Radiological findings do not support lateral residual tumour as a major cause of local recurrence of rectal cancer

BACKGROUND: The aim of this study was to determine the sites of local recurrence following radical (R0) total mesorectal excision (TME) for rectal cancer in an effort to elucidate the reasons for recurrence. METHODS: Thirty-seven patients with recurrence following curative resection for rectal cancer were identified from a population of 880 patients operated on by surgeons trained in the TME procedure. Two radiologists independently examined 33 available computed tomograms and magnetic resonance images taken when the recurrence was detected. RESULTS: Twenty-nine of the 33 recurrences were found in the lower two-thirds of the pelvis. Two recurrent tumours appeared to originate from lateral pelvic lymph nodes. Evidence of residual mesorectal fat was identified in 15 patients. Fourteen of the recurrent tumours originated from primary tumours in the upper rectum; all of these tumours recurred at the anastomosis and 12 of the 14 patients had evidence of residual mesorectal fat. CONCLUSION: Lateral pelvic lymph node metastases are not a major cause of local recurrence after TME. Partial mesorectal excision may be associated with an increased risk of local recurrence from tumours in the upper rectum.     

The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma

OBJECTIVE: To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery. SUMMARY BACKGROUND DATA: Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years. METHODS: One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control. RESULTS: Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P < 0.001). Overall survival at 5 years was 64.2% and 63.5%, respectively (P = 0.902). Subgroup analyses showed significant effect of radiotherapy in reducing local recurrence risk for patients with nodal involvement, for patients with lesions between 5 and 10 cm from the anal verge, and for patients with uninvolved circumferential resection margins. CONCLUSIONS: With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.     

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.     

Local recurrence following surgical treatment for carcinoma of the lower rectum

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).     

Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy

BACKGROUND: Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging. METHODS: A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum. RESULTS: The perioperative mortality rate was 0.9 per cent and anastomotic dehiscence occurred in 2.8 per cent. Local recurrence developed in 4 per cent of patients in the 'curative' group and in seven of 15 of those assigned to the palliative group before operation (P < 0.01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P < 0.001). CONCLUSION: Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.     

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

Experience of surgery for rectal cancer with total mesorectal excision in a general surgical practice

BACKGROUND: Results from specialist centres have shown that total mesorectal excision (TME) produces excellent control of local disease in patients with carcinoma of the rectum. METHODS: The results of TME were reviewed in a surgical practice in which patients with rectal cancer comprised 1 per cent of the total caseload and mean case numbers were less than 15 each year. RESULTS: Eighty-two consecutive patients underwent rectal excision with TME over a 72-month period (68 anterior resection, eight abdominoperineal excision and six Hartmann's procedure). Sixty-nine operations were deemed 'curative' at the time of surgery. Anastomotic leak occurred in two (3 per cent) of 68 patients, both of whom recovered without additional surgery. There were two local recurrences (3 per cent) among 69 patients who underwent 'curative' surgery. At a median follow-up of 190 weeks, the survival rate for Dukes' stage A, B, C and 'D' was 100, 83, 68 and 18 per cent respectively. CONCLUSION: Outcome as measured by perioperative morbidity and local disease control achieved in a surgical practice with a broad case mix and relatively low annual case volume was comparable to that from larger centres. Appropriate surgical training and attention to technical detail may be as important as case volume in determining outcome after surgery for rectal cancer.     

Current problems of the surgical treatment of rectal cancer: analysis of the literature and personal experience

The surgical procedure is a crucial factor in preventing local recurrence in rectal cancer, and total mesorectal excision (TME) particularly is widely accepted as being associated with a decreased local recurrence rate. In this study, concerning 187 patients with rectal cancer, we compare conventional surgery, performed in 140 patients from 1979 to 1993, with a standardised TME procedure in 47 patients over the period from 1994 to 1998. The first group not treated by TME were operated on for 56 (40%) tumours of the upper rectum and 84 (60%) of the lower rectum; 35 (25%) were Dukes' A, 77 Dukes' B and 28 (20%) Dukes' C. 42 abdominoperineal amputations (30%) and 98 anterior resections (70%) were performed. The second group in which TME was performed comprised 17 (36%) tumours of the upper rectum and 30 (64%) of the lower rectum, 8 (17%) in stage I AJCC (Dukes' A), 16 (34%) in II (B) and 23 (49%) in III (C). 9 abdominoperineal amputations (19%) and 38 anterior resections (81%) were performed, 8 (21%) with an ultra-low anastomosis. In the first group of patients we observed 28 local recurrences (20%) and a 5-year disease-free survival in 50% of cases. In the second group we achieved a decreased rate of local recurrence (10.6%) which is about half that observed after conventional surgery, but there was no significant difference in survival. These data confirm the effectiveness of TME in reducing local recurrence rate, according to the literature; in future this procedure can get to reconsider the role of adjuvant therapy in the management of rectal cancer.     

T3N0 rectal cancer: Results following sharp mesorectal excision and no adjuvant therapy

Adjuvant chemoradiation therapy following resection of T3N0 rectal cancer is recommended in order to reduce the incidence of local recurrence and improve survival. However, recent experience with rectal cancer resection utilizing sharp dissection and total mesorectal excision has resulted in a reduction in local recurrence rates to as low as 5% without adjuvant treatment. The purpose of this study was to determine if rectal cancer resection utilizing sharp mesorectal excision alone is adequate treatment for local control of T3N0 rectal cancer. Between July 1986 and December 1993, 95 patients with T3N0M0 rectal cancer underwent resection with sharp mesorectal excision and did not receive any adjuvant therapy. Various prognostic factors were analyzed for their association with local recurrence and survival. Seventy-nine patients had a low anterior resection, 10 of whom had a coloanal anastomosis, and 16 had an abdominoperineal resection. The median follow-up was 53.3 months. Six patients had local recurrence, 12 had distant recurrence, and three had local and distant recurrences. The overall local recurrence rate was 9% crude and 12% 5-year actuarial. The overall crude recurrence rate was 22%. The 5-year disease-specific survival rate was 86.6% with an overall survival of 75%. Postoperative complications occurred in 18 patients (19%). Five patients (6%) had a documented anastomotic leak. Perioperative mortality was 3%. No technical factors, including type of resection (low anterior vs. abdominoperineal), location of tumor, or extent of resection margin, were significant for determining local recurrence. The only histopathologic marker significant for determining local recurrence was lymphatic invasion (P <0.04). Sharp mesorectal excision with low anterior resection or abdominoperineal resection for T3N0M0 rectal cancer results in a local recurrence rate of less than 10% without the use of adjuvant therapy. Therefore, in select patients with T3N0M0 rectal cancer, the standard use of adjuvant therapy for local control may not be justified. Presented at the Thirty-Ninth Annual Meeting of The Society of Surgery for the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

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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。     

Anterior Resection for Rectal Cancer with Mesorectal Excision: Institutional Review

This study aims to compare the operative results and oncological outcomes of patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer. Anterior resection has become the preferred treatment option for rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. Resection of primary rectal and rectosigmoid cancer was performed in 298 patients from January 2003 to November 2010. These 298 patients (163 men and 135 women; median age, 67 years) underwent anterior resection. The curative resection was performed in 269 patients (90.3 %). TME was performed in 202 patients (67.8 %). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8 % and 32.6 %, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1 % and 1.3 % of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the malegender, the absence of stoma, and increased blood loss. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

支撑吻合管在低位直肠癌保肛术中的应用研究

目的 探讨支撑吻合管在低位直肠癌全直肠系膜切除(TME)基础上行结肠一直肠/肛管吻合的应用.方法 155例低位直肠癌TME术后,应用支撑吻合管经肛门行结肠一直肠/肛管吻合进行消化道重建.结果 本组155例无手术死亡及术中严重并发症,术中病理检查无残端癌;术后肛周盆腔感染2例(1.29%),吻合口漏3例(1.94%),吻合13出血5例(3.23%),吻合口狭窄4例(2.58%).寿命表法计算5年生存率和局部复发率分别为78.06%(121/155)及6.45%(10/155).手术后3个月排便功能的优良率为82.58%.结论 低位直肠癌TME术后应用支撑吻合管行结肠-直肠/肛管吻合是安全可行的.     

全直肠系膜切除术的应用

传统的直肠癌根治术后局部复发是影响术后5年生存率的重要因素之一。近年来解剖学研究证明，直肠是具有系膜的脏器，直肠癌可通过多种方式在系膜中播散，这些微转移灶的残留是导致术后局部复发的重要因素。1982年，Heald首次提出了针对中下段直肠癌的全直肠系膜切除术，即直视下在盆筋膜脏层与壁层间锐性分离，完整切除直肠及直肠系膜，同时注意保护自主神经。经过20年的应用，其在降低直肠癌术后复发方面的优势已得到认可，术后吻合口漏、排尿功能及性功能障碍等并发症发生率低，目前已得到广泛应用。     

低位直肠癌保肛手术60例治疗体会

目的探讨直肠全系膜切除联合双器械吻合在低位直肠癌保肛术中应用效果及其实用性和安全性。方法回顾性分析2010年1月至2013年12月我院60例用全直肠系膜切除加双吻合器行保肛根治手术的临床资料。结果 60例均保肛成功,无手术死亡病例(其中32例行预防性造瘘术)。术后共发生并发症8例(13.3%),吻合口漏2例(3.3%),均为未行预防性造瘘术患者。所有并发症经保守治疗后均治愈。术后一年内局部复发3例(5%)。结论全直肠系膜切除联合双器械吻合行低位直肠癌保肛术不仅提高了保肛率且降低了局部复发率,是一种安全有效的手术方式。     

Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit

Despite improved surgical treatment strategies for rectal cancer, 5-15% of all patients will develop local recurrences. After conservative surgery, circumferential resection margin (CRM) involvement is a strong predictor of local recurrence. The consequences of a positive CRM after total mesorectal excision (TME) have not been evaluated in a large patient population. In a nationwide randomized multicenter trial comparing preoperative radiotherapy and TME versus TME alone for rectal cancer, CRM involvement was determined according to trial protocol. In this study we analyze the criteria by which the CRM needs to be assessed to predict local recurrence for nonirradiated patients (n = 656, median follow-up 35 months). CRM involvement is a strong predictor for local recurrence after TME. A margin of < or = 2 mm is associated with a local recurrence risk of 16% compared with 5.8% in patients with more mesorectal tissue surrounding the tumor (p <0.0001). In addition, patients with margins < or = 1 mm have an increased risk for distant metastases (37.6% vs 12.7%, p <0.0001) as well as shorter survival. The prognostic value of CRM involvement is independent of TNM classification. Accurate determination of CRM in rectal cancer is important for determination of local recurrence risk, which might subsequently be prevented by additional therapy. In contrast to earlier studies, we show that an increased risk is present when margins are < or = 2 mm.     

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.     

Prognostic implications of circumferential location of distal rectal cancer

Aim This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. Method All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. Results Two hundred and five patients with distal rectal cancer were operated on for a uT2‐T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty‐three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. Conclusion Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.     

两种TME术式治疗超低位直肠癌疗效及安全性对比

目的研究两种直肠全系膜切除术(TME)对超低位直肠癌患者的治疗疗效和安全性的影响。 方法选择2013年6月至2016年1月治疗的超低位直肠癌患者84例。根据患者治疗方案分为腹腔镜TME组和经肛直肠全系膜切除术(TaTME)组,各42例。两组患者治疗后随访1年,应用SPSS20.0进行数据分析,围手术期指标、PAC－QOL评分比较采用计量资料用( ±s)表示,组间比较采用独立t检验;并发症发生率、死亡率、复发率、转移率计数资料用%表示,采用χ²检验,以P<0.05为差异有统计学意义。 结果两组患者在术后镇痛时间、留置尿管时间、淋巴结清扫数目等方面差异无统计学意义(P>0.05),TaTME组在手术时间大于腹腔镜TME组,术中出血量、住院时间、肛门排气时间低于腹腔镜TME组,差异有统计学意义(P<0.05)。两组患者在并发症发生率及死亡率比较差异无意义(P>0.05); TaTME组患者PAC－QOL评分为(36.8±3.0)分,低于腹腔镜TME组患者的(40.4±3.7)分,差异有统计学意义(P<0.05)。腹腔镜TME组患者术后1年生存率为90.5%,低于TaTME组患者的生存率95.2%,差异无统计学意义(P>0.05),两组患者在局部复发、远处转移差异无统计学意义(P>0.05)。 结论经肛直肠全系膜切除术与腹腔镜直肠全系膜切除术相比,在改善患者生存质量、缩短患者住院时间、术中出血量上具有优势,并发症发生、复发、转移、死亡情况无明显差异。     

腹腔镜直肠全系膜切除治疗中低位直肠癌的前瞻性非随机对照研究

目的：通过与开腹直肠全系膜切除的前瞻性非随机对照研究，评价腹腔镜TME治疗中低位直肠癌的临床疗效。方法：将2001年9月至2005年3月我院外科收治的中低位直肠癌病人，按纳入与剔除标准非随机分为腹腔镜组和开腹组，进行对照分析。结果：人组病例共251例，腹腔镜组和开腹组分别为110例和141例。腹腔镜组的中转开腹率为1．82％。腹腔镜组的平均手术时间、手术切除范围、术后并发症的发生率以及住院天数和开腹组均无显著性差异，而术中出血量、术后肠道功能的恢复要优于开腹组。中位随访期为28（11-57）个月，随访期内两组病例的局部复发率、远处转移率及无瘤生存率均无显著性差异。结论：腹腔镜TME治疗中低位直肠癌是安全、可行的．可以获得和传统开腹手术相同的中长期疗效，且在术后恢复上明显优于传统开腹手术。     

Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences

HYPOTHESIS: Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial. INTERVENTIONS: Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor. RESULTS: There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively. CONCLUSIONS: Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.