低位直肠腺癌保肛手术的临床病理学分析

目的 探讨低位直肠腺癌全直肠切除结肠肛门吻合术后远端肠壁内肿瘤扩散的病理改变。方法 将55例术后患者的标本进行组织学分析。结果 局部复发的因素是:①切缘肿瘤残留;②肿瘤浸润直肠的深度;③淋巴结转移有关。结论直肠肿瘤远侧端切除的长度与局部复发密切相关。     

Laparoscopic coloanal anastomosis for low rectal cancer.

OBJECTIVES: Low anterior resection with hand-sutured coloanal anastomosis for low rectal cancer is technically feasible, and it does not compromise oncologic results. We describe herein the effectiveness of the operation in treating low rectal cancer by a laparoscopic approach followed by intraanal canal dissection. METHODS: From February 1999 to October 1999, we used a laparoscopic procedure to divide the inferior mesenteric vessels and to dissect downward into the pelvic cavity as low as possible. A purse-string suture 1-cm distal to the lower margin of the tumor was secured and transection of the rectum was performed circumferentially via the anal canal near the dentate line. The specimen was removed by the pull-through method and coloanal anastomosis was completed with hand suture. A protective loop ileostomy was fashioned. RESULTS: We operated on 8 patients (4 males) with low tumor localization (average 4-cm above the dentate line). The age ranged from 45 to 83 years, with a median age of 64. The average operation time was 210 minutes (150 to 360 minutes), and the average blood loss was 250 cc (minimal to 750 cc). No operative mortalities occurred, but 2 patients had minor anastomotic slough complications. The average hospital stay was 13 days (7 to 26 days). The postoperative pathologic stage was T2N0M0 in 4 patients, T3N0M0 in 2 patients, T2N1M0 in 1 patient, and T3N2M0 in 1 patient. No local recurrence or distant metastasis occurred during the median 14 months (12 to 20 months) of follow-up. CONCLUSION: Laparoscopic coloanal anastomosis combined with intraanal canal dissection is safe and technically feasible. The oncologic results seem not to be compromised, but need further evaluation.     

结肠J-型贮袋术在中低位直肠癌前切除术中的应用

目的评价结肠J 型贮袋术在中低位直肠癌前切除术中的临床应用价值。方法对1998年 1月至 2 0 0 2年 7月行根治性直肠前切除术治疗的 12 0例中低位直肠癌分为贮袋组 2 2例 ,结肠直肠直接吻合组 98例 ,比较两组的手术情况和术后排便功能。结果中位随访时间为 18个月。两组手术时间、住院天数、术后并发症、复发率和生存率均无显著性差异 (P >0 0 5 )。贮袋组肿瘤下缘距离齿状线距离为 (3 6± 1 5 )cm ,与直接吻合组 (5 2± 1 9)cm相比 ,差异有显著性意义 (P =0 0 0 0 )。术后 3个月和 1年时每日大便次数贮袋组较直接吻合组显著减少 (P <0 0 5 ) ,排便急迫感改善明显 (P <0 0 5 )。术后 2年时两组间上述指标已无显著性差异 (P >0 0 5 )。结论对于低位直肠癌行直肠前切除术时选择结肠J 型贮袋术可以明显改善术后近期的排便功能。     

结肠J型贮袋在低位直肠癌吻合术32例中的应用

目的探讨结肠J型贮袋在低位直肠癌手术中的应用。方法对我科2001年~2004年实施的直肠癌结肠J型贮袋肛管(直肠)吻合术32例的临床资料进行回顾性分析。结果全组无术中意外损伤及大出血病例。无死亡病例。发生吻合口狭窄1例。无吻合口漏及便秘。病人术后1年内排便状况满意。结论低位直肠癌行结肠J型贮袋肛管(直肠)吻合术具有操作方便、易于观察、容易推广等特点,有明显改善排便功能的作用,可显著提高病人术后的生活质量。     

Extended low anterior resection with stapled colorectal or coloanal anastomosis

The use of extended low anterior resection with the aid of the circular stapler for carcinomas of the middle third or upper part of the lower third of the rectum is discussed and salient technical points are emphasized. A collective survey of the results of the operation for such growths has led to the following conclusions: The immediate mortality and morbidity are not excessive. In most cases, even with anastomoses as low as 3.5-4.5 cm from the anal verge, anorectal function eventually reaches a satisfactory state, though there may be quite troublesome diarrhoea and possibly some incontinence during the initial 3-6 months after operation. Adequate data regarding 5-year survival are still lacking, but the high incidence of local recurrence in some reports is perplexing and disappointing and demands continued close attention.     

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.     

Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases

Aim

The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two‐centre study was to determine the clinical success and morbidity after redo CAA.

Method

This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short‐ and long‐term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow‐up.

Results

A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8–27]. The median duration of follow‐up was 27 months (IQR 17–36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2–4) per patient. At the end of follow‐up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004–0.122).

Conclusion

Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.     

中低位直肠癌经腹肛门切除套入式肠直肠黏膜吻合保肛术169例临床研究

目的探讨套入式结肠直肠黏膜吻合术治疗中低位直肠癌保留肛门括约肌功能的安全性和可行性。方法对中低位直肠癌经腹肛门根治性切除行套入式结肠直肠黏膜吻合术治疗的169例临床资料进行分析。169例中男107例,女62例。年龄21～99岁,平均为54.2岁。肿瘤下缘距齿状线5～9cm。病理诊断直肠腺癌163例,其中高分化者70例,中分化者81例,低分化者6例,黏液腺癌6例。腺瘤癌变6例。Dukes分期:A期61例,B期101例,C期7例。结果术后发生吻合口瘘5例(2.9%),狭窄3例(1.7%),术后早期排便次数可达6～12次/d,术后12～18周时排便功能基本恢复正常。169例术后随访率为91%,中位随访时间5.8年。局部复发率为5.8%,肝转移率为13.7%。术后总体5年生存率为66.9%,中位生存时间69(6～132)个月。结论套入式结肠直肠黏膜吻合保肛术式能达到直肠癌根治性切除,且可保留肛门正常的排便控制功能。     

内括约肌切除术用于超低位直肠癌研究进展

近年来,在保证根治性的前提下,保留肛门功能和改善患者的术后生活质量成为低位直肠癌治疗的重要目标。对于距离齿状线小于2cm或距肛缘5cm内的超低位直肠癌,传统的腹会阴联合切除术使患者承受永久性造口的痛苦,而内括约肌切除术（ISR）解决了部分超低位直肠癌患者,因切除肛门及永久性造口而导致生活质量较差的问题。本文将对ISR的研究现状、适应症、手术进展及预后等结合现有文献作一综述。     

Rectum resection with colonic J reservoir and coloanal anastomosis for rectal cancer

A low anterior resection of the rectum followed by a colo-rectal or a straight colo-anal anastomosis often leads to poor functional results (increased frequency and urgency of defecation) due to the loss of the reservoir function of the rectum. In order to improve the functional results the authors performed in 7 patients colo-anal anastomosis with a J shaped colonic pouch. In all the cases a temporary diverting loop ileostomy was performed. This ileostomy was closed 4-5 weeks after the first operation. There was no operative mortality. After stoma closure, the functional results were improved during the first week. A colo-anal anastomosis with a colonic reservoir appears to be an optimal solution comparing with a very low colorectal or a straight colon-anal anastomosis.     

Proctectomy and coloanal anastomosis for rectal cancer.

Fueled by a greater understanding of pelvic physiology along with an improved comprehension of rectal cancer spread, we are now able to offer most patients restoration of intestinal continuity following oncologic proctectomy. Coloanal or ultralow colorectal anastomosis can be performed in most patients with midrectal cancers, provided that anal sphincter function is not impaired preoperatively. Functional results may be improved by construction of a colonic pouch with pouch-anal anastomosis. Temporary fecal diversion, usually with a diverting loop ileostomy, may be prudent, especially in patients undergoing neoadjuvant chemoradiation.     

Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer

Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients’ short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case–control cohort studies with longer follow-up periods are required.     

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma

BACKGROUND: The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours. METHODS: The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis. RESULTS: Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence. CONCLUSION: Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.     

腹腔镜直肠前切除术的双吻合技巧

直肠双吻合技术（DST）给直肠癌切除手术带来了革命性的改变．其克服了因盆腔手术空间狭小而导致的手工肠吻合操作困难等缺点．缩短了手术时间,提高了保且T率．并降低了吻合口瘘等风险。本文结合自身开展腹腔镜结直肠切除手术10年的临床经验．从直肠的吻合方式到吻合操作技巧．阐述了腹腔镜下直肠双吻合技术的操作要点。