探讨直肠癌保肛术后吻合口瘘发生的原因、诊断、处理及防治措施.方法:回顾性分析2003年12月-2008年12月我院收治的220例直肠癌保肛手术患者的临床资料.结果:本组患者术后发生吻合口瘘16例(7.3%),14例予以全身营养支持、局部;中洗引流、抗生素等非手术治疗,另2例再次手术,均获治愈.结论:年龄、患者情况、吻合口位置、吻合技术及肠道准备等是吻合口愈合的影响因素.早期诊断、合理的治疗措施是治愈吻合口瘘的关键.     

男性直肠癌切除术后性功能障碍分析

对25例男性直肠癌切除后性功能进行调查。平均年龄为42．5岁，Miles手术18例，性欲减退8例（44．4％），勃起障碍11例（61.1％），射精障碍13例（72．2％）。Dixon手术7例，性欲减退1例（14.3％），勃起障碍1例（14.3％），射精障碍2例（28．6％）。认为手术损伤盆腔神经是造成术后病人性功能障碍的直接和主要因素。防治关键在于术中完整地保护植物神经，注意剥离层次和切除范围。     

低位直肠癌保肛手术后局部复发的对策

我国结直肠癌的发病率和病死率一直在飙升。根据2004年统计资料．我国结肠癌和直肠癌发病率分别为12．69／10万和11．72／10万,两者合计则仅次于肺癌、胃癌和肝癌,居第4位。1990．1992年我国十分之一人口抽样调查,结直肠癌平均调整病死率为4．54／10万．比1977年全国结直肠癌病死率3．54／10万增加了28．2％。居癌症死亡率的第5位。