腹腔镜Miles根治术治疗低位直肠癌26例临床报告

目的对比分析腹腔镜手术治疗低位直肠癌的可行性和安全性。方法采用前瞻性研究方案,将51例低位直肠癌患者随机分为两组。对照组行常规开腹Miles根治术,观察组(n=26)采用腹腔镜下Miles根治术进行治疗。对比两组患者的临床手术时间、术中出血量、淋巴结清扫数目、术后胃肠功能恢复时间及平均住院时间;同时,完成3个月~2年随访,对比术后排尿功能、并发症、复发率、转移率及生存率。结果两组患者的手术时间和淋巴结清扫数目无统计学差异,观察组术中出血量较少、术后胃肠功能恢复时间与住院时间较短,与对照组相比差异有统计学意义(P<0.05)。所有患者均完成有效随访,观察组排尿功能较高,术后并发症发生率、复发率和转移率较低,且排尿功能和并发症发生率与对照组相比差异有统计学意义(P<0.05)。此外,两组患者术后生存曲线无统计学差异(P>0.05)。结论腹腔镜Miles根治术治疗低位直肠癌安全可行,且在预后方面,优于传统开腹术,具有临床推广价值。     

腹腔镜辅助中低位直肠癌手术治疗的体会

目的：探讨腹腔镜辅助治疗中低位直肠癌的安全性与可行性。方法：回顾分析76例中低位直肠癌患者腹腔镜手术的临床资料。结果：73例成功施行了腹腔镜手术,保肛率84.9%（62/73）,局部复发率0.06%（5/73）,均至少保留了一侧盆腔自主神经,无严重并发症发生。结论：遵循全直肠系膜切除（total mesorectal excision,TME）原则施行保留自主神经的腹腔镜手术可提高疗效及保肛率。     

腹腔镜与开腹低位直肠癌根治术的疗效对比

目的 评估腹腔镜手术治疗低位直肠癌的临床应用价值、疗效以及安全性.方法 回顾性分析2006年10月至2012年10月在上海市嘉定区中心医院行低位直肠癌根治术的患者143例,根据手术方式分为腹腔镜组(69例)和开腹组(74例),比较两组围手术期及术后生存率情况.结果 腹腔镜组和开腹组在年龄、性别、病理类型、肿瘤分化、肿瘤分期等方面差异均无统计学意义(P＞0.05);腹腔镜组手术时间(171.4±63.6 min)大于开腹组(146.1±47.1 min),术中出血量(63.4±23.6 mLvs.92.6±31.8 mL)、术后排气时间(2.5±1.3 d vs.3.6±1.1d)、术后留置导尿管时间(4.6±1.9 d vs.6.3±2.2d)腹腔镜组均小于开腹组,腹腔镜组术后总并发症的发生率与开腹组相似(7.0％ vs 13.2％)(P＞0.05),术后吻合口漏率、肺部感染、切口感染、泌尿系感染两组差异无统计学意义;术后随访时间12～60个月,中位随访时间54个月,腹腔镜组和开腹组在术后1年、3年、5年的生存率、无瘤生存率和局部复发率等方面差异均无统计学意义(P＞0.05).结论 腹腔镜手术治疗低位直肠癌是安全可行的,其远期疗效和开腹手术相似,在对盆腔神经丛的保护和对低位直肠癌的保肛方面可能更有优势,值得推广.     

腹腔镜全直肠系膜切除治疗低位直肠癌(附198例临床资料报告)

目的探讨腹腔镜全直肠系膜切除治疗低位直肠癌的可行性和安全性。方法回顾分析198例腹腔镜全直肠系膜切除治疗低位直肠癌病例资料。结果全组无手术死亡,无中转开腹。平均手术时间（211.5&#177;69.2）min,中位出血量80（50～200）mL,平均切除淋巴结数为（11.5&#177;6.4）枚,平均肛门排气时间（2.8&#177;1.4）d,平均可下地行走时间（1.6&#177;0.9）d,平均术后住院时间（11.8&#177;6.4）d。术后并发症发生率为20.71%,最常见为肠梗阻（占并发症的24.4%）。中位随访时间为26.1（13.6～45.2）个月,随访率86.9%。33例出现术后复发转移,其中吻合口复发2例,盆腔局部复发3例,腹腔广泛转移4例,远处转移24例。死亡共37例,其中死于肿瘤相关因素28例,死于非肿瘤相关因素9例。5例带瘤生存。结论腹腔镜全直肠系膜切除治疗低位直肠癌不仅具有疼痛轻、恢复快等优点,在技术上也是安全可行的,而最终的结果仍有待于大量的、长期的前瞻性随机对照研究。     

腹腔镜下全直肠系膜切除治疗中低位直肠癌的疗效

为探讨腹腔镜下全直肠系膜切除（TME）治疗中低位直肠癌的临床疗效,回顾行TME治疗的123例中低位直肠癌患者资料,其中66例于腹腔镜下行TME（观察组）,57例开腹手术行TME（对照组）,对比分析两组手术情况、患者术后恢复情况、围手术期并发症及标本肿瘤学指标等。结果显示,观察组手术时间比对照组长（P〈0．05）;但切口长度、术中出血量、术后VAS评分、肛门排气排便时问及围手术期并发症总发生率比较,观察组均优于对照组（P〈0．05）,且观察组保肛率与对照组相近（P〉0．05）。两组标本的上下切缘均为阴性,标本长度和清除淋巴结数目比较差异均无统计学意义（P〉o．05）。随访至2010年8月,观察组患者术后性功能、排尿功能障碍发生率明显低于对照组（P〈0．05）,两组在死亡、复发和转移方面差异均无统计学意义（P〉0．05）。结果表明,腹腔镜下TME治疗中低位直肠癌是安全、可行的,可以达到与传统开腹TME手术一样的远期疗效,且创伤小,患者痛苦小,恢复快。     

腹腔镜全直肠系膜切除保肛治疗低位直肠癌

目的：探索腹腔镜全直肠系膜切除（TME）低位、超低位前切除治疗低位直肠癌的可行性。方法：按TME原则、用双钉合技术（DST）,在腹腔镜下对62例低位直肠癌患者实施TME、DST低位、超低位结肠-肛肠吻合术。结果：手术时间11-210min,平均125min;术中出血5-80ml,平均20ml;术后1-2d恢复胃肠功能并下床活动,住院时间5-14d,平均8d。1例患者因凝血障碍中转开腹,其他61例患者手术顺利。术后疼痛剂应用28例,除1例吻合口漏、1例尿潴留外,其余患者未见术中及术后并发症。结论：腹腔镜TME、低位、超低位吻合术治疗低位直肠癌,创伤小、保肛率高、术后疼痛轻、恢复快,是极具应用前景的微创新技术。     

腹腔镜低位直肠癌根治术

1概述1.1低位直肠癌定义2010年版卫生部的《结直肠癌诊疗规范》[1]与2011年美国国立综合癌症网络(NCCN)指南(直肠癌)[2]均将距肛缘5cm以内的癌性病变定义为低位直肠癌。1.2手术原则中下段直肠癌根治术采用全直肠系膜切除(TME)原则已获共识[1-2]。1.3术式选择卫生部《结直肠癌诊疗规范》对低位直肠     

低位直肠癌腹腔镜下全直肠系膜切除保肛术的临床效果分析

为探讨腹腔镜下全直肠系膜切除保肛手术在低位直肠癌治疗中的临床效果,选取本院50例低位直肠癌患者为研究对象,分为常规组与腹腔镜组,各25例。常规组给予传统开腹手术,腹腔镜组给予腹腔镜下全直肠系膜切除低位直肠保肛术治疗。观察比较2组治疗情况及术后并发症。结果显示,腹腔镜组患者在肛门排气时间、进食时间、术后离床时间、住院时间等方面均优于常规组,差异有统计学意义(P <0.05)。腹腔镜组术后并发症发生率(4.0%)低于常规组(24.0%);肛门功能优良率(48.0%)高于常规组(32.0%),差异均有统计学意义(P <0.05)。结果表明,低位直肠癌采取腹腔镜下全直肠系膜切除保肛术治疗,临床疗效满意,并发症发生率低,肛门功能优良。     

腹腔镜下直肠癌全直肠系膜切除术

目的 探讨腹腔镜下行直肠癌全直肠系膜切除根治术的临床效果。方法 对38例直肠腺癌患者采用腹腔镜下联合应用超声刀循盆筋膜壁层和脏层的间隙行锐性游离全直肠系膜,切除一个不间断的直肠整体标本,并对全组病例随访2年余。结果 38例患者手术顺利,无中转开腹,术后排便、排气时间平均为32h,术后平均住院天数为7．5d。术后随访至今,38例患者均无腹部穿刺口种植,其中2例出现局部复发(1例伴肝转移)。38例患者均无排尿困难,6例患者有性功能减退。结论 腹腔镜下行直肠癌全直肠系膜切除术手术既能有效降低术后局部复发率和保护盆腔自主神经功能,又具有微创优点,值得临床推广。     

腹腔镜辅助经肛门全直肠系膜切除术治疗低位直肠癌36例临床分析

目的探讨腹腔镜辅助经肛门全直肠系膜切除术(La-Ta TME)治疗低位直肠癌的方法及效果。方法回顾性分析2017-04—2019-12间在濮阳市人民医院接受La-Ta TME治疗的36例低位直肠癌患者的临床资料。结果 36例患者均完成La-Ta TME,其中31例(86.11%)患者成功保肛。手术时间(257.31±17.96)min,术中失血量(63.15±12.05)mL,术后首次下床活动时间(2.03±0.32)d,住院时间(8.74±1.02)d。成功保肛的31例患者中,1例(3.23%)于术后第4天发生吻合口瘘,经充分引流愈合。患者均顺利出院。结论 La-Ta TME治疗低位直肠癌患者,创伤小、保肛率高、并发症少,是一种近期疗效较好、安全和可行的手术方式。     

Laparoscopic-Assisted Modified Intersphincter Resection for Ultralow Rectal Cancer

Background

Intersphincter resection (ISR) is considered to be a superior technique offering sphincter preservation in patients with ultralow rectal cancer.1 Because high-definition laparoscopy offers wider and clearer vision into the narrow pelvic cavity and intersphincteric space, ISR has been further refined.2 However, functional outcome after ISR has not been optimal. More than half of patients receiving ISR suffer partial or even complete anal incontinence.3 We therefore propose a laparoscopic-assisted modified ISR, with the aim of improving sphincter function following ISR.

Methods

The video describes the technique for performing such laparoscopic-assisted modified ISR in a 62-year-old woman with ultralow rectal cancer (3 cm from anal verge). Preoperative staging by endorectal ultrasound and pelvic magnetic resonance imaging revealed stage I rectal cancer (cT₂N₀M₀). The operation consisted of an abdominal and a perineal phase. The abdominal phase routinely involved colonic mobilization with high ligation of inferior mesenteric vessels, total mesorectal excision (TME), as well as transabdominal intersphincteric dissection. The procedure for laparoscopic TME was performed according to our published method.4 Along the TME dissection plane, the puborectalis could be reached and the intersphincteric space was entered posterolaterally. The hiatal ligament at the posterior side of the rectum was transected afterwards. The dissection of the intersphincteric space was continued caudally at the anterior side of the rectum. The distal bowel wall was mobilized for 2 cm from the lower edge of the tumor to obtain adequate distal margin. At this point, circular dissection of the intersphincteric space was completed. After the abdominal phase, perineal dissection was performed with wide exposure by use of a hooked self-retaining retractor. The lower margin of the tumor was identified under direct vision. We developed a modified ISR technique. Resection of the mucosa and internal sphincter was initiated 2 cm distal to the lower edge of the tumor at the tumor side to obtain the necessary distal margin. Meanwhile, at the opposite side of the tumor, the resection line was just above the dentate line so that partial dentate line could be preserved. After removal of the specimen en bloc per anus, the pelvic cavity was generously irrigated with diluted povidone iodine solutions. The distal margin of the specimen was then examined by frozen section for presence of cancer. If clear, coloanal anastomosis was performed using a handsewn technique. The colon was rotated 90° and anastomosed to the anal canal with interrupted absorbable 3–0 sutures. Finally, a pelvic suction drain was placed, and a temporary diverting stoma made in the terminal ileum.

Results

There were no intraoperative complications. The operating time was 180 min. Blood loss was 50 mL. The distal margin was clear, and the final pathology was pT₂N₀M₀. The patient underwent an uneventful recovery. She began sphincter-strengthening exercises 2 weeks after surgery. The stoma was closed after examinations 3 months later. No local recurrence or distant metastasis was found. At 12-month follow-up, in terms of sphincteric function, the patient was continent to solids, liquids, and flatus.

Conclusions

Laparoscopic-assisted modified intersphincter resection for ultralow rectal cancer is safe and feasible. This technique should be considered whenever possible as a means to offer sphincter preservation and improve sphincter function in patients with ultralow rectal cancer.

     

Laparoscopic-Assisted Versus Open Abdominoperineal Resection for Low Rectal Cancer: A Prospective Randomized Trial

Background  Laparoscopic resection of colonic cancer has been shown to improve postoperative recovery without jeopardizing tumor clearance and survival, but information on low rectal cancer is scarce. The aim of this randomized trial was to compare postoperative recovery between laparoscopic-assisted versus open abdominoperineal resection (APR) in patients with low rectal cancer. Recurrence and survival data were also recorded and compared between the two groups. Methods  Between September 1994 and February 2005, 99 patients with low rectal cancer were randomized to receive either laparoscopic-assisted (51 patients) or conventional open (48 patients) APR. The median follow-up time of living patients was about 90 months for both groups. The primary and secondary endpoints of the study were postoperative recovery and survival, respectively. Data were analyzed by intention-to-treat principle. Results  The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with earlier return of bowel function (P < .001) and mobilization (P = .005), and less analgesic requirement (P = .007). This was at the expense of longer operative time and higher direct cost. There were no differences in morbidity and operative mortality rates between the two groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 75.2% and 76.5% respectively (P = .20). The respective probabilities of being disease-free were 78.1% and 73.6% (P = .55). Conclusions  Laparoscopic-assisted APR improves postoperative recovery and seemingly does not jeopardize survival when compared with open surgery for low rectal cancer. A larger sample size is needed to fully assess oncological outcomes. Part of this paper has been presented as free paper in the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, October 18–21, 2006, Seoul, Korea. An erratum to this article can be found at     

改良Parks术治疗低位直肠癌（附72例报告）

目的 介绍一种低位直肠癌保留肛门括约肌的新的手术方法。方法 采用塑料螺纹管对72例低位直肠癌行结肠－肛管吻合术（Parks)。结果 完全恢复正常排便功能的71例（98．6％），1例度排便失禁（1．4％），术后并发症1例（1．4％），局部复发1例（1．4％），无手术死亡，随访率100％，平均48个月。结论 塑料螺纹管明显提高了低位直肠癌的保肛成功率，并发症低，局部复发未见增加，说明了该术式设计的合理性。     

侧方淋巴结清扫在低位直肠癌手术中的应用研究

目的探讨低位直肠癌手术中侧方淋巴结清扫的临床价值。方法将112例在我院施行直肠癌根治术的低位直肠癌患者随机分为两组,观察组(n=54)行全直肠系膜切除(total mesorectalexcision,TME) 侧方淋巴结清扫,对照组(n=58)单纯行TME,比较两组的平均手术时间、术中失血量、局部复发率、远处转移率及生存率等指标。结果两组平均手术时间、失血量比较差异无统计学意义(P>0.05),观察组局部复发率、远处转移率及3年生存率分别为6.1%、8.2%、87.8%,对照组分别为19.2%、23.1%、71.2%,两组比较有统计学差异(P<0.05)。结论低位直肠癌手术时施行侧方淋巴结清扫可有效降低局部复发率及远处转移率,提高患者的生存率,改善生存质量,值得提倡。     

腹腔镜直肠癌手术的手术方式选择探讨

目的:探讨腹腔镜直肠癌根治术的手术方式选择。方法:回顾性分析2002年11月至2005年11月间施行的88例腹腔镜直肠癌手术,包括中转率、手术要点和并发症率等。结果:本组中转开腹7例(8.0%)。88例中经腹腔镜前切除吻合40例,经腹腔镜肛管根治性切除乙状结肠肛管吻合14例,经腹腔镜腹会阴联合切除术33例,1例因合并3度会阴撕裂伤行经腹腔镜Hartmann手术。无术中并发症及手术死亡,术后并发症8例,5例为出血并发症。结论:腹腔镜直肠癌手术安全、有效,但应个体化选择手术方式。     

Laparoscopic Intersphincteric Resection for Low Rectal Cancer

Background  

Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility, the functional outcome, and the short-term oncologic outcomes of laparoscopic ISR for low rectal adenocarcinoma at our institution.     

人工结肠瓣在低位直肠癌根治术中的应用(附12例报告)

目的 探讨人工结肠瓣在低位直肠癌根治术后对排便功能的影响.方法 对12例低位保肛直肠癌患者在行低位保肛术后采用人工结肠瓣技术,并观察其术后肛门功能.结果 12例患者成功行低位保肛手术治疗,术后随访6～12个月,患者排便次数减少,排便紧迫感较轻,有较强的排便控制能力.结论 人工结肠瓣的应用,可以延缓粪便通过时间,改善排便功能.     

直肠癌经腹会阴柱状切除术应用体会

目的总结低位直肠癌采用柱状经腹会阴切除术（APR）的应用体会。方法徐州医学院附属医院普通外科于2010年1月至2013年7月期间采用柱状APR治疗22例低位直肠癌患者（柱状APR组）,并与同期行传统APR治疗的35例患者（传统APR组）进行对比,分析术中、术后和随访的各项指标。结果与传统APR组比较,柱状APR组的环周切缘阳性率及术中穿孔率明显降低[4．55％（1／22）比34．29％（12／35）和4．55％（1／22）比31．43％（11／35）],差异有统计学意义（P〈0．05）;2组手术时间、术中出血量、并发症发生率比较,差异无统计学意义（P〉0．05）。术后随访3～30个月（平均21个月）,柱状APR组无肿瘤复发及远处转移患者,未见死亡病例;传统APR组出现盆底局部复发4例,远处转移3例,死亡2例。2组局部复发、远处转移及死亡率比较差异均无统计学意义（P〉0．05）。结论柱状APR可以切除更多的肿瘤周围组织,降低环周切缘阳性率,减少术中肠穿孔的发生,降低局部复发。     

腹腔镜超低位直肠癌经肛门外翻拖出切除吻合术的临床分析

目的探讨腹腔镜超低位(肿瘤下缘距肛缘小于5 cm)直肠癌经肛门外翻拖出切除吻合术的可行性。方法回顾性总结2006年12月至2009年12月期间我院46例行腹腔镜超低位直肠癌经肛门外翻拖出切除吻合术患者的临床资料,分析患者的术中情况、术后并发症及随访情况。结果 46例患者均顺利完成手术,无一例中转开腹,术中出血量(202±56)ml(100～290 ml),胃肠功能恢复时间(60±16)h(36～82 h)。无吻合口出血及吻合口漏发生。随访(31±5)个月(21～45个月),15例出现轻中度吻合口狭窄,1例局部复发,2例肝转移。所有患者在造瘘还纳术后10个月肛门控便、控气功能良好,无肛门失禁;造瘘还纳术后(4.5±1.2)个月(2～10个月)排便功能逐渐恢复正常。结论腹腔镜超低位直肠癌经肛门外翻拖出切除吻合术安全、可行,疗效满意。