经前会阴超低位直肠前切除术的临床应用

目的总结经前会阴超低位直肠前切除术（APPEAR）治疗低位直肠癌的临床经验。方法回顾性分析2009年9月至2011年8月间在北京协和医院基本外科施行APPEAR手术的26例低位直肠癌患者的临床和随访资料。结果26例患者中男19例,女7例,年龄（63．4±9．5）岁。术前检查见肿瘤距肛缘距离（4．6±0．7）cm。14例患者术前接受新辅助放化疗。26例患者均顺利保肛,手术时间（170±21）min,术中出血量（140±69）ml。术中发生直肠破损1例,术后发生会阴切口感染4例。术后病理：高中分化腺癌10例,中分化腺癌伴部分黏液腺癌7例,低分化腺癌1例,绒毛状腺瘤高级别上皮内瘤变1例．直肠绒毛状腺瘤1例,标本未找到癌细胞6例。术后全组均获随访,随访时间（11．4±5．6）个月,随访期间未出现泌尿功能障碍和肿瘤复发。18例患者于术后6个月行横结肠造口还纳术,术后wexner控粪功能评分平均为5．5分。肛门直肠功能测压显示,肛门括约肌最大主动收缩压为（224．0±59.3）mmHg,肛门括约肌最大静息压为（42．5±11．8）mmHg,直肠最大耐受量为（120．0±27．4）m1,直肠肛门抑制反射均存在。结论经前会阴超低位直肠前切除术适用于部分保留肛门的低位直肠癌手术．并能取得较为满意的肛门排粪功能。

Clinical application of anterior perineal plane for ultra-low anterior resection of the rectum

Objective To summarize clinical experience in the treatment of low rectal cancer with anterior perineal plane for ultra-low anterior resection of the rectum （APPEAR）. Methods Clinical and follow-up data of 26 patients with low rectal cancer undergoing the APPEAR operation in Department of General Surgery at Peking Union Medical College from September 2009 to August 2011 were retrospectively analyzed. Results The 26 cases consisted of 19 male and 7 female patients with an average age of （63.4±9.5） years. The average tumor distance from the anal verge was （4.6±0.7） cm according to preoperative examinations. Fourteen patients received neoadjuvant radiochemotherapy before the operation. All the 26 patients had successful sphincter-preserving operations. The average operative time was （170±21） rain and the average inta-operative blood loss （140±69） ml. Complications included one case of intraoperative injury to the rectal wall and 4 cases of postoperative perineal wound infection. Postoperative pathological examination showed well to moderately differentiated adenocarcinomas（n=10）, moderately differentiated adenocarcinomas with partial mucinous adenocarcinomas （n=7）, poorly differentiated adenocarcinoma （n = 1 ）, villous adenoma with high-grade intraepithelial neoplasia （n=l）, and rectal villous adenoma （n=1）. In 6 cases no residual tumor cells were detected in the surgical specimens. All the patients were followed-up for an average period of （11.4±5.6） months. No impaired urinary function or tumor recurrence was observed during the follow-up. Eighteen patients had the transverse colon stoma closure six months after the operation. The average Wexner continence score was 5.5 after colostomy reversal surgery. The anorectal manometry tests showed that maximum squeeze pressure of the anal sphincter was（224.0±59.3） mm Hg.The maximum resting pressure was （42.5±11.8） mm Hg, and the maximum tolerable volume of the rectum was （120.0±27.4） ml. Anorectal reflexes were present in all these patients. Conclusion The APPEAR technique can be applied in the sphincter-preserving operations for low rectal cancer patients with satisfactory anal function.