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.     

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.     

全直肠系膜切除术治疗直肠癌

近年来 ,我国结直肠癌的发病率不断上升 ,目前结直肠癌是第三位常见的癌 ,其中直肠癌约占其中的 1 3 ,直肠癌患者中只有大约 5 0 % -60 %能够根治性切除。传统方法进行的直肠癌根治术术后局部复发率为 2 0 % -3 0 % ,复发率与病理分期有关 ,DukesC期患者局部复发率为 40 %以上 ,局部复发是影响患者长期生存率的主要问题。通过对直肠癌术后复发病例的研究 ,表明直肠系膜的切除与否与直肠癌术后复发密切相关。因此 ,如何提高局部手术的根治性 ,降低术后复发率是提高患者生存率的关键[1 ] 。　　全直肠系膜切除术 (totalmesorectalexcision ,…     

直肠癌全直肠系膜切除术

目的 比较全直肠系膜切除（ TME）和传统手术方法对直肠癌术后局部复发及长期生存率的影响。 方法 将 1993年 9月起采用 TME术的直肠癌患者 168例与 1981～ 1992年行传统切除方法的 126例患者进行比较,分析两组的临床病理参数。结果 手术后并发症发生率无差异, TME组 2年复发率为 4. 6％, 明显低于对照组的 20. 6％ (P=0.001)。 2年及 3年生存率 TME组分别为 87.1％和 80.3％,对照组分别为 76.1％ 和 68.7％, TME组生存率高于对照组 (P=0.013)。 TME技术、肿瘤的 Dukes分期、患者的年龄、肿瘤距肛门的距离等因素中,只有 TME是独立的影响生存率的指标, TME、肿瘤的 Dukes分期是独立的影响局部复发的指标。结论 对于距离肛门 12 cm范围内的直肠癌,采用 TME技术能有效地降低局部复发率及提高患者生存率。     

Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer

Background  Bladder and sexual dysfunction are well-documented complications of rectal cancer surgery. This study aimed to determine whether laparoscopy can improve the outcome of these dysfunctions or not. Methods  The study included 63 of the 116 patients who underwent surgery for rectal cancer between 2002 and 2006. Bladder and male sexual function were studied by means of a questionnaire on the basis of the International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIEF). In addition, bladder function was determined by means of postvoid residual urine measurement and uroflowmetry. Postoperative functions were compared with the preoperative data to detect subjective functional deterioration. Outcomes were compared between patients who underwent open (group 1, n = 29) and laparoscopic (group 2, n = 34) total mesorectal excision. Results  Only minor disturbances of bladder function were reported for one patient (3%) in group 1 and three patients (9%) in group 2 (p > 0.05). Impotency after surgery was experienced by 6 of 17 preoperatively sexually active males (29%) in group 1 and 1 of 18 males (5%) in group 2 (p = 0.04). Similarly, 5 of 10 women (50 %) in group 1 and 1 of 14 women (7%) in group 2 felt that their overall level of sexual function had decreased as a result of surgery (p = 0.03). Conclusions  Open rectal cancer resection is associated with a higher rate of sexual dysfunction, but not bladder dysfunction, compared with laparoscopic surgery. Laparoscopic rectal cancer surgery offers a significant advantage with regard to preservation of postoperative sexual function and constitutes a true advance in rectal cancer surgery compared with the open technique. The proposed advantages can be attributed to improvement in visibility by the magnification feature of laparoscopic surgery. Presented orally at the 8th National Endoscopic Laparoscopic Surgery Congress, Antalya, Turkey, 1–4 July 2007.     

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.     

腹腔镜直肠全系膜切除术

目的探讨腹腔镜外科技术在直肠全系膜切除术(TME)的应用。方法对39例腹腔镜直肠全系膜切除术患者进行随访和回顾性分析。结果腹腔镜直肠前切除术30例,中转手术1例;腹腔镜辅助Miles手术9例。无手术死亡,术中盆底静脉丛破裂出血1例(发生率2.6%)。平均手术时间185min,平均出血量85ml,平均术后住院日为8.5d。术后发生吻合口瘘1例,尿潴留1例。39例患者术后随访1～28个月,仅1例DukesC1期的低分化腺癌患者,术后12个月盆腔局部肿瘤复发。全组患者的trocar穿刺孔及腹壁切口无肿瘤种植。结论腹腔镜直肠全系膜切除术创伤小、疼痛轻、恢复快。只要严格掌握手术适应证,正确应用腹腔镜技术就能完成此类手术。     

经肛门全直肠系膜切除和腹腔镜全直肠系膜切除对直肠癌的疗效对比

目的分析比较经肛门全直肠系膜切除（TaTME）与腹腔镜全直肠系膜切除（LaTME）在中低位直肠癌治疗中的疗效及预后。 方法选择东营市东营区人民医院2015年2月至2016年2月收治的64例择期行全直肠系膜切除术（TME）的中低位直肠癌患者,随机分为TaTME组与LaTME组,各32例。观察并比较两组患者的手术时间、术中出血量、标本完整率、环周切缘（CRM）阳性率、远端切缘（DRM）阴性率、淋巴结清扫数目、保肛率、中转开放手术率、术中及术后并发症、术后住院时间、局部复发率、远处转移率、2年总体生存率（OS）各指标间的差异。 结果TaTME组患者的术中出血量、中转开放手术率、手术时间、标本完整率、CRM阳性率、保肛率、术后住院时间、尿潴留发生率均显著优于LaTME组（均P<0.05）。患者均获随访2~24个月,TaTME组中位生存时间为23.9个月,局部复发率、转移率分别为6.2%（2/32）、3.1%（1/32）。LaTME组中位生存时间为19.7个月,局部复发率、转移率均为3.1%（1/32）。两组术后复发率、转移率比较,差异无统计学意义（χ²=0.350、0.516,P=0.554、0.472）。TaTME组与LaTME组1年OS分别为100.00%、93.75%,2年OS分别为96.87%、81.25%。两组1年OS比较,差异无统计学意义（χ²=0.516,P=0.472）,TaTME组的2年OS显著高于LaTME组患者（χ²=4.402,P=0.036）。 结论与LaTME术相比,TaTME术治疗中低位直肠癌具有较高的安全性和有效性,且术后并发症较少,术后住院时间短,可以改善患者预后。     

Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer

BACKGROUND: Bladder and sexual dysfunction, secondary to pelvic nerve injury, are recognized complications of rectal resection. This study investigated the frequency of these complications following laparoscopically assisted and conventional open mesorectal resection for cancer. METHODS: A total of 170 patients with rectal cancer was identified from a previous randomized trial of laparoscopic versus open resection. A retrospective analysis of bladder and sexual function before and after operation was performed by means of postal questionnaires and telephone interviews. RESULTS: At the time of the study, 111 (65 per cent) of the 170 patients were alive, of whom 80 (72 per cent) responded. Of the responders, 40 patients had undergone laparoscopically assisted resection and 40 had had an open operation. No significant deterioration in bladder function following operation was observed, although two patients in the laparoscopic group required long-term intermittent self-catheterization. A significant difference in male, but not female, sexual function was noted, with seven of 15 sexually active men in the laparoscopic group reporting impotence or impaired ejaculation, compared with only one of 22 patients having an open operation (P = 0.004). All patients with bladder or sexual dysfunction in the laparoscopic group had resection of either bulky or low rectal cancers. CONCLUSION: Laparoscopically assisted rectal resection is associated with a higher rate of male sexual dysfunction, but not bladder dysfunction, compared with the open approach. This has implications, particularly for sexually active males with bulky or low rectal cancers, when deciding the best operative approach.     

Laparoscopic total mesorectal excision for low rectal cancer

Background

Laparoscopic total mesorectal excision for rectal cancer is coming out of age with recent publications highlighting its safety, feasibility, sound oncological outcomes, and improved quality of life. Nevertheless, laparoscopic proctectomy remains a challenging procedure. An embedded didactic video demonstrates a step-by-step laparoscopic total mesorectal excision with coloanal anastomosis for a low rectal cancer.

Methods

A five-trocar technique is shown. The key steps demonstrated are: high division of the inferior mesenteric artery, medial-to-lateral mobilization of the descending colon, high division of the inferior mesenteric vein, take-down of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end coloanal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter and pelvic autonomic nerves.

Results

A series of ten consecutive patients operated for low rectal cancer with total mesorectal excision is reported. Median (range) operative time and estimated blood loss were 274 (135?C360) minutes and 25 (10?C50)?ml. Median tumor height from the anal verge was 7 (4?C10)?cm. Reconstruction included three coloanal J-pouch and seven side-to-end anastomosis. Nine anastomoses were performed by using a double-stapled technique. One patient with an intersphincteric dissection required a handsewn anastomosis. A diverting ileostomy protected all coloanal anastomosis. Median length of stay was 3 (range, 2?C7) days. One of ten patients was readmitted for a small bowel obstruction. The embedded video demonstrates a total mesorectal excision down to the pelvic floor in a patient who had a T2 cancer 6?cm from the anal verge with prior open cholecystectomy and hysterectomy.

Conclusions

Laparoscopic total mesorectal excision is a safe and effective procedure. Patient selection and advanced laparoscopic skills are paramount. It is hoped that this didactic video will contribute to a wider and safer practice of laparoscopic total mesorectal excision for low rectal cancer.     

腹腔镜下直肠癌全直肠系膜切除手术

目的 探讨腹腔镜下直肠癌全直肠系膜切除(total mesorectal excision，TME)手术的可行性。方法 自2000年3月至2003年11月共行腹腔镜下直肠癌TME手术67例，其中直肠癌前切除术(anterior resection，AR)45例，直肠癌腹会阴联合切除术(abdominal pelineal resection，APR)22例。结果 本组67例患者按TME原则采用腹腔镜完成直肠癌手术，术中出血量10～50ml，手术时间2.5～5．0h，无术中死亡，术后持续胃肠减压时间8～24h，平均术后24～48h开始进食水，术后1～3d下床活动，术后1～5d开始排便。术后住院时间7～10d。术后随访时间3～43个月，2例患者局部复发，2例患者肝转移；术后因局部复发和肝转移各死亡1例，失访3例；有19例术后不足1年的患者，未发现转移及复发。结论 只要有较好的开腹TME手术经验和腹腔镜操作技能，腹腔镜下直肠癌TME手术是可行的。     

腹腔镜辅助经肛全直肠系膜切除术与腹腔镜全直肠系膜切除术治疗低位直肠癌的疗效比较

背景与目的：全直肠系膜切除术（TME）是治疗直肠癌的标准术式,与开放TME比较,腹腔镜辅助TME（LaTME）不仅降低了手术创伤,且疗效相当。但对于肥胖、骨盆狭窄、男性低位直肠癌患者,LaTME的盆腔操作仍十分困难,且环周切缘（CRM）阳性的风险增加。腹腔镜辅助经肛TME（TaTME）的出现为低位直肠癌切除术提供了一种创新的微创选择,给外科医生提供新的解决方案。本研究比较分析腹腔镜辅助TaTME与LaTME治疗低位直肠癌的临床疗效。 方法：回顾性分析广东省中医院胃肠外科2018年7月—2019年1月收治的30例低位直肠癌患者（肿瘤下缘距肛门距离≤5 cm）的临床资料。其中12例行腹腔镜辅助TaTME（TaTME组）,18例行LaTME（LaTME组）。比较两组患者的相关临床指标。 结果：两组患者在年龄、性别、BMI、ASA分级、肿瘤学分期、肿瘤下缘距肛门距离、肿瘤直径等一般资料均无明显差异（均P>0.05）。两组患者无中转开腹手术,无近期死亡病例。TaTME组较LaTME组手术时间明显缩短（168.5 min vs. 239.33 min,P=0.007）、出血量明显减少（66.50 mL vs. 160.00 mL,P=0.002）。两组在预防性造口、保肛率、CRM阳性率、淋巴结清扫总数方面差异无统计学意义（均P>0.05）。TaTME组术后住院时间明显短于LaTME组（6.33 d vs. 10.83 d,P<0.001）、住院费用明显低于LaTME组（58 963元 vs. 81 341元,P<0.001）,TaTME组的术后排气时间及恢复全流饮食时间均短于LaTME组,但差异无统计学意义（均P>0.05）。两组术后并发症发生率差异无统计学意义（P>0.05）。  结论：腹腔镜辅助TaTME治疗低位直肠癌与LaTME的短期疗效相当,且在某些方面具有一定优势;是安全可行的,值得临床进一步研究和应用。     

Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

BACKGROUND: Anastomotic leakage is a major complication of rectal cancer surgery. The aim of this study was to investigate risk factors associated with symptomatic anastomotic leakage after total mesorectal excision (TME). METHODS: Between 1996 and 1999, patients with operable rectal cancer were randomized to receive short-term radiotherapy followed by TME or to undergo TME alone. Eligible Dutch patients who underwent an anterior resection (924 patients) were studied retrospectively. RESULTS: Symptomatic anastomotic leakage occurred in 107 patients (11.6 per cent). Pelvic drainage and the use of a defunctioning stoma were significantly associated with a lower anastomotic failure rate. A significant correlation between the absence of a stoma and anastomotic dehiscence was observed in both men and women, for both distal and proximal rectal tumours. In patients with anastomotic failure, the presence of pelvic drains and a covering stoma were both related to a lower requirement for surgical reintervention. CONCLUSION: Placement of one or more pelvic drains after TME may limit the consequences of anastomotic failure. The clinical decision to construct a defunctioning stoma is supported by this study.     

The fate of anastomotic sinuses after total mesorectal excision for rectal cancer

Objective  Chronic anastomotic sinus is a recognized complication of total mesorectal excision (TME) surgery. We observed two patients who developed new tumours within chronic anastomotic sinuses 6 and 19 years after initial surgery. The aim of this study was therefore to report the incidence and outcome of anastomotic sinuses, thus identifying those at potential risk of malignant change.
Method  We retrospectively reviewed patient records and radiology reports to identify potentially curative rectal cancer cases between 1998 and 2005.
Results  In a consecutive series of 100 TMEs with ileostomy, there were 70 males and 30 females, aged 66 (33–88) years. Anastomosis was by double staple technique. A policy of instant enema was used prior to ileostomy closure. Eighty-six patients had instant enemas. Of the 14 that did not, four died prior to enema, one returned to theatre for sepsis, three had their anastomoses assessed by sigmoidoscopy alone. Six had incomplete records. Of the 86 patients, eight presacral sinuses were identified. Three sinuses closed spontaneously. Five persisted of whom two required further surgery.
Conclusion  Persistent anastomotic sinuses occurred in 5% after curative TME. Malignant transformation can occur. Active treatment for chronic sinuses should, therefore, be considered.     

直肠癌全系膜切除术

直肠癌是我国常见恶性肿瘤之一,约占大肠癌总发病率的60％～70％[1^],且多以腹膜反折平面以下的中、低位直肠癌占大多数。目前,手术切除仍是治疗直肠癌的最确切、最有效的手段。随着人们由过去单一追求“生命数量”向现在“生命数量和质量并重”观念的改变,外科治疗在根治切除的前提下,     

经肛直肠癌全直肠系膜切除术实践与策略

经肛门全直肠系膜切除术在近几年成为了结直肠外科学界的研究热点,在经历了动物实验、尸体试验和伦理认证等过程后,该手术的临床试验在国内外多个国家得到迅速发展。虽然该术式的初步结果尤其在肥胖患者、骨盆狭窄、前列腺肥大等情形时可改善全直肠系膜切除的质量,降低远切缘及环周切缘的阳性率。但目前开展单位尚少,样本累积亦不足,缺乏多中心研究的长期结果,该术式仍处于探索性的研究阶段。鉴于该术式与传统手术路径不同,需要有更为充分的前期基础来谨慎开展。开展高质量多中心随机对照临床研究,以获得更多循证医学证据的支持,是今后临床工作的重点。     

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。