经肛内外括约肌间切除术治疗超低位直肠癌的保肛效果观察

目的 探讨经肛内外括约肌间切除术(ISR)联合经腹全直肠系膜切除术(TME)及经肛结肠肛管吻合术治疗超低位直肠癌的保肛效果.方法 经肛ISR联合经腹TME及经肛结肛吻合术治疗34例无肛门外括约肌受侵的超低位直肠癌患者,术后进行肛门功能训练及功能评价.结果 34例患者远切缘距肿瘤下缘的中位距离为2.3 cm.病理类型为腺癌28例(其中高分化11例,中分化17例),乳头状癌1例,绒毛状腺瘤癌变5例.病理TNM分期Ⅰ期28例,Ⅱ a期1例,Ⅲa期4例,Ⅲb期1例.术后吻合口狭窄3例,吻合口裂开2例,直肠阴道瘘2例.术后早期肛门控便能力明显下降,术后6～12个月肛门功能逐渐恢复.术后5个月吻合口复发1例,术后40个月肝转移1例.结论 在严格掌握适应证的前提下,经肛ISR联合经腹TME及经肛结肠肛管吻合术符合肿瘤根治性原则,并保留了肛门功能,是一种超低位直肠癌保肛的有效手术方法.

Clinical application of intersphincteric resection in the anal-preserving operation for ultra-low rectal carcinoma

Objective To investigate the clinical application of intersphincter resection(ISR)combined with total mesorectal excision(TME)and colon.anal anastomosis in the treatment for ultra-low rectal carcinoma.Methods To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma(without external anal sphincter involvement)who received treatment of ISR,TME and colon-anal anastomosis.Results Partial resection of intemal sphincter was performed in the patients with a distal edge ofthe tumor greater than or equal to 2 cm from the dentate line.Subtotal removal of the rectum was performed between 1 cm and 2 cm.Total resection was performed in less than 1 cm or involvement of dentate line.Reconstruction of digestive tract was done by manual colon-anal anastomosis.The average distance from distal excised margin to the tumor was 2.3(1.8-3.2)cm among 34 patients.The pathological types were as follows:28 cases of adenocarcinoma(11 were well differentiated,17 maderatelydifferentiated),1 case of papillary carcinoma and 5 cash of villous adenoma with malignant change.The postoperative pathological stages were:Dukes stage A in 28 cases,stage B in 1 and stage C in 5 cases.The pTNM staging wag 28 cases in phase Ⅰ,1 in phase Ⅱ a,4 in phase Ⅲa and 1 in phase Ⅲb.The T stages of the patients were as following:16 T1.17 T2 and 1,T3.Postoperative anastomotic stenosis occurred in 3cases.anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases.The ability of controlling feces of patients decreased significantly in the early postoperative period,and restored gradually at 6 to 12 months after operation.Anastomotic recurrence occurred in 1 case at 5 months aftcr operation and liver metastasis in 1 cage at 40 months.Conclusion With strictly grasping indications.radicl resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis.It is an effective sphincterpreserving operation.