腹腔镜全直肠系膜切除联合经肛内括约肌切除保肛治疗超低位直肠癌

目的 探讨腹腔镜全直肠系膜切除（TME）联合经肛内括约肌切除（ISR）保肛治疗超低位直肠癌的可行性.方法 对13例超低位直肠癌（肿瘤距肛缘2.0～5.0cm）患者采用腹腔镜TME联合经肛ISR治疗.结果 13例患者无中转开腹或改行腹腔镜Miles术,行部分ISR 7例,次全ISR 4例,完全ISR 2例.6例同时行回肠造口术,术后未发生吻合口瘘;7例未行回肠造口术,术后发生吻合口瘘2例,加行回肠造口术及充分引流后痊愈.全组无围手术期死亡,无腹腔出血等并发症,1例患者术后阴茎勃起硬度下降.术后平均随访16个月,无复发及转移.术后早期肛门经常粪污,每日排便3～10次.术后1年控便时间可达5min以上,排便次数减为每日1～4次.绝大多数患者能控便,但内括约肌全切除患者腹泻时仍有粪污.结论 选择合适的的超低位直肠癌,特别是没有侵犯外括约肌的早期患者,采用腹腔镜TME联合经肛ISR是可行的,能体现根治、保肛、微创和经济的优点.回肠造口术能有效预防吻合口瘘的发生.但如何理想地解决早期排便功能障碍仍需进一步研究;肿瘤的复发和转移问题仍需长期随访.

Laparoscopic total mesorectal excision combined with intersphincteric resection for ultra-lower rectal cancer: a report of 13 cases

Objective To assess the feasibility and afficacy of laparoscopic total mesorectal excision （TME） combined with intersphincter resection （ISR） in treatment for the ultra-low rectal cancer. Methods The procedure of the laparoscopic TME combined with ISR was performed in 13 patients with ultra-low rectal cancer （the distance between the margin of the cancer and the anus was 2-5cm）. Results Among 13 cases, 7 underwent partial ISR, 4 subtotal ISR and 2 total ISR; none of which were transferred to open procedure or laparoscopic Miles. There were no anastomotic leakage in 6 cases with ileostomy, while it occurred in 2 of 7 cases without ileostomy all cases cured after ileostomy and sufficient drainage. There were no perioperative death or intra-abdominal bleeding, one patient complained of declined hardness of penile erection after the procedure. There was no recurrence or metastasis after the mean follow-up period of 16 months. The stool contamination was common at early stage after surgery, with 3-10 defecation a day. While one year later, the defecation tolerance lasted for more than 5 min, with 1-4 defecation a day. However, liquid stool contamination was occasionally found in those patients with total ISR. Conclusion It is feasible for the appropriate patients with very lower rectal cancer to undergo the laparoscopic TME combined with ISR, especially for those in early stage, without cancer invasion to the external sphincter. The procedure is a radical; sphincter-saving, minimally invasive and economical one.