目的:评价双吻合器技术在超低位直肠癌保肛术中的实用性。方法:回顾分析我院2006年1月至2009年11月60例超低位直肠癌应用双吻合器技术保肛的临床资料。结果:本组手术中结直肠56例吻合顺利,术后1例吻合口瘘及无出血病例发生,吻合口狭窄2例(333％),无手术死亡病例。结论:应用双吻合器技术可极大提高超低位直肠癌保肛率且并发症少,值得推广。
Objective To investigate the safety and feasibility of the total mesorectal excision （TME） and intersphincteric resection （ISR） for ultra-low rectal cancer and anal sphincter preservation surgery for anorectal cancer， and to evaluate the short term efficacy and postoperative anal function. Methods A retrospective analysis of clinical and follow-up data of 86 cases with TME＋ISR for ultra-low rectal cancer and anorectal cancer from January 2009 to December 2010 in West China Hospital of Sichuan University were performed. Results Eighty-six patients were successfully performed the operation， the lower edge of tumor from the anus was 1-5 cm （average 1.63cm）； tumor diameter was 2-7 cm （average 3.4cm）. The tumors were high differentiation in 4 cases， moderately differentiation in 60 cases，and poorly differentiation in 22 cases. The pTNM stages were stageⅠin 12 cases， stageⅡA in 11 cases， stage ⅡB in 15 cases， stage ⅢA in 2 cases， stage ⅢB in 23 cases， stage ⅢC in 16 cases， and stage Ⅳ in 7 cases. There were postoperative anastomotic leakage in 3 cases， perianal infection in 2 cases （1 case received reoperation with permanent colostomy because of pelvic peritoneal infection caused by perianal severe infections）. Anastomotic bleeding and anastomotic stenosis were of 2 cases respectively. Rectovaginal fistula， inflammatory ileus， urinary retention， and abdominal infection were of 1 case respectively. Eighty-six patients were followed-up for 12-24 months， the mean time was 18 months. Liver metastases was found in 1 case in 7 months after operation， 2 cases dead in the 7th month and 12th month after operation respectively. Local recurrence were found in 3 cases （3.5%） in 1 year after operation. The survival rate of 1-year was 97.7% （84/86）. The times of defecation was 1-5 times a day. The Kirwan’s score level on function of control defecation was 1-2 grade. Conclusions TME＋ISR for low rectal cancer and anorectal cancer is a viable， safe， and radical operation type for preservation of anus. The short term efficacy is satisfactory.
Objective To summarize the assessment methods of anal function after low/ultralow rectal anastomosis in patients with rectal cancer. Methods Domestic and international publications on the study of evaluation of anal function after low/ultralow rectal anastomosis in patients with rectal cancer were collected and reviewed. Results Anal function of patients with rectal cancer was usually evaluated by feeling of discharge, continence, perceptual function of rectum, defecate frequency, and defecation time, anal manometry and three-dimensional vector manometry were used as well. Recovery of anal function in patients with rectal cancer after low/ultralow rectal anastomosis depended on the integrity of anal canal, length of remaining rectum, level of anastomosis, and integrity of mucosa. Conclusions Subjective assessment methods and auxiliary measuring instruments are the common means to evaluate the rectal-anal function. Subjective assessment method is simple and direct, but its accuracy is low; Auxiliary measuring instruments have high accuracy, while their examination costs are high and that of costs are not popular, the new assessment methods are needed for further research.
目的 探讨腹腔镜超低位直肠癌保肛手术的可行性。方法 回顾性总结2004年9月至2007年10月期间行腹腔镜超低位直肠癌保肛手术58例患者的临床资料。结果 54例在腹腔镜下顺利完成手术，中转开腹4例，无手术死亡病例。平均手术时间187 min，术中平均失血110 ml，术后肛门排气时间平均为2.3 d。手术切除淋巴结平均为18.5个； 随访6~42个月(平均17.6个月)未见切口种植及吻合口复发。结论 腹腔镜超低位直肠癌保肛手术具有创伤小、术后恢复快等优点，可以取得比开腹手术更好的根治效果。
Objective To approach the curative effect of laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo anal anastomosis for patients with ultra-low rectal cancer. Methods Thirteen patients were prospectively studied from June 2005 to December 2007. There were 8 male and 5 female patients, with a mean age of 53 (range, 41-69) years. All the tumors located less than 5 cm above the anal verge. All the patients were treated with general anaesthesia and then went through the following procedures: lied the reverse Trendelenburg reforming lithotomy position, the laparoscope went inside the abdomen through two apertures, the hylus aperture (observing aperture) and the McBurney point aperture (main performing aperture). After the resection through the laparoscope, the operation was translocated to the perineal region, the anus was enlarged to expose the operation area. Results The operation on all cases succeeded, there was no operative mortality, and no stomal leak in all patients. The follow-up duration ranged from 1 to 30 months (mean 17 months). Up to now, one patient developed recurrence in pelvic cavity, and one suffered hepatic metastasis, there was no port-site implantation metastasis， 9 patients had satisfactory functional recovery of anus in the sixth month after operation. Conclusion The therapy laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo-anal anastomosis for patients with ultra-low rectal cancer is a safe, minimally invasive, anal-preserving technique with reliablity in curative effect and satisfaction in anal sphincter function.
目的 探讨肛管拖出式双吻合器在超低位直肠癌保肛手术中的应用价值。方法 回顾性总结我院23例超低位直肠癌保肛手术的经验。结果 本组病例利用肛管拖出和双吻合器技术行超低位保肛术均获成功，术后发生吻合口漏1例（4.3%），切口感染2例（8.7%），术后局部复发2例（8.7%），无手术死亡。结论 肛管拖出式双吻合器技术行超低位保肛术是安全可靠的，它可以大大提高超低位直肠癌保肛手术的成功率。
ObjectiveTo compare the perioperative safety and oncologic efficacy of transanal endoscopic intersphincteric resection (TaE-ISR) and the completely transabdominal approach intersphincteric resection (CTA-ISR) for the treatment of ultra-low rectal cancer. MethodsClinical data of patients who underwent TaE-ISR or CTA-ISR at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from June 2022 to June 2023, were retrospectively analyzed. A total of 38 cases of TaE-ISR and 16 cases of CTA-ISR were included. Comparison of surgery-related indexes (including operation time, injury of adjacent organs, protective stoma, and placement of anal tube), postoperative recovery and complications, and oncological results (including positive rate of circumferential resection margin, positive rate of distal resection margin, and number of lymph nodes) were compared between the 2 groups. ResultsThe distance of the lower edge of the tumor from the anal verge was lower in the TaE-ISR group than that in the CTA-ISR group [4.0 (3.4, 4.5) cm vs. 4.9 (4.1, 5.9) cm, P<0.001]. A longer duration of the surgery [(177.18±37.24) min vs (146.25±38.86) min], a higher rate of the anal tube [97.4% (37/38) vs 56.3% (7/16)], a higher rate of protective stoma [94.7% (36/38) vs 12.5% (2/16)], and a higher rate of transanal specimen extraction [92.1% (35/38) vs 0% (0/16)], faster time to first postoperative semi-liquid diet [4 (3, 5) d vs 6 (5, 6) d] were observed in the TaE-ISR group (P<0.05). No adjacent organ injuries occurred in the TaE-ISR group, whereas 2 patients in the CTA-ISR group had intraoperative adjacent organ injuries (0% vs 12.5%), the difference was statistically significant (P=0.026). There was no statistically significant difference between the 2 groups in terms of postoperative hospitalization, postoperative time to first flatus, Clavien-Dindo grading of postoperative complications, the incidence of anastomotic leakage and anastomotic stenosis, distal margin distance, the total number of lymph nodes cleared, and the number of positive lymph nodes (P>0.05). Postoperative specimens in all cases were adequate for distal margins and negative for circumferential margins.ConclusionTaE-ISR and CTA-ISR can both be applied to anus-preserving surgery for ultra-low rectal cancer, but TaE-ISR may be a more reasonable approach than CTA-ISR when the lower edge of the tumor is closer to the anal verge.