经骶尾部入路的肛门直肠手术(Kraske手术)

目的 :介绍和评价经骶尾部入路的肛门直肠手术 ( Kraske手术 )。方法 :对 Kraske手术进行回顾性分析。结果 :全部病例共 2 2例 ,男 12例 ,女 10例。平均年龄 ( 6 2 .3± 13.8)岁。良性病变 8例 ,恶性肿瘤 14例。手术过程顺利 ,切口均一期愈合 ,无肛门禁病例。肿瘤患者随访 1～ 5年 ,无死亡病例。结论 :Kraske手术是处理肛门直肠疾病的一种显露良好、创伤合理、并发症相对较少的手术方式     

中低位直肠及周围盆底肿瘤局部切除手术入路选择策略

目的探讨中低位直肠及周围盆底腹膜外肿瘤局部切除手术入路选择策略、手术适应证以及手术技巧。方法回顾性分析2004年7月一2008年7月给予局部切除的122例中下段直肠及周围盆底腹膜外肿瘤患者的临床资料。结果122例患者中经肛门入路45例,经骶尾入路32例,经括约肌入路45例,肿瘤距肛门5．6（0～12）cm,病灶大小4．2（0．5～11）Cm。病理报告直肠良性肿瘤81例,直肠周围盆底良性肿瘤16例,直肠肛门恶性肿瘤25例,所有标本切缘阴性。经肛门入路、经骶尾入路、经括约肌入路的并发症发病率分别为8．9％（4／45）、18．8％（6／32）、20．0％（9／45）,复发再手术率分别为6．7％（3／45）、9．4％（3／32）、4．4％（2／45）。结论中低位直肠及周围盆底肿瘤经会阴切除三种手术入路各有优缺点,经括约肌手术入路适应证更加广泛,但并发症发病率高,需要掌握良好的手术技巧。     

直肠局部切除术治疗直肠良恶性肿瘤(附44例报告)

目的:探讨直肠局部切除术在直肠良恶性肿瘤治疗中的应用。方法:回顾性分析1998年1月至2005年12月收治的44例中、低位直肠良恶性肿瘤的临床资料。经骶尾后入路局部切除24例;经肛局部切除17例。对于3例直肠多发性病灶的患者,经腹局部扩大切除多发性病灶1例,同时经骶尾后入路和经肛局部切除1例,同时经腹和经肛局部切除1例。结果:术后病理学诊断显示直肠管状绒毛状腺瘤伴上皮异型增生17例(其中多发性腺瘤1例);直肠管状绒毛状腺瘤癌变11例;直肠类癌9例;直肠早期腺癌1例;直肠恶性黑色素瘤1例;直肠间质瘤1例;增生性息肉4例(其中多发性息肉2例)。全组44例患者切口均I期愈合。无肛门失禁发生。在25例经骶尾后入路局部切除的患者中,2例并发粪瘘(2/25,8%),均于术后1月痊愈。经骶尾后入路局部切除的2例直肠腺瘤患者,术后1年出现复发(2/25,8%),1例追加Parks术,1例再次经肛局部扩大切除。结论:直肠局部切除术在直肠良恶性肿瘤的外科治疗中应用广泛,是保留肛门功能手术的最佳选择之一。     

Kraske后入路直肠腺瘤切除术

目的　探讨Kraske后入路局部切除中低位直肠腺瘤的适应证及优缺点。方法　回顾分析 8例距肛门 5～ 10cm直肠腺瘤的手术治疗及术后随访结果 :结果　 8例腺瘤切除彻底 ,近期无局部复发征象。 3例 (37.5 % )术后并发粪瘘 ,1～ 3月后痊愈。结论　Kraske后入路局部切除中低位直肠腺瘤具有损伤小、显露良好、操作简便、病灶清除彻底的优点 ,值得临床推广运用。     

经骶尾入路手术在低位直肠肿瘤局部切除中的应用

目的：探讨经骶尾入路手术在低位直肠良性病变及早期直肠癌局部切除中的应用价值。方法：对我院1997～2002年问，应用经骶尾人路手术治疗的24例低位直肠肿瘤患者进行随访及疗效判断。结果：直肠绒毛状腺瘤14例，绒毛状腺瘤癌变7例，直肠类癌3例，经5个月～6年的随访，所有患者均无瘤存活。结论：骶尾入路手术具有简单易行、手术创伤小、术野宽敞等优点，是治疗低位直肠肿瘤的较好方法。     

直肠绒毛状腺瘤手术方式的探讨

目的 探讨直肠绒毛状腺瘤手术方式的合理选择。方法 对70例手术治疗的直肠绒毛状腺瘤病例进行回顾性研究及随访。经肛门括约肌径路切除(Mason术)29例，直肠前切除术(Dixon术)16例，经肛门局部切除(transanal excision，TE)11例，经骶部切除(Kraske术)5例，其他手术9例。结果 25例(35．7％)直肠绒毛状腺瘤已发生癌变。70例患术后并发症发生率为15．7％，术后复发率为14．3％。Mason术后并发症发生率和复发率分别为6．9％和0。结论 选择直肠绒毛状腺瘤的手术方式应综合考虑腺瘤的具体部位、大小以及术前活检的病理结果，对于腺瘤癌变的病例还应考虑肿瘤浸润肠壁的深度。Mason术是治疗直肠中下段绒毛状腺瘤的理想术式。     

经骶尾部入路治疗直肠下段肿瘤

经骶尾部入路治疗直肠下段肿瘤15冽，其中良性肿瘤11例，恶性肿瘤4例，都取得了满意效果。我们认为此入路具有简捷方便、手术创伤小、肿瘤定位准确、手术显露好、操作方便等优点，非常适合经腹或经肛门手术有困难的直肠下段肿瘤。对手术方法、适应证以及并发症的防治等均作了介绍。     

直肠后肿瘤65例临床诊治分析

目的 探讨直肠后肿瘤的诊断与治疗。方法 回顾性分析65例直肠后肿瘤患者的临床资料,直肠后肿瘤患者65例均行直肠指检、B超检查、CT或MRI检查作出诊断。65例患者均行手术切除,单纯经骶入路手术35例,单纯经腹入路手术17例,经腹经骶联合入路手术13例。结果 本组肿瘤完全切除有59例,部分切除6例,肿瘤切除率90.8%。术后直肠瘘1例,切口Ⅰ期愈合58例,术后切口感染3例,骶前脓肿3例。全组无围手术期死亡病例。65例中有56例获得随访6月~4年。3例术后复发,再手术后治愈。结论 合理的手术入路、方式是治疗直肠后肿瘤的关键,同时充分的术前准备、术后积极的辅助治疗以及多学科的通力合作也是需要重视的。     

经骶尾后路低位直肠肿瘤切除术的临床应用

目的:比较经骶尾后路低位直肠肿瘤切除术式与Miles手术的临床应用价值.方法:46例直肠癌分为2组,26例行经骶尾后路保留肛门肿瘤切除术(A组),20例接受Miles手术治疗(B组),总结临床治疗效果.结果:46例手术顺利,无手术死亡,3年生存率100%,无局部复发.A组平均手术时间1h 40min,并发症发生率为11.5%,术后肛门排便功能恢复良好.B组平均手术时间2h 30 min,并发症发生率10.0%,术后失去自主肛门排便功能.结论:经骶尾后路低位直肠肿瘤切除术是一种术式简捷、疗效肯定、真正意义上保留肛门排便功能的手术方式,对早期低位直肠癌肿,可以达到根治目的.     

一期后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形疗效分析

目的探讨一期后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形的疗效。方法回顾分析了2003年10月至2008年4月在我院采用后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形12例．总结术后疗效并随访其排便功能。结果病例随访显示，12例患者的肛门具有良好收缩力，无明显肛门失禁，排便功能良好，效果满意。排便情况经临床评分结果为优良。结论经后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形，可以达到充分暴露术野．缩短治疗时间的目的，效果良好。     

经肛门内镜微创手术治疗直肠肿瘤

目的:比较相同适应证下经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)和传统手术治疗直肠肿瘤的效果。方法:回顾分析63例直肠原发距肛缘4cm以上的良性肿瘤和T2期前恶性肿瘤患者的临床资料。2005年3月至2007年3月为34例患者行传统手术,包括经肛门局部切除术、Kraske术、Dixon术;2007年3月至2009年3月为29例患者行TEM手术。结果:两组患者年龄、性别、疾病种类和肿瘤分期具有可比性,TEM组和传统手术组肿瘤直径(2.4cm vs.2.35cm,P=0.983)和肿瘤距肛门距离(8.0cm vs.7.0cm,P=0.296)差异无统计学意义。TEM组手术时间(58min vs.77.5min,P=0.044)、出血量(10ml vs.80ml,P0.001)、术后进食时间(1d vs.2d,P0.001)、术后住院时间(3d vs.5d,P0.001)和应用止痛药(0mg vs.10mg,P0.001)等方面优于传统手术组。两组短期并发症(2 vs.7,P=0.235)差异无统计学意义;TEM组在17个月的中位随访过程中未发现肿瘤复发,传统手术组中位随访40个月,2例(5.9%)复发。两组均无肿瘤相关死亡病例。结论:在把握适应证的前提下,TEM是治疗直肠肿瘤的有效方法。同传统手术相比,TEM具有患者创伤轻、住院时间短和并发症少等优点。     

Posterior surgical approaches to the rectum.

This report summarizes experience with 19 posterior approaches to the rectum including nine trans-sacral (Kraske) and ten trans-sphincteric (Mason) procedures. This study included 12 men and 7 women, ranging in age from 18 to 89 years. Surgical indications included villous tumors in nine patients, various benign problems in four patients, primary carcinomas in three patients, and recurrent cancer in three patients. Eight complications developed in the 19 patients including: four fecal fistulae, two wound dehiscences, one rectal stricture, and one sacrococcygeal hernia. Spontaneous closure of the fecal fistulae occurred in two patients, and two patients required proximal colostomies. Fecal continence was achieved in 18 of the 19 patients. No patient died as a complication of the procedure. No recurrent tumors have developed. The conclusion is that a posterior approach to the rectum is a safe and effective procedure for various benign and for selected malignant conditions. It is particularly suitable for villous tumors that are too high for transanal resection and too low for transabdominal resection. It is an effective procedure for small, exophytic, mobile carcinomas of the lower 10 cm of the rectum in selected patients.     

经骶局部切除直肠肿瘤术式探讨

目的：探讨经骶尾部局部切除直肠肿瘤的适应证及疗效。方法：经骶尾部切口对28例直肠良、恶性肿瘤行局部切除术的临床资料作回顾性分析。结果：良性肿瘤12例术后均治愈。恶性肿瘤16例，术后1年生存率100％，3年生存率87．5％，5年生存率68．7％，术后吻合口瘘为17．8％。结论：在严格掌握适应证的前提下，早期直肠癌经骶尾部行局部切除术治疗可获理想效果。     

Presacral tumors: a practical classification and treatment of a unique and heterogeneous group of diseases

BACKGROUND: Presacral tumors are a rare and diverse group of diseases that originate from the different tissues that comprise the potential presacral space. Because of their relative rarity, confusion exists regarding their clinical presentation, natural history, and treatment. The aim of this study is to describe a single institution's experience with the management of presacral tumors and to suggest a practical method of classification. METHODS: Records of all patients who underwent operation for presacral tumors from the years 1991 to 2001 were reviewed. Clinical, pathologic, treatment, and outcome variables were evaluated. RESULTS: Forty-two patients were included in the study and were divided into 4 groups according to lesion pathology: benign congenital (n = 12), malignant congenital (n = 9), benign acquired (n = 9), and malignant acquired (n = 12). Symptoms were nonspecific, and 26% of the cases were completely asymptomatic. Diagnosis was made with rectal examination and confirmed with pelvic computerized tomographic scan. Surgical approach varied among the different groups, with the posterior approach used mainly for congenital tumors and the anterior approach for acquired. Complete surgical resection of the tumor was obtained in all cases of benign tumors and in 76% of malignant tumors. No postoperative mortality was seen, and complications occurred in 36% (15/42); most were reversible. None of the patients with benign tumors had recurrences, and all are alive at this time. The survival rate of patients with malignant tumors was significantly improved when complete resection was possible. CONCLUSION: Classification of presacral tumors into congenital versus acquired and benign versus malignant is simple and efficient. Treatment is complete surgical resection, which can be performed safely with low morbidity and no mortality.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: XII. Anorectal mobilization: A new surgical access to rectal lesions. Preliminary report

A new technique for the removal of inaccessible benign intrarectal lesions and malignant lower third rectal tumors with sphincter preservation is presented. The procedure was performed in eight patients, four with huge bilharzial papillomas and four with malignant lower third rectal tumors. The essential feature of the operation is preservation of the levator tunnel, which is responsible for maintaining normal, voluntary continence and defecation. The results were satisfactory. The technique provides easy access to the interior of the rectum, and it extends the indications for sphincter-saving operations to include malignant lower third rectal tumors. It is hoped that this procedure will eliminate the use of abdominoperineal excision in the treatment of rectal cancer.     

Complications are increased with the need for an abdominal-assisted Kraske procedure

The Kraske procedure offers a sphincter-saving alternative for surgical correction of rectal disease. This study was performed to investigate the complication rate with the traditional (transsacral) Kraske procedure versus an abdominal-assisted Kraske approach (laparoscopic or open). We conducted a retrospective review of all patients undergoing the Kraske procedure at Harper University Hospital over a 10-year period. A total of 54 patients were identified. Indications for surgery included rectal carcinoma (43), large villous adenomas (6), and other (5). Average post-operative follow-up was 40 +/- 25 months (mean +/- SD). Complications included rectocutaneous fistulae (9), perineal infections (13), and incontinence (8). In patients requiring an abdominal-assisted approach for colorectal mobilization, the fistula rate was significantly higher (33% vs 3%; P = 0.007), as were the rates of perineal infections (33% vs 17%) and of initial incontinence (25% vs 7%). The laparoscopic-assisted approach significantly reduced the operating time (272 +/- 72 minutes) compared to the open-assisted approach (498 +/- 138 minutes) (P < 0.001). The traditional Kraske procedure can be utilized in a safe, effective manner for treatment of rectal disease. Knowledge of the increased rate of complications with the abdominal-assisted Kraske approach can guide the patient and physician considering sphincter salvage.     

经骶直肠肿瘤切除32例临床体会

目的:探讨经骶直肠肿瘤切除术的适应证及疗效。方法:回顾分析32例直肠良、恶性肿瘤行经骶切除术的临床资料。结果:32例病人,男19例,女13例,平均年龄(62.3±3.7)岁。肿瘤距肛缘4~8 cm,直径1.5~3.5 cm。25例病人行肿瘤局部切除,肠壁间断缝合,7例病人行直肠节段切除端端吻合。手术顺利,术后病理诊断为绒毛状腺瘤16例,绒毛状腺瘤恶变5例,管状腺瘤7例,管状腺瘤恶变1例,腺癌3例。9例恶性肿瘤切缘阴性。3例直肠腺癌病人术后予以放、化疗。术后1例发生吻合口瘘,行结肠造瘘转流手术后治愈,无排便失禁;术后随访6个月至5年,均未发生局部复发和转移。结论:在严格掌握适应证的前提下,经骶直肠肿瘤切除术治疗直肠肿瘤可获得理想效果。     

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??Objective:To evaluate the outcome and the prognosis of transanal local excision in the treatment of patients with benign and malignant lower rectal tumors. Methods:From January 2003 to July 2006,86 patients (49 man,37 women) with benign (n=55) and malignant (n=31) rectal tumors underwent transanal local excision.Data were analyzed retrospectively and 69 patients obtained follow??up. Results:Among 86 patients,there were 26 cases of adenocarcinomas??30.2%??,39 cases of adenoma ??45.3%??,3 cases of carcinoid ??3.5%??,1 case of GIST ??1.2%??,and 17 cases of others ??19.8%??.All tumors located 1 to 12cm from the dentate line.The tumor size was less than 3cm in 68 patients (79.1%),and more than 3cm in 18 patients (21.9%).During the follow??up of 69 patients,tumor recurrence was observed in 6 of 57 patients with the tumor size ??3cm,in 5 of 12 patients with ≥3cm,and the difference was significance (P??0.01).Among the assessable patients of adenocarcinoma,there were 19 cases in T1 and 7 cases in T2.The tumor recurrence was observed in 2 of 16 patients for T1 and in 4 of 7 patients for T2 (P??0.05). Conclusion:Transanal local excision for low rectal tumor is appealing for its less morbidity and excellent functional results.It may be used in the curative management of benign rectal tumors and selected early malignant neoplasm with small tumor size.It is also a treatment option for patients who would be unable to tolerate radical surgery.     

直肠肿瘤经肛门内窥镜微创手术后肛门功能测压评估

目的：探讨直肠良性肿瘤及早期直肠癌经肛门内窥镜微创手术（TEM）治疗后对肛门功能的影响。方法：随访2008年2月至2010年2月30例经肛门内窥镜微创术治疗的直肠肿瘤患者,于术前1周,术后2周、3个月、6个月和9个月时采用肛门测压法评估肛门功能。统计数据采用t检验和χ2检验进行比较。结果：30例患者中,术前经活检证实绒毛状腺瘤20例,直肠腺癌10例（T1期8例,T2期2例）,肿瘤距肛缘为5～16 cm。与术前相比,术后3个月平均静息压和最大耐受容量均较术前降低,差异有统计学意义（t=17.4、22.8,P〈0.05）,至术后6个月时恢复正常（t=1.75、0.93,P〉0.05）;缩榨压于术后2周时降低,与术前相比差异有统计学意义（t=24.0,P〈0.05）,术后3个月恢复正常（t=1.65,P〉0.05）;直肠容量感觉阈值于术后6个月内降低,与术前相比差异有统计学意义（t=3.38,P〈0.05）,至术后9个月趋于正常（t=1.40,P〉0.05）。术前有3例未引出直肠肛门抑制反射,术后3个月有14例阴性,差异有统计学意义（χ2=9.93,P〈0.05）,术后6个月下降至4例,与术前相近（χ2=0.16,P〉0.05）。结论：对于直肠良性肿瘤及早期直肠癌患者,采用TEM治疗后9个月起肛门测压结果基本正常,证明TEM不但是一种保肛及微创手术,而且对肛门功能影响很小。