腹腔镜全直肠系膜切除联合经肛内括约肌切除保肛术治疗超低位直肠癌

目的探讨腹腔镜全直肠系膜切除（total mesorectal excision,TME）联合经肛内括约肌切除（intersphinctericresection,ISR）保肛术治疗超低位直肠癌的可行性及疗效。方法 2006年5月~2009年5月,18例超低位直肠癌（肿瘤直径0.8~5.5 cm,下缘距肛缘1.9~4.5 cm）行腹腔镜TME联合ISR术。病例选择标准：肿瘤下缘距肛门〈5 cm;直肠指诊肿块可以推动;腔内B超、MRI或CT提示无外括约肌受累;无远处转移;肛门括约肌功能正常。腹部：在腹腔镜下TME法分离直肠及其系膜至肛提肌水平。肛门部：切开肛管黏膜至内外括约肌间隙,沿间隙向盆腔分离,与腹部操作部位会合,移除标本,结肠肛管吻合。术后进行随访。结果 18例均在腹腔镜下顺利完成手术,无围手术期死亡。手术时间180~300 min,平均220 min。术中出血40~160 ml,平均100 ml。手术切缘均阴性。10例未行回肠造口者中发生吻合口漏3例,加行回肠造口术及充分引流后痊愈。全组随访12~46个月,平均23个月。术后早期肛门经常粪污,每日排便3~10次。术后1年排便次数减为每日1~4次,控便时间可达5 min以上。根据Kirwan分级,1年后肛门功能Ⅰ级＋Ⅱ级16例,Ⅲ级2例。结论选择合适的超低位直肠癌,特别是没有侵犯外括约肌的早期患者,采用腹腔镜TME联合经肛内括约肌切除保肛术是可行的,能体现根治、保肛、微创和经济的优点。

Laparoscopic Total Mesorectal Excision Combined with Intersphincteric Resection for Ultra-Lower Rectal Cancer

Objective To investigate the feasibility and therapeutic effect of laparoscopic total mesorectal excision（LTME） combined with intersphincteric resection（ISR） for ultra-low rectal cancer.Methods We performed LTME combined with ISR on 18 patients with ultra-lower rectal cancer（tumor diameter was 0.8-5.5 cm and the lower edge to the anal was 1.9-4.5 cm） from May 2006 to May 2009.Case selection criteria： the edge of tumor away from the anus less than 5 cm,the mass can be pushed with DRE,without sphincter involvement shown by intracavity B-sonography,CT,or MRI,without distant metastasis,with normal function of the anal sphincter.The procedure of abdomen group： separate the rectum and its mesentery to the level of levator ani muscle by LTME.The procedure of anal group： slit the anal mucosa,muscularis mucosa and serosa,then enter the gap between the inner and external sphincters,separate along the gap toward the pelvic cavity till the abdominal operation site shown the specimens,anastomose the colon and anal canal.Results The 18 cases were successfully treated by laparoscopic surgery without perioperative deaths.The operation time was 180-300 min（mean,220 min） and blood loss was 40-160 ml（mean,100 ml）.The surgical margins were all negative.All the cases were followed up for 12 to 46 months（mean,23 months）.3 of the 10 cases that without ileostomy developed anastomotic leakage and recovered after receiving ileostomy and sufficient drainage.All the cases defecated 3-10 times a day in the early postoperative stage and were often polluted by manure;it was then reduced to 1-4 times a day one year after the operation,and the time of keeping defecation could reach up to 5 minutes.According to Kirwan grade,the Ⅰ ＋ Ⅱ grade was shown in 16 patients,and the other two showed grade Ⅲ. Conclusions It is feasible,for appropriate patients,to perform LTME combined with ISR,especially for the patients with ultra-lower rectal cancer that were in early stage without cancer invasion to the external sphincter.The procedure has the advantages of radical sphincter-saving,minimally invasive and economic.