经肛门内镜手术治疗结直肠肿瘤可行性研究

目的 评估经肛门内镜显微手术治疗结直肠肿瘤的临床应用可行性,探讨手术中操作困难的处理策略。方法 回顾性分析上海交通大学医学院附属瑞金医院外科2006年9月至2008年6月期间36例经肛门内镜显微手术病人的临床资料。结果 36例病人均成功完成经肛门内镜显微手术,无中转开腹病例。平均手术时间为71（20~200）min。术后病理：腺瘤22例,腺癌8例,类癌5例,炎性肿块1例。术后平均住院时间为4.7（3~9）d。并发症方面：1例术后有肛门内出血,1例术后有暂时性排便失禁感。1例术后5个月发现直肠肿瘤复发。结论 经肛门内镜显微手术是一种对直肠中、上段及乙状结肠下段肿瘤有效、安全、可行性强的微创切除手术。严格选择病例,注意临床处理策略,经肛门内镜显微手术可取得和传统手术相仿甚至更优的结果,且住院时间短,并发症少,有良好的临床应用前景。     

经肛门内镜显微手术切除直肠肿瘤的近况

经肛门内镜显微手术(transanal endoscopic microsurgery, TEM)是一种对直肠中、上段,乙状结肠下段肿瘤有效、安全、可行性强的外科切除技术,由Buess设计发明,并于1983年首次报道.TEM符合肿瘤学原则,对严格选择的病例可取得和传统手术相仿甚至更好的效果,且住院时间短,并发症少.本文对TEM的特殊器械及手术方法、适应证、临床应用结果、并发症等进行综述,并对笔者的初步经验进行概括.     

经肛门内镜显微手术治疗直肠肿瘤12例

为探讨经肛门内镜显微手术（TEM）治疗直肠肿瘤的手术效果,回顾分析12例行TEM的直肠肿瘤患者资料。结果显示,12例直肠肿瘤均获完整切除,平均手术时间90min（60-200min）。无术后出血、吻合口感染、吻合口漏。2例术后肛门轻度疼痛,2例暂时性不完全性肛门失禁。术后病理示9例腺瘤（管状腺瘤3例,绒毛状腺瘤4例,管状绒毛状腺瘤2例,其中2例伴高级别上皮内瘤变）,1例肌层内有钙化灶,1例直肠黏膜炎性组织,1例低危间质瘤（直径〈1．0cm）。随访1～12个月,1例管状腺瘤患者于术后3个月局部复发。结果表明,TEM治疗良性直肠腺瘤和早期直肠癌安全、有效。     

经肛门内镜微创手术治疗直肠肿瘤

经肛门内镜微创手术（transanal endoscopic microsurgery,TEM）是一种经肛门切除肿瘤的微创保肛手术方法,集内镜、腹腔镜和显微手术三种技术特点于一身,在手术时间、出血量、术后镇痛、平均住院时间方面均显著优于经腹手术,较传统的局部切除术具有明显的优点。     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

探讨经肛门内镜显微手术(TEM)在治疗局限性直肠肿瘤中的应用效果.方法 总结分析2006年4月至2008年12月接受TEM的75例直肠肿瘤患者的临床资料,分析TEM在直肠肿瘤治疗中的应用效果.结果 患者病灶平均直径为(1.6±0.8)cm(0.5～5.0 cm).病灶距肛缘平均(7.6±2.8)cm(5～20 cm).病灶在直肠内的部位:前壁25例,后壁24例,左侧壁14例,右侧壁12例.手术方式包括:肠壁全层切除64例,黏膜下及肌层部分切除11例.平均手术时间(73.7±32.1)min(30～180 min),术中平均失血(9.8±7.7)ml(3～50 ml).术后病理检查:直肠腺瘤28例,直肠腺瘤癌变和直肠癌25例(其中Tis期14例,T1期5例,T2期6例),直肠类癌7例,炎性息肉等15例.所有标本切缘均为阴性.全组术后4例(5.3%)发生并发症,其中并发肛门出血2例,肺部和泌尿系感染各1例.术后平均住院(3.4±1.2)d(2～7 d).术后平均随访8.4个月(3～26个月),未发现疾病或肿瘤有复发转移.结论 TEM治疗直肠肿瘤具有手术损伤小,出血少、疗效好、恢复快等优点,是目前直肠肿瘤局部切除的较佳方法.     

经肛门内镜显微手术治疗直肠肿瘤(附7例报道)

目的探讨经肛门内镜显微手术(TEM)治疗直肠肿瘤的疗效。方法回顾性分析2009年1~12月期间我院行TEM治疗7例直肠腺瘤患者的临床资料。结果 7例直肠肿瘤均获完整切除,切缘均阴性。手术时间55~240 min,平均110 min;术中出血量5~100 ml,平均45 ml。术后病理诊断:直肠绒毛状腺瘤4例,绒毛管状腺瘤2例,直肠腺癌1例。手术并发症:术中直肠穿孔1例,肺部感染1例,尿潴留1例。7例随访6~13个月,平均8个月,肿瘤无复发。结论 TEM治疗直肠肿瘤安全、有效。     

经肛门内镜微创手术治疗直肠肿瘤研究进展

目的 总结目前经肛门内镜微创手术（transanal endoscopic microsurgery,TEM）在治疗直肠肿瘤的研究进展。方法 收集经肛门内镜治疗直肠肿瘤的文献并予以综述。结果 TEM是局部切除手术方式中的一种,为腹腔镜和内镜相结合的微创手术,TEM设备主要由特殊的直肠镜镜头和高压气腹机组成。对病变部位进行全层切除后,在内镜直视下对缺损部位进行缝合,从而避免了根治性手术带来的严重术后并发症。TEM适用于直肠腺瘤、直肠息肉等良性病变和无淋巴结转移的T1期直肠癌,对于更高级别的直肠癌的治疗仍存在一定的争议,新辅助放化疗联合TEM治疗直肠癌在积极的开展当中。结论 TEM对部分直肠肿瘤是一种安全有效的手术方式,具有围手术期并发症发生率低、术后恢复快和复发率低的特点。     

经肛门内镜显微手术治疗直肠神经内分泌肿瘤

目的探讨经肛门内镜显微手术(TEM)直肠全层切除治疗直肠神经内分泌肿瘤的效果。方法回顾性分析北京协和医院2006年12月至2015年12月间74例采用TEM治疗的直肠神经内分泌肿瘤患者。收集患者的一般资料、肿瘤特点、手术情况、术后病理及随访结果。结果其中50例患者行原发病灶切除,24例患者因结肠镜下切除后标本切缘不清或阳性行二次手术。肿瘤直径平均(1.02±0.43)cm,距离肛缘(7.9±1.7)cm。平均手术时间(58.7±12.1)min,平均术中出血量(13.1±5.0)ml。所有标本基底和侧切缘均阴性。平均随访3.6年,无肿瘤复发。结论 TEM可以作为直径较小的中上段直肠神经内分泌肿瘤手术治疗的首选。     

经肛门内镜显微手术在直肠肿瘤切除中的应用

目的 评估经肛门内镜显微手术（TEM）治疗直肠肿瘤的近期疗效,并对创面缝合方法进行探讨.方法 对经TEM治疗的19例直肠肿瘤的临床资料进行回顾性分析.结果 本组患者中直肠良性肿瘤13例,直肠类癌2例,T1期直肠癌1例,T2期直肠癌3例.手术时间为40~100（平均58.3） min,其中10例未予以创面缝合,6例采用连续缝合后银夹固定,3例采用强生自动打结线盒缝合.所有肿瘤均获完整切除,切缘阴性.术后1例患者少量出血,2例出现低热 未见切口并发症及肛门功能障碍.随访中除1例腺瘤恶变患者可疑复发外,余未见复发及其他异常.结论 TEM治疗直肠肿瘤的安全有效 为直肠肿瘤局部切除提供了一种新的选择.     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

Objective To investigate the therapeutic effect of transanal endoscopic microsurgery (TEM) for localized rectal neoplasms. Methods Seventy-five patients with localized rectal neoplasms were treated by using TEM between April 2006 and December 2008. The clinical data was summarized and analyzed retrospectively to report the therapeutic effect of TEM in these cases. Results The mean diameter of the rectal lesions was (1.6 ± 0.8) cm (range, 0.5-5.0 cm). The average distance of lesions from the anal verge was (7.6 ± 2.8) cm (range, 5-20 cm). Locations of the lesions at the rectal wall : 25 located at the anterior wall, 24 at the posterior wall, 14 at the left wall and 12 at the right walL Surgical procedures included the transmural excision (64 cases) and the submucosal excision with partial muscular layer excision (11 cases) was performed. The average operating time was (73.7±32.1) win (range, 30-180 min). The mean operative blood loss was (9. 8 ± 7.7) ml (range, 3-50 ml). The postoperative pathological examination identified 28 cases of rectal adenoma, 25 rectal adenocarcinoma or carcinomatous changes of adenoma (14 cases with phase Tis tumor, 5 cases T1 and 6 cases T2), 7 rectal carcinoid and 15 cases of inflammatory polyps or others. Surgical margins of all specimens were negative. Postoperative complications occurred in 4 cases (5.3%), included 2 cases of anal hemorrhage, 1 case of pulmonary infection and 1 urinary infection. The average postoperative hospital stay was (3.4 ± 1.2) d (range, 2-7 d). All the patients were followed-up for a mean period of 8.4 months (range, 3-26 months), no tumor recurrence or metastasis was observed. Conclusion Being a kind of minimally invasive surgery, TEM shows advantages of decreased blood loss, better therapeutic effect and faster recovery, and it is a better choice of procedure for local excision for rectal neoplasms.     

经肛手套通路联合结肠镜微创手术治疗直肠肿瘤

目的：探讨经肛手套通路联合结肠镜微创手术治疗直肠肿瘤的可行性及疗效。方法杭州市第三人民医院肛肠外科自2012年10月至2013年3月,选择经评估适合行局部切除的直肠肿瘤患者8例,使用经肛手套通路联合结肠镜微创手术治疗。经肛手套通路的建立：将手套袖口连同扩肛器缝合固定于肛周,再将手套5指经由透明肛门镜翻转出肛门,将超声刀、无损伤肠钳和肠镜镜头分别从3个指套伸入并结扎固定。结果8例患者均成功完成肿瘤切除手术,制作手套入路装置平均耗时12．5（10．0～15．0） min,平均手术时间55．6（30．0～110．0） min,平均住院时间为5．0（3．0～8．0） d,术后病理提示绒毛状腺瘤3例,管状腺瘤2瘤,管状绒毛状腺瘤2例,锯齿状腺瘤1例,其中2例伴低级别上皮内瘤变,1例高级别上皮内瘤变,所有肿瘤组织标本边缘及基底部均为阴性。术后2例患者少量便血,随访1～5（中位3．1）月,无肿瘤复发。结论采用经肛手套通路联合结肠镜微创手术治疗直肠早期肿瘤具有简单和安全的特点,具有一定的应用价值。     

腹腔镜联合经肛门内镜手术治疗重度功能性便秘

目的：探讨腹腔镜联合经肛门内镜结肠次全切除加改良Duhamel术治疗重度功能性便秘（SFC）的安全性及疗效。方法回顾性分析2010年5月至2012年10月间在上海交通大学医学院附属瑞金医院接受腹腔镜联合经肛门内镜结肠次全切除加改良Duhamel手术治疗的10例SFC患者的临床资料,采用胃肠生活质量评分和Wexner便秘评分来评价手术疗效。结果10例患者均成功完成腹腔镜联合经肛门内镜手术,无中转开腹病例。1例患者行末端回肠造口,术后无任何并发症。手术时间（256±58） min,术中出血量（178±67） ml,术后肠道功能恢复时间（40±11） h,术后住院天数（9．0±1．5） d。仅1例患者术后1周内出现粘连性肠梗阻,经保守治疗缓解。术后1年,患者胃肠生活质量评分和Wexner便秘评分均较术前显著改善[（112±10）比（75±12）分,P＝0．000;（5．2±1．8）比（20．8±2．2）分,P＝0．000],8例患者便秘症状明显改善,排粪次数1～3次／d;1例出现腹泻,排粪次数4～6次／d;1例患者仍有轻度便秘,2～3 d排粪1次。结论腹腔镜联合经肛门内镜结肠次全切除加改良Duhamel术为SFC提供了一种安全、有效的微创手术治疗方式。     

Outcomes for early rectal cancer managed with transanal endoscopic microsurgery

Background This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM). Methods The study reviewed 69 patients with T_is/T₁/T₂ rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 T_is, 23 T₁, and 21 T₂. The median follow-up period was 6.5 years (range 5–10.2 years). Results The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for T_is, 8.6% for T₁, and 9.5% for T₂. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for T_is, 100% for T₁, and 70% for T₂. The overall cancer-related mortality rate was 7.2%. Conclusions After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent T_is/T₁ cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T₂ rectal cancers appears inadequate. Presented in part at the Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Ft Lauderdale, FL, USA, 13–16 April 2005     

Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps

Methods: Between January 1986 and December 1995, 238 patients with benign rectal polyps under-went either transanal endoscopic microsurgery (n = 226) or transanal excision (n = 12) at the Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz. Results: Mean polyp size was 4.2 cm; 89.1% of polyps measured more than 2 cm in diameter. In 89.1% of cases, histological analysis revealed polyps containing tubulovillous or villous adenomas. Synchronous colonic polyps were detected in 12.5% of patients. Follow-up data are available on 222 patients (94%). At follow-up examination, 169 of the 193 surviving patients (87.6%) were recurrence free. Seven of 193 patients (3.6%) had developed neoplastic colonic polyps and, in 17 patients (8.8%), metachronous polyps were detected. Conclusions: Transanal endoscopic microsurgical polypectomy was furthermore demonstrated to be a low-risk procedure with a low recurrence rate for the complete resection of large rectal polyps. At a follow-up rate of 61.1%, the incidence of metachronous carcinoma ranged at 3.1%, which is markedly below the rate of 8–18% for tubulovillous or villous adenomas larger than 1 cm in diameter cited in the literature. Received: 24 October 1997 / Accepted: 13 July 1998     

经肛门内镜微创手术治疗32例直肠腺瘤

目的 评估经肛门内镜微创手术（TEM）治疗直肠腺瘤临床应用的安全性及疗效.方法 2006年9月至2010年2月共32例术前诊断为直肠腺瘤的患者接受TEM治疗,总结其治疗结果.结果 全组患者肿瘤直径0.6～10.0（2.31.2）cm.手术时间为20～180（平均70）min,术中平均出血量小于10 ml,无中转开腹手术.22例（68.8%）行创面缝合,其中全层切除14例;有2例上段直肠肿瘤行全层切除时切穿至腹膜腔,予腔内连续缝合修补破损,术后均未发生肠漏.R0切除31例（96.9%）.术后病理示单纯腺瘤12例;腺瘤伴低级别上皮内瘤变10例;腺瘤伴高级别上皮内瘤变5例;腺瘤局灶癌变5例,均为T1期.术后并发肛门出血、急性尿潴留和肺部感染各1例.术后平均住院时间为4.5（3～8）d;平均随访23（2～43）个月,2例出现复发.结论 TEM手术创伤小、切除精确,是一种对直肠较大腺瘤安全有效的微创手术方法.     

Benign rectal strictures managed with transanal resection – A novel application for transanal endoscopic microsurgery

Objective Six cases of management of rectal strictures by transanal endoscopic microsurgery (TEM) are described. Method Patients are placed in the lithotomy – Trendelenburg position and the stricture is resected from 4–8 o’clock through the entire thickness of the fibrosis. The upper resection edge is mobilized including all layers of the rectal wall and the defect is sutured along the circumference. Results Satisfactory anatomical and functional long‐term results were obtained in 5 of 6 patients. Conclusion TEM resection of benign strictures is feasible in some patients and should be tested in a randomized study against known procedures.     

Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery

Background Natural orifice translumenal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, may offer advantages over open and laparoscopic surgery. Most investigations to date have focused on small end-organ resections, and none have described en bloc regional lymphadenectomy. This study aimed to describe a method of anal transcolonic sigmoid colon resection. Methods A fresh frozen then thawed cadaver model was used. Three male human cadavers were subjected to transanal sigmoid colon mobilization, high vascular ligation, en bloc lymphadenectomy, and stapled end-to-end anastomosis performed by a single operator using transanal endoscopic microsurgery instrumentation. Results The findings showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully. The critical steps of the procedure were (1) luminal suture occlusion of the sigmoid colon, (2) transrectal bowel division, (3) entry through the mesorectum into the presacral space, (4) en bloc mobilization of the sigmoid colon mesentery off of the retroperitoneum, (5) high ligation of the superior hemorrhoidal artery, (6) transanal delivery of the intact sigmoid colon specimen, (7) extracorporeal division of the colon, and (8) creation of a stapled end-to-end colorectal anastomosis. Postprocedure laparotomy confirmed adequate lymphadenectomy and anastomosis with no untoward events. Conclusions It is possible to complete the critical steps of a NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions using transanal endoscopic microsurgery instrumentation.     

直肠癌经肛门内镜显微手术疗效及复发危险因素分析

目的 分析直肠癌经肛门内镜显微手术（TEM）疗效及复发危险因素,以探讨直肠癌TEM适应证.方法 对2006年6月至2009年6月间山东省千佛山医院胃肠外科收治的60例行TEM的直肠癌患者的临床资料进行回顾性分析.结果 本组直肠癌pTis期12例,pT1期38例 pT2期10例.全部病灶均一次性全层整块切除,标本切缘均阴性.手术时间30～190（65.0±36.5）min,术中失血量9～75（10.5±5.8）ml,住院时间3～9（4.5±2.7）d,无手术死亡和严重并发症出现.随访时间12～48（平均28.5）个月,无一例死亡.pTis患者均未现复发 38例pT1期患者中1例（2.6%）出现局部复发 10例pT2期患者中有4例（40.0%）出现局部复发,显著高于pT1期患者（P＜0.05）.肿瘤直径大于3 cm的21例患者中有4例复发,显著高于肿瘤直径小于3 cm者（1/39,P＜0.05）.多因素复发危险因素分析证实,浸润深度和肿瘤大小是TEM术后复发的独立风险因素.结论 对pTis、pT1期及肿瘤小于3 cm的早期直肠癌患者,TEM安全有效,值得推广.     

Retroperitoneal phlegmon following transanal endoscopic microsurgery for rectal adenoma

Summary. We report the case of a 55-year-old male patient who underwent transanal endoscopic microsurgery for recurrent benign rectal adenoma. He developed severe postoperative retroperitoneal phlegmon and sepsis and died 28 days after the operation due to untreatable diffuse intraabdominal bleeding caused by persistent thrombocytopenia.      

How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery

Background

The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15?cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM).