直肠系膜内微病灶不利于直肠癌患者的预后

直肠癌的特征是侵犯直肠系膜 ,这与术后局部高复发有关。评估的指标主要是从切除的标本中观察到肿瘤组织浸润到直肠系膜内以及系膜内淋巴结。术前对患者进行影象学检查发现 80 %～ 90 %系膜受侵犯 ,5 6%～ 60 %有淋巴结转移。在病理检查中观察到系膜内的新生物病灶被认为是由于腺癌原发病灶的非连续性分布造成直肠系膜受到侵犯 ,但不伴有淋巴结的转移。 Heald依据此现象提出直肠全系膜切除术 ( TME)来减少局部复发的可能性。因此可通过系膜内微小病灶对直肠癌患者进行预后分析研究。　　目的 :明确直肠癌患者直肠系膜内微小肿瘤病灶的发生…     

TME及双吻合器在中低位直肠癌保肛手术的应用

目的探讨全直肠系膜切除、双吻合器技术在中低位直肠癌保肛手术中的应用价值。方法回顾性分析25例采用直肠全系膜切除、双吻合器行中低位直肠癌前切除术患者的临床资料。结果全组无手术死亡,术后无大便失禁,吻合口漏发生1例,吻合口狭窄2例。术后随访2-5年,局部复发1例。结论直肠全系膜切除可降低中低位直肠癌术后局部复发,而双吻合器的应用能提高中低位直肠癌的保肛率。     

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目的探讨中下段直肠癌根治性切除术后局部复发的危险因素。方法回顾性分析2001年12月至2003年7月广东省人民医院收治的行直肠系膜全切除的中下段直肠癌56例临床资料,采用病理大切片技术检测直肠系膜转移及环周切缘情况,分析其与局部复发的相关性,同时分析局部复发与临床病理特征的关系。结果中下段直肠癌根治性切除术后局部复发率为12.5%(7/56)。局部复发与肿瘤家族史(P=0.047)、血CEA水平(P=0.026)、癌性穿孔(P=0.004)、肿瘤分化程度(P=0.009)及脉管侵袭(P=0.001)密切相关。中下段直肠癌直肠系膜环周切缘阳性率为21.4%(12/56);环周切缘阳性的中下段直肠癌局部复发率为33.3%(4/12),明显高于环周切缘阴性的6.8%(3/44),两组差异有统计学意义(P=0.014)。中下段直肠癌直肠系膜转移率为64.3%(36/56);系膜转移阳性的中下段直肠癌局部复发率为16.7%(6/36),高于系膜转移阴性的5.0%(1/20),但两组差异无统计学意义(P=0.206)。结论肿瘤家族史、血CEA水平、癌性穿孔、肿瘤分化程度、脉管侵袭和环周切缘是中下段直肠癌根治性切除术后局部复发的重要因素。     

直肠癌全系膜切除96例临床报告

直肠癌是消化道常见的恶性肿瘤,占消化道癌的第2位.外科手术是直肠癌最主要的治疗手段,但术后局部复发是导致手术失败的重要因素之一.因此如何降低和防止局部复发一直是临床外科研究的重要课题之一.直肠全系膜切除(totalmeso-raectal excision,TME)能有效降低直肠癌术后的局部复发率,已成为目前直肠癌术中必须遵循的原则之一.河南省南阳市第一人民医院遵循TME原则为96例患者施行了直肠癌根治术,全部随访5年以上,报道如下.     

直肠上动脉亚甲蓝灌注法判断全直肠系膜切除术后标本系膜的完整性

目的探讨经直肠上动脉灌注亚甲蓝对低位直肠癌行全直肠系膜切除术（TME）后标本系膜完整性判断的临床意义。方法将按照TME原则进行根治性手术的20例低位直肠癌患者的切除标本．按随机数字表法分为亚甲蓝组和常规检测组．每组10例。常规检测组术后肉眼观察直肠系膜完整性情况．亚甲蓝组经直肠上动脉灌注肝素和亚甲蓝．观察有无亚甲蓝从系膜表面溢出．并进一步对亚甲蓝溢出处系膜及系膜淋巴结情况进行镜检。结果所有病例标本肉眼下观察直肠系膜均完整．亚甲蓝组经直肠上动脉灌注亚甲蓝后，直肠系膜染色明显．8例直肠系膜面无亚甲蓝溢出．提示直肠系膜完整．2例出现亚甲蓝溢出，提示系膜存在肉眼观察无法辨别的缺损，并在镜下得到证实。此外，亚甲蓝组淋巴结平均检出数目（17．3±2．4）枚，而常规检测组为（12．4±5．4）枚，两组差异有统计学意义（P=0．016）。结论结直肠外科医生应在TME术后常规对直肠系膜完整性进行细致评价，亚甲蓝灌注染色是判断系膜微小缺损的一种简便、有效的方法．并能提高淋巴结检出率。     

直肠癌局部复发的综合治疗

直肠癌术后局部复发通常指直肠癌根治性切除术后盆腔内的复发,包括吻合口、直肠周围间隙、会阴部切口和盆腔内淋巴结的复发,可分为单纯的盆腔内局部复发和伴有盆腔以外其他脏器转移的局部复发两种情况。随着对盆腔解剖认识的不断深入,全直肠系膜切除术、术前和术后辅助治疗的广泛应用,直肠癌治疗的总体水平得到明显提高,保肛率明显上升,术后长期生存率明显提高。近10年来,直肠癌术后局部复发率已从2.6%～32%降低至6％～10％。     

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目的：探讨直肠全系膜切除在预防直肠癌术后肿瘤局部复发中的作用以及同该操作相关的一些问题。方法：对1998年8月以来共75例直肠癌术中行全直肠系膜切除的疗效和并发症等进行分析。结果：全组无手术死亡，术后吻合口漏4例，发生率为10％(4／40)；吻合口狭窄2例，发生率为3．3％(2／21)；会阴切口感染2例，发生率为14．3％(2／14)；术后肿瘤局部复发1例，复发率为1．3％。结论：直肠癌术中全直肠系膜切除能有效预防和降低直肠癌术后的局部复发率，但该操作给病人带来的不利因素也不容忽视。     

未加辅助治疗的直肠癌治愈性切除后局部复发

未加辅助治疗的直肠癌治愈性切除后局部复发率,各家报道的变异很大,多变量分析提示与多种不同因素有关。悉尼大学结肠直肠外科自1979年采用标准的切除术式,1981年应用了全解剖学分离方法。中、下1／3直肠肿瘤还采用了全直肠系膜切除术,系膜包裹筋膜予以完整切除;上正／3直肠癌仅作全解剖学分离,结扎和切断直肠系膜而不作全直肠系膜切除。以统一的标准检查切除标本。根据前瞻性临床病理分期,分别观察切除线残余癌和远处转移等。凡在盆腔或会阴疤痕中有局限肿瘤者列为局部复发。分析病人包括在1971～1991年施行手术者,并至少随访至199…     

近20年中、下段直肠癌外科治疗的十大进展

结直肠癌的发病率逐年上升 ,欧美已跃升为恶性肿瘤的第 2位 ,国内则升至第 3位。结肠与上段直肠癌的手术已较定型 ,进展不大。但中、下段直肠癌近 2 0年来却出现很多治疗进展。今择较为公认的十大进展作简要评述。1　全直肠系膜切除术 (TME)　　 1 982年Heald提出全直肠系膜切除术 (totalmesorectalexcision ,TME)时并未受到重视 ,但 90年代后不断被证实其确能降低局部复发率 ,现已成为中、下段直肠癌根治术操作时必须遵循的一项原则。　　众所周知腹膜返折下的直肠解剖学上并无系股 ,TME所指的系膜为盆筋膜脏层 (也称直肠固有筋膜 )所…     

未行全系膜切除的直肠癌根治性切除后的局部复发

直肠癌根治性切除后的局部复发预后差 ,很少可以治愈 ,并与肿瘤引起的死亡密切相关。如果初次手术是根治性的 ,很少一部分局部复发患者适合进一步根治性切除。 Healb强调直肠系膜内肿瘤扩散的重要性 ,并要求切除直肠远端的全部系膜。本文目的是研究未进行全系膜切除的直肠癌根治性切除后的局部复发。方法 :前瞻性收集 1 96 9～ 1 993年由一个医师治疗的 5 4 9例直肠癌根治性切除患者资料 ,1 7例术后 30 d内死亡 ,对其余 5 32例进行分析。男 30 4例 ( 5 7.1 % ) ,平均年龄 6 1 .3岁 ( 32～ 88岁 )。女 2 2 8例 ( 4 2 .8% ) ,平均年龄 6 1 .9…     

TOTAL MESORECTAL EXCISION: EVALUATING THE EVIDENCE

The present paper reviews information from pathological and clinical studies examining the role of total mesorectal excision (TME) in the treatment of rectal cancer. The pathological studies provide information about the spread of rectal cancer within the mesorectum, and the adequacy of excision obtained with conventional surgery and TME. The clinical studies provide information about the safety of TME and the reported local recurrence rates. Taken together, these studies provide a rationale for using TME to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from randomized controlled trials.     

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.     

Distal dissection in total mesorectal excision,and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4–5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.     

直肠系膜全切除与阴道切除在女性低位直肠癌根治术中的应用体会

目的：探讨直肠系膜全切除与阴道切除在降低女性低位直肠癌局部复发中的价值。方法：回顾性总结43例女性Dukes B－C期低位直肠癌病例,其中22例按TME原则行直肠癌根治术（含阴道全部或后壁切除）,21例按传统直肠癌根治术（未切除阴道）。结果：TME组22例术后2年内局部复发率为4．55％（1／22）,阴道后壁肌层癌组织检出率50％（11／22）,直肠系膜有癌率63．64％（14／22）。传统组21例术后2年内局部复发率为23．67％（5／21）,直肠系膜有癌率38．10％（8／21）。结论：TME加阴道切除能降低女性Dukes B-C期低位直肠癌患者的局部复发率。     

Present and future tense in operable rectal cancer

In the last three decades it has been repeatedly insisted on the total mesorectal excision (TME), as being the key for pelvic recurrence. The authors have focused upon issues still "questionable", that invite reflection, having as a starting point now become the classic precepts of RJ Heald. The authors stop mainly on defining points that justify the complex therapeutical approach of rectal cancer. There are discussed some issues still subject to controversy: the extent of regional extirpation, critical points of surgical risk, the attitude towards the protection of genito-urinary innervation. In this purpose surgical considerations are presented on: the anatomy of the rectum and mesorectum, TME and its limits, on dissemination issues and pathology tumor grading, pelvic relapse and the place of adjuvant therapy. Complication rate is also analyzed and the quality of life of patients undergoing TME. Finally conclusions are advanced, some of them having the capacity to provide topics for future study and debate.     

Factors that influence the adequacy of total mesorectal excision for rectal cancer

OBJECTIVE: In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05. RESULTS: Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001.Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966). CONCLUSION: There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.     

Treatment of lateral node metastasis from lower rectal cancer

Lateral lymphatics of the rectum originate in the area where branches of the inferior hypogastric plexus and the middle rectal vessels from the internal iliac vessels enter the mesorectum below the level of the peritoneal reflection in the pelvis, then reach the bifurcation of iliac vessels along the internal iliac vessels. Among lateral lymph nodes, the middle rectal, obturator, and internal iliac lymph nodes are important from the viewpoint of both the incidence of metastais and treatment effects. Although total mesorectal excision (TME) had become the standard surgical treatment for rectal cancer by the 1990s, this technique does not treat lateral node metastasis. A randomized clinical trial of TME versus D3 lymphadenectomy (JCOG0212) was started in 2003, and the registration of 701 patients with lower rectal cancer was completed in August 2010. The results of this clinical trial are highly anticipated. In Japan, where the rate of local recurrence after surgery is low, patients at high risk of local recurrence such as those with lateral node metastasis, T4 disease, and multiple lymph node metastases in the mesorectum should be selected to receive preoperative chemoradiation. Japanese surgeons who treat rectal cancers are in an advantageous position because they have the additional measure of lateral node dissection along with TME and chemoradiotherapy.     

Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma

Background

After total mesorectal excision (TME) surgery, patients with an incomplete mesorectum have an increased risk of local and overall recurrence. With the introduction of laparoscopic TME, an improved quality of the specimen was expected. However, the quality-related results were comparable to the results after traditional open surgery. Transanal TME is a new technique in which the rectum is mobilised by using a single-port and endoscopic instruments through the so called ‘down to up’ procedure. This new technique potentially leads to an improved specimen quality. This study was designed to investigate the pathological quality of specimens after transanal (TME) and to compare these with specimens after traditional laparoscopic TME.

Methods

This matched case control study compared the specimens of a cohort of consecutive patients who underwent transanal TME with the specimens after traditional laparoscopic TME. The pathological quality of the mesorectum was determined by the definitions of Quirke as ‘complete’, ‘nearly complete’, or ‘incomplete’.

Results

From June 2012 until July 2013, 25 consecutive patients underwent transanal TME because of a rectum carcinoma. Within the transanal TME group, 96 % of the specimens had a complete mesorectum, while in the traditional laparoscopic group, 72 % was deemed complete (p < 0.05). Other pathological characteristics, such as the circumferential resection margin, were comparable between the two groups.

Conclusions

Transanal TME appears associated with a significant higher rate of completeness of the mesorectum. Further studies are necessary to evaluate this novel technique.     

敞开式缝吊荷包法在低位直肠癌保肛术中的应用

观察敞开式缝吊荷包法在低位直肠癌保肛术中的临床应用效果,为低位直肠癌保肛手术提供一种方便有效的远端直肠荷包缝合法。对32例低位直肠癌患者采用敞开式缝吊荷包法行低位直肠癌保肛术治疗。按TME原则应用电刀锐性游离直肠至肛提肌水平,于直肠肿瘤下缘左右侧壁用4号丝线各缝扎一道作指示线。于指示线水平的直肠前壁开始边切边缝吊向左右侧切开直肠壁,至直肠后壁时将直肠壁与直肠系膜分离,将直肠系膜继续向远端游离5cm。完整去除直肠肿瘤和直肠系膜。提起远端直肠缝吊线,用荷包线于直肠断端作一锁边荷包。自肛门将32mm环状吻合器器身置入直肠,中心杆自直肠断端荷包中央突出,收紧荷包线后结扎。再次检查以保证吻合口内肠壁无多余脂肪组织后与放置于乙状结肠的抵钉座结合。此后按环状吻合器吻合操作常规行乙状结肠直肠端端吻合。结果32例手术均成功。除2例低分化腺癌外,在远切缘处未发现残留癌组织。术后无吻合口漏发生。所有患者术后3个月经结肠镜复查吻合口无肿瘤复发。结果表明,该法是一种可靠的低位直肠癌保肛术中远端直肠荷包缝合法,其优点：（1）既保证切缘无癌残留又可提高保肛成功率;（2）可保证完整去除肿瘤远端5cm的直肠系膜,达到TME标准;（3）减少吻合口漏的发生;（4）操作方便,出血少。     

中低位直肠癌逆向转移的研究

目的探讨中低位直肠癌实施直肠全系膜切除术（TME）时，肿瘤平面以下系膜与肠管切除的范围。方法将60例经标准TME切除的中低位直肠癌肿瘤标本，以5mm间距由肿瘤下缘横断面连续取材至下切缘．大组织切片常规苏木精-伊红染色观察转移灶，并进行统计分析。结果有15例（25．0％）患者出现肠系膜逆向转移，转移距离0．5～4．0（2．47±1．06）cm；肠系膜逆向转移与Dukes分期（P〈0．01）、肠旁淋巴结转移（P〈0．01）和组织分化程度（P〈0．05）相关。11例（18．3％）患者为肠壁内逆向浸润，转移距离0．5～4．0（1．64±1．16）cm。肠壁内逆向浸润与组织分化程度相关（P〈0．05）。结论中低位直肠癌实施保肛手术时，宜切除4．0cm远端系膜和2．5cm肠管；肿瘤病理分期晚、有肠旁淋巴结转移和分化程度不良时，最好切除5cm远端系膜和肠管。