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.     

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±69.2）min,中位出血量80（50～200）mL,平均切除淋巴结数为（11.5±6.4）枚,平均肛门排气时间（2.8±1.4）d,平均可下地行走时间（1.6±0.9）d,平均术后住院时间（11.8±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。     

全直肠系膜切除术治疗直肠癌--附168例报告

目的　探讨全直肠系膜切除术在预防直肠癌术后局部复发中的作用 ,以及同该操作相关的一些并发症。方法　回顾性分析 16 8例直肠癌的临床资料。结果　全组无手术死亡 ,术后随访1～ 36月 ,局部复发 6例 (3.6 % ) ,术后吻合口漏 13例 (10 .7% ) ,多数保肛患者出现便频、便急等症状。结论　全直肠系膜切除术能有效降低直肠癌术后局部复发率 ,提高保肛率 ,但存在吻合口漏 ,控便功能等问题需进一步解决。     

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。     

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 total mesorectal excision can be performed on a nonselective basis in patients with rectal cancer with excellent medium‐term results

Aim Concerns exist regarding laparoscopic rectal cancer surgery due to increased rates of open conversion, complications and circumferential resection margin positivity. This study reports medium‐term results from consecutive unselected cases in a single surgeon series. Method The results of laparoscopic total mesorectal excision (TME) for rectal cancer over a 9‐year period within the context of an evolving ‘enhanced recovery protocol’ (ERP) were reviewed from analysis of a prospectively maintained database. Results One hundred and fifty patients (91 male, median age 69 years, median BMI 26) underwent laparoscopic TME over 9 years. Median follow up was 28.5 months (range 0–88). Sixteen (10.6%) patients underwent neoadjuvant radiotherapy. Six (4.0%) required open conversion and 13 (9.0%) had an anastomotic leakage. The proportion of Dukes stages were: A, 33.3%; B, 30.7%; C, 31.3%; D, 4.7%. Five (3.3%) patients had an R1 and one an R2 resection. Median length of postoperative stay was 6 days. Three (2.0%) patients died within 30 days. Four (2.7%) developed local recurrence and 14 (9.3%) developed distant metastases. Predicted 5‐year disease‐free and overall survival rates by Kaplan–Meier analysis were 85.8% and 78.7%, respectively. Conclusion Laparoscopic TME surgery can safely be offered to unselected patients with rectal cancer with excellent medium‐term results.     

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。     

中低位直肠癌全直肠系膜切除术前MRI评价

MRI在直肠癌术前评价中的价值已得到国际的公认。由于全直肠系膜切除（TME）是基于盆腔局部解剖基础提出的手术方法,在术前应用MRI成像清晰显示TME相关解剖结构和变异及其与肿瘤的关系,并能够正确识别和掌握与TME相关的MRI征象将有助于外科医生在术前更全面了解病变情况。文章从影像学角度对TME相关解剖的MR显示及其征象,直肠癌MR术前分期,环周切缘的术前判定及直肠MR成像技术4个方面做一系统的阐述和总结,以期对外科医生应用和掌握直肠癌术前MR检查有所帮助。     

直肠癌全直肠系膜切除术107例临床分析

目的探讨直肠癌全直肠系膜切除法在直肠癌中的应用。方法回顾性分析107例直肠癌患者行全直肠系膜切除的临床资料。本组病例行Miles术式18例;Dixon术式89例,其中76例使用吻合器吻合。结果全组术中出血100-150ml,术中术后均无输血。术后发生吻合口瘘3例,占2.8%。性功能障碍1例,占0.93%。排尿功能障碍1例,占0.93%。术口感染12例,占11.21%。随访6-42个月,局部复发率4.67%（5/107）。结论直肠癌全直肠系膜切除术,对提高直肠癌术后患者生存质量和生活质量确有裨益。     

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

OBJECTIVE: Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME. METHOD: Fifty-four patients underwent TEM for a T1 carcinoma. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used included the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared with a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons. RESULTS: Thirty-one patients after TEM returned completed questionnaires (overall response rate 86%). Quality of life was compared with 31 TME patients and 31 healthy controls. From the patients' and social perspective quality of life did not differ between the three groups. Compared with TEM, significant defecation problems were seen after TME (P < 0.05). A trend towards better sexual functioning after TEM, compared with TME, was seen, especially in male patients, although it did not reach statistical significance. CONCLUSION: Transanal endoscopic microsurgery and TME do not seem to differ in quality of life postoperatively, but defecation disorders are more frequently encountered after TME. This difference could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studies are needed to confirm our conclusions.     

单孔腹腔镜辅助经肛门全直肠系膜切除临床应用价值及展望

经肛门全直肠系膜切除（TaTME）已成为近年来直肠癌手术领域的新热点。由于该新兴技术尚未完全成熟,目前,绝大多数的TaTME均需在腹腔镜辅助下方能完成。出于完全单孔腹腔镜直肠癌手术技术难度大以及传统多孔腹腔镜辅助的TaTME微创优势不明显的考虑,在预定回肠造口位置引入单孔腹腔镜进行辅助的TaTME术式被认为可实现技术难度、微创和手术切除质量三者间的最佳平衡。