改良的经内外括约肌间切除术在超低位直肠癌治疗中的应用

目的:报告经内外括约肌间切除术治疗低位直肠癌的初步结果。方法:对31例瘤灶下缘距离齿状线≤2cm的直肠低位肿瘤进行术前评估,其中18例进展期直肠癌患者先行术前放化疗。腹部手术施行全直肠系膜切除,向下切断骶骨直肠韧带和部分提肛肌达肛门外括约肌环上缘,可沿外括约肌环和肠壁(内括约肌)之间再向下分离1～2cm。肛门手术组在于癌灶下缘2cm之齿状线下方垂直于肛管长轴切开内括约肌全层,然后沿内外括约肌环向上游离,与腹部手术组会师。将近端结肠或结肠贮袋与肛管或肛管齿状线行端端吻合。结果:无手术死亡,31例平均随访12月,29例没有复发和转移。1例证实出现复发和转移,另1例CA19.9增高,但未见转移灶。30例手术后肛门功能较满意。结论:经内外括约肌切除用于超低位直肠癌的保肛手术,可以达到良好的根治性,并保留较好肛门功能。

Modified Intersphincteric Resection in the Sphincter-saving Procedure for Ultra-low Rectum Cancer

Objective:To report the premier results of intersphincteric resection in the sphincter-saving procedure for ultra-low rectum cancer. Methods:Thirty-one rectal neoplasm patients with distal tumor edge less than 2 cm from the dentate line were evaluated preoperatively. Eighteen advanced rectal cancer patients received preoperative chemo-radiation. Total mesorectal excision (TME) was performed by abdominal operative group, with the rectum immobilized down and the puborectal ligament and partial levator ani cut to the level of the dentate line. In some well-exposed patients, it was possible to further immobilize between the external spincter ring and the rectum inner sphincter wall. In anal approach, good exposure was attained and the cut-line was made vertically to the anal canal 2 cm below the lower edge of malignancy, to reach the intersphincter level and further immobilization was made upright to meet with the abdominal group. Colon or colon pouch were anastomosed to distal anal wall. Results:There was no peri-operative death. Twenty-nine patients showed no evidence of recurrence or metastasis. Recurrence occurred in one case 1 year after operation. Another one had higher CA19.9 level, but without evidence of metastasis. Thirty patients had good fecal control. Conclusion: Radical resection can be attained and anal sphincter saved by intersphincter resection which is an alternative sphincter-saving procedure.