侧方淋巴结清扫对进展期低位直肠癌预后的影响

目的 应用治疗指数(therapeutic index,TX)(TX=肿瘤相关5年生存率×区域淋巴结转移的概率)评估侧方淋巴结清扣对于改善进展期低位直肠癌预后的价值.方法 回顾性分析直肠癌行根治性切除+全直肠系膜切除+侧方淋巴结清扫的96例进展期低位直肠癌患者的临床资料.结果 进展期低位直肠癌直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移率分别为21%(20/96),13%(12/96),10%(10/96)和15%(14/96).检出直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移阳性的进展期低位直肠癌患者5年生存率分别为35%,25%,20%和36%.TX:清扫直肠系膜淋巴结和侧方淋巴结的TX分别为7.4和5.4,明显高于清扫直肠上动脉和肠系膜下动脉旁淋巴结的3.3和2.0.侧方淋巴结转移阳性者术后局部复发率为64%(9/14),TX明显高于侧方淋巴结转移阴性者的11%(9/82)(x2=22.308/P=0.000).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月(95%置信区间:24.8～51.2个月),明显短于侧方淋巴结转移阴性的(80.9±2.1)个月(95%置信区间:76.7～85.1个月),两者差异有统计学意义. 结论侧方淋巴结清扫可降低进展期低位直肠癌根治性切除术后局部复发率以及改善预后.除全直肠系膜切除外,进展期低位直肠癌术中还应进行侧方淋巴结清扫.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

Adjuvant radiotherapy in rectal cancer and total mesorectal excision

Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done "en-bloc" and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphincter saving operations are also allowed.     

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter

Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the ‘staging effect’ and limits the ‘therapeutic effect’ of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.     

Historical review of colorectal cancer surgery

The classical standard surgical technique for rectal carcinoma, abdominoperineal excision (Miles operation), has been gradually replaced by sphincter-saving surgery and more than 70% of rectal carcinomas are treated by anterior resection in which autosuture machines have played a major role in recent years. Wide lateral lymphadenectomy has been replaced by autonomic nerve preservation because of the high frequency of sexual and urinary dysfunction. Total mesorectal excision (TME) proposed by Heald et al which ignores the lateral nodes of the pelvic wall is the most popular technique in Western countries. The concept of TME is contradictory to that of wide lateral lymphadenectomy and the true merits of the latter should be examined in the near future. Minimally invasive surgery, including various procedures of local excision of low rectal tumors and colonoscopic polypectomy, has given great benefits to many patients. In Japan there seems to have been a lack of interest in adjuvant radiotherapy and chemoradiotherapy in the past, but they should be more seriously considered for the adjuvant treatment of advanced rectal carcinoma in the future.     

Multimodality management of locally advanced rectal cancer

Despite the routine use of adjuvant chemoradiation for curatively resected stage II and III rectal cancer a significant percentage of patients ultimately fail locally and/or distally; this underscores the need for continued improvement in the efficacy of combined-modality therapy and quality of rectal cancer resection. The recognition of the significance of lateral or circumferential margins of resection has paralleled the widespread use of total mesorectal excision. In addition to facilitating negative margins of resection and local control, sharp mesorectal techniques also facilitate identification and preservation of pelvic autonomic nerves thereby greatly reducing the incidence of urinary and sexual dysfunction following radical resection. Lastly, restorative options can result in excellent bowel function in carefully selected patients undergoing a "very low" anterior resection. Efforts are currently directed at identifying the subset of locally advanced rectal cancer patients who may be adequately treated with a resection alone thereby avoiding the added morbidity of adjuvant radiation and chemotherapy.     

Major urinary dysfunction after mesorectal excision for rectal carcinoma

BACKGROUND: Urinary dysfunction may occur after mesorectal excision and pelvic autonomic nerve preservation (PANP) in patients with rectal carcinoma. The aim of this prospective study was to identify factors predictive of long-term urinary catheterization. METHODS: Two hundred and ten patients without significant urological problems underwent resection of rectal cancer with mesorectal excision. The number of patients with complete, partial or no identification of the nerves was documented and correlated with possible predictive factors for postoperative major urinary dysfunction. RESULTS: Eight patients (3.8 per cent) required long-term urinary catheterization: two after complete PANP (two of 168) and six in whom PANP was incomplete (six of 42) (P = 0.001). Multiple regression analysis identified incomplete PANP (odds ratio 13.8 (95 per cent confidence interval 2.7 to 71.3); P = 0.002) as a predictive factor for major urinary dysfunction. CONCLUSION: Major urinary dysfunction after mesorectal excision for rectal cancer is associated with an incomplete nerve-sparing technique.     

腹腔镜辅助直肠癌根治术对盆腔自主神经保护的操作要点

目的 探讨腹腔镜辅助保留盆腔自主神经直肠癌根治术的临床疗效.方法 2011年3月至2013年3月经病理确诊的149例病人进行保留自主神经的直肠癌根治术,其中腹腔镜组84例,开腹组65例.术后1年内通过门诊和问卷方式观察两组病人术后排尿功能与性功能状况.结果 术后排尿功能障碍发生率,腹腔镜组和开腹组分别为18.57％、21.82％,两组比较差异无统计学意义（P＞0.05）.术后勃起功能障碍发生率,腹腔镜组和开腹组分别为47.14％、43.64％,射精功能障碍发生率分别为34.29％ 、32.13％,两组比较差异无统计学意义（P＞0.05）.结论 腹腔镜辅助保留盆腔自主神经的直肠癌根治术是安全、有效的.     

Impact of Autonomic Nerve Preservation and Lateral Node Dissection on Male Urogenital Function after Total Mesorectal Excision for Lower Rectal Cancer

Introduction Urogenital dysfunction is a well recognized complication of rectal cancer surgery. The aim of this study was to assess the impact of autonomic nerve preservation (ANP) and lateral node dissection (LND) on male urogenital function after total mesorectal excision for lower rectal cancer. Methods We studied, using a questionnaire, preoperative and current urogenital function in 47 male patients who underwent total mesorectal excision with the ANP technique for lower rectal cancer. Patients with and without LND were analyzed separately. Results A total of 37 patients (78.7%) (22 patients without LND, 15 with LND) returned the questionnaire. Among the 15 patients with LND, 2 underwent unilateral ANP. One patient without LND had urinary dysfunction preoperatively, and among the other 21 patients only 2 (9.5%) reported minor urinary complications postoperatively. After LND, 5 patients (33%) reported minor complications; there were no severe complications. Among patients who were sexually active prior to the operation, 90% and 70% of patients without LND and 50% and 10% of those with LND maintained sexual activity and ejaculation, respectively. However, 50% of patients who underwent low anterior resection or Hartmann resection without LND and all patients with abdominoperineal resection or LND reported reduced overall sexual satisfaction. Conclusions The ANP technique offers the great advantage of maintaining urogenital function after rectal cancer surgery. After LND, although the ANP technique minimized urinary dysfunction, sexual function, particularly ejaculation, was often damaged. Careful follow-up is important even after ANP to improve postoperative sexual satisfaction.     

腹腔镜全直肠系膜切除术中保留盆腔自主神经对术后男性患者性功能的影响

目的:对比腹腔镜及开腹全直肠系膜切除术中保留盆腔自主神经对男性患者术后性功能的影响。方法:回顾分析2011年6月至2015年6月92例直肠癌根治术(均行Dixon术)患者的临床资料,其中45例行腹腔镜下保留盆腔自主神经的全直肠系膜切除术(腹腔镜组),47例开腹行保留盆腔自主神经的全直肠系膜切除术(开腹组),对比两组患者术后勃起功能障碍、射精功能障碍发生率及术后1年盆腔局部复发情况。结果:术后1、3、6个月,开腹组勃起功能障碍、射精功能障碍发生率明显高于腹腔镜组,差异有统计学意义(P0.05);术后12个月后,两组差异无统计学意义(P0.05)。1年后两组患者盆腔局部复发率差异无统计学意义(P0.05)。结论:腹腔镜全直肠系膜切除术中保留盆腔自主神经在达到与开腹手术相同的根治效果的基础上,术后早期(6个月内)患者性功能恢复效果更好,且于术后12个月达到与开腹手术相同的保护患者性功能的效果,明显改善了男性患者的术后生活质量,具有较高的临床应用价值。     

我国直肠癌诊断和治疗的现状

Colorectal cancer is one of the most common malignancies in the world, and rectal cancer accounts for a large percentage of this disease in Chinese patients. Surgical extirpation is the mainstay of therapy, Intraluminal ultrasound is highly accurate in detecting depth of invasion and lymph node metastasis, and is also helpful in preoperative staging of rectal cancer. Preoperative adjuvant therapy could down-stage tumors, improve the radical resection rates of advanced lower rectal cancer, increase the rate of sphincter-saving surgery, and decrease the local recurrence rate. Total mesorectal excision could signifi-candy decrease the local metastasis of rectal cancer, and rectal cancer resection with preservation of pelvic autonomic nerve is effective in preventing urinary or reproductive dysfunction. Recently, minimally invasive surgery has been introduced for the management of rectal cancer, and transanal endoscopic microsurgery is a new method with advantages in rectal cancer treatment.     

Intraoperative parasympathetic nerve stimulation with tumescence monitoring during total mesorectal excision for rectal cancer

BACKGROUND: Unilateral or bilateral division of the parasympathetic nerves during resection of rectal cancer may result in sexual erectile dysfunction. The purposes of this project were twofold: to determine the ability to demonstrate penile tumescence in response to parasympathetic nerve stimulation after rectal cancer resection and to correlate the nerve stimulation response with clinical sexual function 6 months after operation. STUDY DESIGN: In 21 consecutive male patients with normal erectile function undergoing total mesorectal excision, cavernous nerve identification and integrity before and after pelvic dissection were assessed intraoperatively, both visually by an experienced surgeon and by using the CaverMap nerve stimulator. The minimal effective current necessary to produce a 2% increase in penile tumescence was recorded for both the left- and right-sided nerves, primarily the largest nerve trunk, S3. Postclearance stimulation data were then correlated with sexual function outcomes, specifically erection and orgasm at 6 months after surgery. RESULTS: The operating surgeon's visual assessment of the pelvic autonomic nerve's integrity after pelvic dissection was deemed intact in 20 of the 21 patients (95.2%). Of the 20 patients who were evaluated with CaverMap after completion of total mesorectal excision, 17 (85%) had tumescence response after nerve stimulation on either side, and 3 patients (15%) had unilateral response only. Of the 19 patients evaluated for sexual function 6 months after surgery, 18 (94.7%) had normal function, including the 3 patients with only unilateral nerve stimulation tumescence response. CONCLUSIONS: Intraoperative mapping of the parasympathetic nerve trunks with the CaverMap nerve stimulator may be a valuable aid to less experienced pelvic surgeons and may help in autonomic nerve preservation during total mesorectal excision clearance.     

Complications after preoperative combined modality therapy and radical resection of locally advanced rectal cancer: a 14-year experience from a specialty service

BACKGROUND: Preoperative combined modality therapy followed by total mesorectal excision has emerged as the optimal treatment paradigm for locally advanced rectal cancer (T3 to 4, N1, or both). But its impact on postoperative complications has not been adequately evaluated. Our aims were to evaluate our comprehensive experience and identify factors predictive of complications in this patient population. STUDY DESIGN: The study group consisted of 297 consecutive patients with locally advanced rectal adenocarcinoma treated with preoperative combined modality therapy (radiation: 5,040 cGy; chemotherapy: 5-FU-based) and then operation. Major complications were defined as those requiring medical or surgical treatment. A prospectively collected database was queried to determine the incidence of postoperative complications and associated clinicopathologic factors. RESULTS: Median followup was 43.9 months (range 0.8 to 128.6 months). There were no postoperative mortalities (within 30 days of operation). But there were 145 major complications in 98 patients (33% of study population). The most common complications were small bowel obstruction (n = 32 [11%]) and wound infection (n = 31 [10%]). There were eight anastomotic leaks (4%) and nine pelvic abscesses (4%) in patients treated with low anterior resection (n = 210). Preoperative comorbidity was the only clinicopathologic factor associated with postoperative complications (p = 0.02). Postoperative complications had no significant impact on oncologic outcomes. CONCLUSIONS: Although postoperative mortalities are rare, complications requiring treatment can be anticipated in one-third of patients undergoing preoperative combined modality therapy and total mesorectal excision. A policy of selective fecal diversion after preoperative combined modality therapy and total mesorectal excision for locally advanced rectal cancer can achieve low rates of pelvic sepsis, but may lead to an increased incidence of small bowel obstruction.     

Extraperitoneal rectal cancer surgery

Despite recent advances in radiation and chemotherapy, surgical resection remains the only potentially curative procedure for rectal cancer. The introduction of total mesorectal excision with autonomic pelvic nerve sparing and new modalities in restoring bowel continuity has improved significantly the prognosis as well as life quality of rectal cancer patients. Better results will be achieved only with a correct multidisciplinary approach. The Authors report their experience with surgical treatment of extraperitoneal rectal cancer, examine some important technical innovation and emphasize the oncological principles of radical surgery.     

Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer

BACKGROUND: The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation. METHODS: Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy. RESULTS: Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men. CONCLUSION: A laparoscopic approach can be considered in most patients with mid or low rectal cancer.     

Rectal carcinoma. Optimizing therapy by partial or total mesorectum removal]

The role of total mesorectal excision for rectal cancer treatment is one of the most exciting findings in surgical oncology of the recent years. The patient's prognosis largely depends on the surgical quality of rectal resection. The excision of the cancer bearing rectum has to follow very precisely along the mesorectal fascia by sharp dissection without damaging the mesorectum itself. This technique reduces the local recurrence rate to below 10% and allows long-term survival in two thirds of all patients. Rectal cancers of the middle and lower third of the rectum need to be treated by total mesorectal excision down to the muscular pelvic floor, the ones of the upper third and the sigmoideo-rectal junction are appropriately treated by partial mesorectal excision down to 5 cm below the tumor. No additional survival benefit may be expected when pelvic lymphadenectomy has been performed. The direct tumor spread along the bowel wall and the lymphatic tumor spread in a caudal direction are uncommon and late findings in rectal cancer disease. Low and ultralow rectal carcinomas may therefore be treated by a sphincter preserving procedure respecting a safety margin of at least 1 to 2 cm. Thus, continence preserving surgery may be performed in over 80% of patients suffering from rectal cancer without compromising long-term outcome.     

腹腔镜手术联合术中放疗治疗进展期直肠癌的临床研究

目的:探讨腹腔镜手术联合术中放疗代替术前放疗治疗进展期直肠癌的的安全性及疗效。方法:回顾性分析上海交通大学医学院附属瑞金医院外科在2012年2月至2013年2月间行腹腔镜手术联合术中放疗的8例进展期直肠癌。本研究所有病人均接受腹腔镜Dixon术,术中运用Mobetron移动式术中放疗加速器照射瘤床,剂量为10~18 Gy,均接受术后随访。结果:本研究病人均顺利完成腹腔镜辅助Dixon术,其中5例行预防性末端回肠造口,平均手术时间(151.2±18.6)(125~180)min,平均术中出血量(112.5±58.2)(50~200)m L,术后中位住院时间为8 d,术后并发腹泻2例、尿潴留及盆腔疼痛各1例,无手术相关死亡病例及吻合口漏等严重并发症。中位随访时间为24个月,随访期间未出现局部复发病例。结论:腹腔镜联合术中放疗治疗局部进展期直肠癌创伤小、恢复快,具有一定的安全性及可行性。     

腹腔镜保留盆腔神经的广泛子宫切除治疗子宫肿瘤

目的回顾性分析腹腔镜下保留盆腔自主神经的广泛子宫切除术在子宫肿瘤患者治疗中的可行性。 方法选择2013年8月至2015年6月在新乡市中心医院接受手术治疗的早期宫颈癌及Ⅱ期子宫内膜癌患者95例,其中43例患者接受腹腔镜保留盆腔神经的广泛子宫切除术 ＋ 盆腔淋巴结清扫术(A组),52例患者行经腹广泛子宫切除 ＋ 盆腔淋巴结清扫术(B组)。总结两组的手术时间、术中出血量、切除宫旁组织及阴道长度、淋巴结数量,以及术后膀胱、直肠及性功能恢复情况。 结果两组的手术时间、切除范围及淋巴结数量差异无统计学意义(P> 0.05);两组的术中出血量,以及术后膀胱、直肠及性功能评估治疗比较[(180±55)ml vs (340±75)ml, (51.2±10.3)h vs (74.9±12.8) h, (11.6±2.1) d vs (18.3±2.9) d, 19.9分 vs 23.4分],差异有统计学意义(P<0.05)。 结论腹腔镜下保留盆腔神经的广泛子宫切除术在子宫肿瘤中是安全可行的,与传统术式相比更有利于膀胱直肠功能恢复,提高生命质量。     

Abdominal Sacral Resection of Locally Recurrent Rectal Cancer

Local recurrence of rectal cancer develops in the posterior bony pelvis as an isolated event in about half of the patients with recurrence. Although radiation can palliate sacral root pain, the disease is usually progressive and is rarely amenable to conventional resection. We have adapted a surgical technique usually used for primary sacral tumors, which permits a complete en bloc excision of recurrent rectal cancer in most instances. This approach consists of a laparotomy with pelvic dissection and mobilization of structures to be resected. The patient is repositioned prone and the posterior pelvis (sacrum and side walls) is then resected with preservation of appropriate nerve roots of the posterior pelvis and the sciatic nerve. Reconstruction is done with muscle and skin flaps. We have done 21 such procedures, of which, 11 were for pelvic recurrence of rectal adenocarcinoma. Seven patients had resections for cure and four had palliative resections of fungating or infected tumors. All but one patient was postabdominal perineal resection and nine patients had been irradiated (3000-9000 rads). Two patients had received up to 9000 rads in separate courses (external beam in one and interstitial radiation in the other). The posterior extent of resection was S1-2 to 5 in six patients; S3 to 5 in three patients, and S4-5 in two patients. Anterior exenteration was performed in three patients and three patients had additional resection of other organs. In the curative resection group, three patients are living free of disease at six, ten, and 52 months, and one patient was NED at 60 months, but has again had tumor recurrance and is living with disease at 65 months. One patient died of disease at 13 months and one patient died of a pulmonary embolus following resection for ureteral obstruction at five months. One postoperative death occurred from a cerebrovascular accident at 52 days. In the palliative resection group, three patients survived with relief of local tumor symptoms four, eight, and 12 months. One patient who had received a total of 9000 rads developed flap necrosis, small bowel fistula and died 60 days after resection. Although this is a small series, it suggests that abdominal sacral resection of locally advanced pelvic cancer is feasible and may provide good palliation in most and possible cure in some patients who develop recurrence after primary resection of adenocarcinoma of the rectum.     

低位直肠癌保肛手术中吻合器的应用

目的探讨吻合器在低位直肠癌保肛手术中的应用效果。方法回顾性分析2004年11月至2009年8月256例直肠癌应用全直肠系膜切除联合吻合器行低位直肠前切除的临床资料。结果本组无死亡病例,无生殖功能障碍;发生吻合口漏2例,出现排尿功能障碍6例。结论全直肠系膜切除联合吻合器的应用可保持盆腔脏器功能,是治疗低位直肠癌的有效方法。