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。
目的 探讨内镜反转黏膜切除术治疗超低位直肠大型侧向发育型肿瘤的价值。 方法 回顾性分析四川大学华西医院消化内镜中心2010年1月－2011年12月间38例内镜反转黏膜切除术治疗超低位直肠大型侧向发育型肿瘤病变残留、治疗效果。 结果 38例患者，男18例，女20例，年龄8～80岁；病变下缘距肛门齿状线1～4.0 cm24例，侵及齿状线14例。病变大小（按病变最大径分类）：1.5～3.0 cm 12例，3.1～4.0 cm 8例，4.1～5.0 cm4例，5.1～7.0 cm 10例，10 cm 4例。病变直径在5.0 cm以下的24例患者，经首次手术治疗肿瘤完整切除，术后2例灶性癌变，追加外科手术；其余22例2个月复查，病变无残留，6个月复查，2例复发，经再次手术病变完整切除。随访1年，全部未见复发，治愈率为100%，无残留。病变直径5.1～7.0 cm的10例患者，经首次手术治疗肿瘤分次切除，2个月复查，6例病变完整切除无残留，6个月复查，其中2例复发，经再次内镜下手术切完病变，随访1年，无复发；另4例有残留，经再次内镜下手术切完病变，6个月复查无复发，随访1年，4例均未见复发。病变直径10 cm 的4例患者，经多次手术后复查均有病变残留，无法完全切除，患者拒绝外科手术。5.1 cm以上病变治愈率71.43%，残留率高达57.14%。本组术后出血16例，感染1例，直肠狭窄1例，肛门坠胀3例，无穿孔发生。 结论 内镜反转黏膜切除术治疗超低位直肠大型侧向发育型肿瘤有效，对5.0 cm以下病变能一次完整切除，5.1 cm以上病变残留率高，需再次内镜下手术，10 cm以上病变切除不完全。应慎重选择病例，术后密切随访。
目的 评价超低位直肠癌保肛手术的安全性和疗效。方法 回顾性分析笔者所在医院2004年10月至2010年12月期间收治的48例行管扎式结肠肛管吻合术的超低位直肠癌患者的临床资料。结果 48例患者手术均获成功，手术时间120～221min，（178±37） min； 术中出血量70～210mL，（167±38） mL； 术后排气时间2～5d，（3.1±1.2） d； 术后排便时间8～11d，（9.1±1.4） d。保留完整齿状线者27例，保留齿状线≥1/2者14例，保留齿状线＜1/2者7例。所有患者均获随访，随访时间1～7年，平均32个月。术后有3例患者发生吻合口狭窄，无吻合口漏发生。术后1年有25例患者的肛门括约肌功能达优，其中保留完整齿状线者18例，保留齿状线≥1/2者7例； 良好16例，其中保留完整齿状线者9例，保留齿状线≥1/2者7例； 一般7例，均为保留齿状线＜1/2的患者，优良率为85.4%（41/48）。随访期间，2例患者分别于术后9个月和13个月直肠癌局部复发，其中1例于术后23个月死亡。结论 超低位直肠癌保肛手术是一种安全的、可行的手术方式，可以在根治的前提下达到保肛的目的。
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 investigate the feasibility of laparoscopic-assisted transanal everted pull-through resection and anastomosis in the treatment for ultra-low rectal cancer （the inferior margin of the tumor from the anal margin of less than 5cm）. Methods From December 2006 to December 2009，46 patients with ultra-low rectal cancer had been undergone laparoscopic-assisted transanal everted pull-through resection and anastomosis. The intraoperative condition，postoperative complications，and the result of follow-up were analyzed retrospectively. Results The operation was successfully performed on all the patients. The intraoperative blood loss was （202±56） ml （100-290m1）. The time of recovery of gastrointestinal function was （60±16） h （36-82 h）. No anastomotic bleeding or stomal leak was observed. All the patients were followed-up for （31±5） months （21-45months），15 patients developed mild to moderate anastomotic stricture，1 local recurrence， and 2 liver metastasis. All the patients had no anal incontinence 10months after stoma closure operation， the defecation of all the patients became normal （4.5±1.2） months（2-10months） later. Conclusions Laparoscopic-assisted transanal everted pull-through resection and anastomosis for ultra-low rectal cancer is safe and feasible， and the effect 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。
Objective To discuss whether age has an influence on short-term effect of intersphincteric resection (ISR) for elderly (≥75 years old) patients with ultra-low rectal or canal cancer or not. Methods From February 2016 to February 2017, 196 patients with ultra-low rectal or canal cancer received ISR in the Gastrointestinal Surgery Center of West China Hospital were eligible to include in this study, then they were divided into ≥75 years old group and <75 years old group according to the patients’ age. The intraoperative index, postoperative index, and complications rate were compared between these two groups. Results There were 113 cases in the ≥75 years old group, 83 cases in the <75 years old group, the baselines such as the gender composition, body mass index, tumor histology type, differentiation degree, tumor size, and distance from the anal margin had no significant differences ( P>0.05), but the preoperative anaesthetized ASA grade, proportions of pulmonary insufficiency, hypoproteinemia, anemia, hypertension, diabetes, and cardiac insufficiency of the ≥75 years old group were significantly higher than those of the <75 years old group (P<0.05). The operative time, intraoperative bleeding, and total complications rate had no differences between these two groups (P>0.05), the first exhaust time, the first eating time, the first defecation time, the first ambulation time, and hospitalization time of the ≥75 years old group were significantly longer than those of the <75 years old group (P=0.023, 0.037, 0.019, 0.020, and 0.012, respectively). There were no significant differences in the incidences of the anastomotic leakage, perianal infection, intestinal obstruction, and wound infection between these two groups (P>0.05). All the 196 patients were followed-up with an average follow-up of 7 months, there were 4 cases of recurrent patients, of which 3 were in the ≥75 years old group and 1 in the <75 years old group; there were 3 cases of death, of which 2 were in the ≥75 years old group and 1 in the <75 years old group. Conclusions Short-term recovery of elderly patients with ultra-low rectal or canal cancer is slower than younger patients because of poor preoperative conditions. ISR surgery is still safe and effective for elderly patients with ultra-low rectal or canal cancer and postoperative complications rate has no obvious increase, but it needs a surgeon’s skilled operation technology and multi-disciplinary team cooperation.