低位前切除术与经腹会阴联合切除术治疗中低位直肠癌疗效比较

直肠癌外科治疗的主要肠道重建方式为低位前切除术（EAR）和腹会阴联合切除术（APR）,全直肠系膜切除术（TME）是中低位直肠癌治疗的标准手术。为探讨在TME前提下肠道重建方式对直肠癌预后的影响,本文回顾分析了中低位直肠癌患者用LAR、APR术式治疗的相关临床资料。现报告如下。     

腹腔镜腹会阴联合切除术治疗低位直肠癌

目的探讨按照全直肠系膜切除(TME)原则，腹腔镜腹会阴联合切除术(Miles)治疗低位直肠癌的可行性。方法按照TME治疗原则，在腹腔镜辅助下，对14例低位直肠癌患者实施TME腹会阴联合切除术。结果14例患者均手术顺利。手术时间120～240分钟，平均180分钟．术中出血30～180ml，平均50ml；术后1～2天恢复胃肠功能并下床活动，住院5～14天，平均为6天。术后6例应用镇痛剂，无术中及术后并发症发生。结论腹腔镜腹会阴联合切除术治疗低位直肠癌，能完全达到TME要求，且创伤小、术后疼痛轻、恢复快。     

直肠癌ELAPE手术会阴操作的神经保护

肛提肌外腹会阴联合切除术（ELAPE）已经成为治疗低位进展期直肠癌的重要术式。在降低局部复发率的同时,ELAPE手术由于切除更多肿瘤周围组织,有可能增加泌尿生殖神经损伤的发生率。笔者认为,在ELAPE手术的会阴操作过程中,对盆丛、阴部神经和神经血管束的保护是可行的,有助于保留术后的泌尿功能和性功能。在术前MRI分期的指导下,结合肿瘤的垂直浸润深度和环周生长情况,提出的个体化ELAPE技术,有助于在保证肿瘤根治性前提下,进一步减少手术创伤和保护会阴部神经。     

直肠癌全直肠系膜切除术中盆腔植物神经的易损区域及保护

全直肠系膜切除术（TME）是目前国际公认的直肠癌标准术式,随着TME手术的推广和认识,盆腔植物神经保护（PANP）的理念逐渐受到重视。笔者认为,在开展直肠癌TME手术时,有六个区域容易发生盆腔植物神经损伤,需要识别和保护：肠系膜下动脉根部的肠系膜下丛、上腹下神经丛及腹下神经的近端、盆丛前丛的近端、盆丛后丛的主干、盆丛后丛的终末支及盆腔内脏神经。熟悉盆腔筋膜、植物神经解剖,开展以TME手术层面为主导,盆腔植物神经为引导的精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。     

ELAPE降低直肠癌术后环周切缘阳性率

近期,首都医科大学附属北京朝阳医院普通外科王振军就"不能保肛的直肠癌手术治疗进展及评价"发表了自己的观点和看法。该论文发表在2012年第9期《中国实用外科杂志》。大规模的临床研究显示,传统直肠癌腹会阴联合切除术[APE,或称APR]环周切缘(CRM)阳性率较高和手术中穿孔率较高是其术后局部复发率高和病人存活率低的重要原因。因此,其作为不能保留肛门的低位直肠癌的手术治疗金标准逐渐受到挑战。王教授认为,直肠癌柱状腹会阴联合切除(CAPE)即直肠癌肛提肌外腹会阴联合切除(ELAPE)手术能够显著降低直肠癌手术后环周切缘阳性率及局部复发率,     

改良的腹腔镜辅助下ELAPE手术临床效果观察

目的比较一种改良的腹腔镜辅助下的肛提肌外肌腹会阴联合切除术（ELAPE）和常规腹腔镜辅助的腹会阴联合切除术（APR）两种手术方法治疗需切除肛门的低位直肠癌的临床效果差异。 方法选取2015年12月至2021年6月68位低位直肠癌患者的病例资料，随机分为APR组和改良ELAPE组，每组34例。APR组患者给予常规APR术，改良ELAPE组患者给予改良的ELAPE术，比较分析两组患者治疗效果。临床参数包括手术时间、术中出血量、淋巴结阳性率、术中穿孔、环周切缘阳性率、排气时间、排便时间、进食时间、腹腔引流量、会阴切口拆线时间、盆腔引流管拔除时间、住院时间；术后并发症包括术后盆腔出血、肠梗阻、会阴切口感染、会阴切口周围血肿以及其他少见并发症，随访结果项目包括局部复发率、远处转移率和死亡率。 结果改良ELAPE组手术时间长于APR组，差异具有统计学意义（t=5.490，P=0.000）；术中出血量（t=-0.775，P=0.441）、淋巴结阳性率（χ²=0.553，P=0.457）、环周切缘阳性率（χ²=0.863，P=0.353）、穿孔率差异无统计学意义；改良ELAPE组排气时间（t=-4.403，P=0.000）、排便时间（t=-2.934，P=0.005）、会阴切口拆线时间（t=-2.490，P=0.015）均早于APR组，腹腔引流量少于APR组（t=3.524，P=0.001），差异具有统计学意义；两组进食流质食物时间（t=0.593，P=0.555）、盆腔引流管拔除时间（t=1.581，P=0.122）、住院时间（t=-1.465，P=0.148）无明显差别，差异均无统计学意义；两组患者术后盆腔出血（t=4.24，P=0.94）、肠梗阻（t=5.55，P=0.58）、会阴切口感染（t=7.74，P=0.54）、会阴切口周围血肿（t=8.55，P=0.14）以及其他少见并发症（t=3.11，P=0.41）比较差异均无统计学意义；术后随访6~60个月，改良ELAPE组局部复发率（χ²=5.639，P=0.018）、远处转移率（χ²=4.178，P=0.041）均低于APR组，差异具有统计学意义，两组死亡率差异无统计学意义（χ²=2.601，P=0.107）。 结论改良的腹腔镜辅助的ELAPE手术较传统腹腔镜辅助的APR手术来说是一个安全有效的手术方式，能有效减少局部复发和远处转移，加快患者术后康复，值得临床推广。     

直肠癌柱状经腹会阴切除术

柱状经腹会阴切除术(肛提肌外腹会阴切除术)作为直肠癌的一种新术式,较常规经腹会阴切除术可以切除更多的癌周组织,减少术中穿孔,降低环周切缘阳性率,从而达到改善预后的目的。作者在国内率先开展本术式,并创新性使用生物材料进行盆底重建,不但简化了手术,而且减少手术并发症发生的机会,使本术式更加安全可靠。笔者详细介绍了柱状腹会阴切除术操作要点和注意事项,阐述了本术式的优势和发展前景,柱状经腹会阴切除术有望成为无法保肛直肠癌患者的标准术式。     

直肠癌的外科治疗

对于直肠癌,目前仍采用以手术切除为主的综合疗法。由于直肠癌可向上、侧和下方的淋巴结转移,故腹会阴联合切除术一直被认为是治疗直肠癌唯一的标准术式。但此术式需做永久性人工肛门,术后患者的生存质量明显降低。近年来,随着人们对直肠解剖及组织病理学认识的不断加深及...     

直肠癌全直肠系膜切除术的若干问题探讨

83例直肠癌患者在根治术中行全直肠系膜切除术（TME）和盆腔自主神经保留术（PANP），观察其疗效并了解术后泌尿和生殖功能情况。术后随访5～38个月。术后肿瘤发生盆腔内局部复发3例，肝转移2例。其中1例行肝转移瘤手术切除，1例行肝动脉介入栓塞。认为直肠癌术中行TME能有效预防和降低直肠癌术后的局部复发率；如同时行PANP，可以改善患者术后的排尿功能与性功能，提高患者的术后生存质量。TME有术后的吻合口瘘发生率增高和直肠、肛门丧失储便功能之弊。     

腹腔镜下直肠癌根治术保留自主神经的解剖和技术要点

全直肠系膜切除术（TME）是目前国际公认的直肠癌标准术式,随着腹腔镜技术的推广和TME手术的普及,盆腔植物神经保护（PANP）的理念逐渐受到重视。本文根据作者经验和结合国内外文献,介绍保留PANP相关的新认识和技术进展。笔者认为,在开展直肠癌TME手术时,有六个部位容易发生盆腔植物神经损伤,需要识别和保护：肠系膜下动脉根部的肠系膜下丛,上腹下神经丛及腹下神经的近端,盆丛前丛的近端,盆丛后丛的主干,盆丛后丛的终末支,盆腔内脏神经以及血管神经束（NVB）。要完整保留PANP,需要熟悉盆腔筋膜解剖层次和神经走行在层次部位,在直肠固有筋膜和腹下神经输尿管前筋膜之间分离,可以完好地保留腹盆腔自主神经系统,以筋膜层膜为导向,进行筋膜之间分离,以神经为导向,实现精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。     

Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go

Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.     

Modern management of rectal cancer： A 2006 update

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with early (T1/T2 and NO), as well as locally advanced (T3/T4 and/or N1) rectal cancer. Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Information concerning the depth of tumor penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. Local excision is likely to be curative in most patients with a primary tumor which is limited to the submucosa (T1N0M0), without high-risk features and in the absence of metastatic disease. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Once the tumor invades the muscularis propria (T2), radical rectal resection in acceptable operative candidates is recommended. In patients with transmural and/or node positive disease (T3/T4 and/or N1) with no distant metastases, preoperative chemoradiation followed by radical resection according to the principles of TME has become widely accepted. During the planning and conduct of a radical operation for a locally advanced rectal cancer, a number of surgical management issues are considered, including: (1) total mesorectal excision (TME); (2) autonomic nerve preservation (ANP); (3) circumferential resection margin (CRM); (4) distal resection margin; (5) sphincter preservation and options for restoration of bowel continuity; (6) laparoscopic approaches; and (7) postoperative quality of life.     

腹腔镜直肠全系膜切除术治疗中、低位直肠癌的临床研究

目的探讨腹腔镜直肠全系膜切除术(TME)治疗中、低位直肠癌的临床疗效。方法选择中、低位直肠癌患者96例,随机分为观察组与对照组各48例,观察组在腹腔镜下行TEM术,对照组则行开腹TME术,对比两组患者临床疗效。结果观察组术后肛门排气时间、住院时间及手术切口长度、术中出血量、术后VAS疼痛评分、围术期并发症发生率、术后性功能及泌尿功能障碍发生率等方面均显著优于对照组(P0.05),而手术时间、保肛率、肿瘤转移及复发率差异均无统计学意义(P0.05)。结论腹腔镜直肠全系膜切除术治疗中、低位直肠癌疗效确切且安全可靠,可在达到传统开腹手术疗效基础上降低并发症发生率。     

经腹腔镜全直肠系膜切除术治疗低位直肠癌

目的探讨经腹腔镜全直肠系膜切除术(TME)治疗低位直肠癌的可行性。方法经腹腔镜对14例低位直肠癌患者实施TME。结果14例患者手术顺利。手术时间120～240分钟，平均180分钟；术中出血30～180ml，平均50ml；术后1～2天恢复胃肠功能并下床活动；住院5～14天，平均6天。术后6例应用镇痛剂，无死亡者，无并发症发生。结论经腹腔镜TME治疗低位直肠癌安全可行，且创伤小、术后疼痛轻、恢复快。     

Recent progress in diagnosis and treatment of rectal cancer]

Rectal cancer is an emerging health issue in Korea because its incidence is rapidly increasing with changes in life styles and diets. The optimal treatment of rectal cancer is based on multimodality. Among them, surgical treatment is the corner-stone. In the past, local recurrence rate has been reported as high as 30-40%, but the concept of total mesorectal excision (TME) lowered the rate of local recurrence down to less than 10%. TME focuses on sharp pelvic dissection and complete removal of rectal cancer with surrounding mesorectum inside the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of mid and low rectal cancer. With the introduction of pelvic magnetic resonance imaging (MRI) for preoperative staging of rectal cancer, risk factors for local recurrence can be predicted before surgery to distinguish patients who are in high risk for recurrence that requires preoperative neoadjuvant chemoradiation therapy. Early rectal cancer was assessed by transrectal ultrasonography (TRUS) and endorectal MRI with coil. Transanal local excision can be applied with anal sphincter preservation safely. Neoadjuvant chemoradiation therapy was performed in patients with locally advanced rectal cancer, and this resulted in tumor size reductions and histopathologic downstaging effect. As far as the quality of life is concerned, sexual and voiding function are much improved by techniques preserving nerve. Many experts have dealt with challenging practical problems of managing rectal cancer from diagnosis to quality of life. This issue contains recent progresses in the diagnosis and treatment of rectal cancer which will serve as a comprehensive reference for those who manage rectal cancer in their medical practice.     

Transanal total mesorectal excision:Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision(Ta TME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impactson postoperative outcomes and to discuss the future of Ta TME. METHODS: MEDLINE(Pub Med), EMBASE, and The Cochrane Library were systematically searched through the 1st of March 2015 using a predefined search strategy. RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced. CONCLUSION: Ta TME was also associated with better TME specimens and a longer distal resection margin. Ta TME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Longterm follow-up regarding anal function and oncological outcomes should be performed in the future.     

闭合式切除术在直肠癌腹腔镜全系膜切除根治术中的应用效果研究

目的评价闭合式切除术（CE）在直肠癌腹腔镜全系膜切除（TME）根治术中的临床应用效果。 方法以潍坊医学院附属寿光市人民医院2011年2月至2014年6月收治的54例原发性直肠癌患者为研究对象,30例为实验组进行CE＋ TME腹腔镜根治术,24例为对照组进行TME腹腔镜根治术。术中均联合动脉灌注化疗。比较两组患者手术时间、术中出血量、淋巴结清扫数目、环周切缘（CRM）阳性比例、术后恢复饮食时间、肛门排气时间、尿管留置时间、住院时间、术后并发症发生比例及术后1年局部复发比例等指标。 结果术中出血量（t=11.775,P<0.001)显著低于TME组,CE＋TME组手术时间（t=2.207,P=0.035）、术后肛门排气时间（t=2.059,P=0.045）、导尿管置留时间（t=2.083,P=0.042）、术后1年内局部复发率（χ²=3.97,P=0.047）显著低于TME组;淋巴结清扫数目显著高于TME组（t=9.613,P<0.001）。 结论CE可显著降低TME术后局部复发率,具有一定的临床应用价值。