腹腔镜下双离断-双吻合器技术联合直肠外翻体外切除术在低位直肠癌保肛治疗中的应用价值  

Application value of laparoscopic double stapler firings and double stapling technique combined with rectal eversion and total extra-abdominal resection in the sphincter-preserving resection of low rectal cancer

作　　者：梁鸿 吴凯强 范青文 郑伟 张辉 白军伟 李俊蒙 陈嘉琦 张超 Liang Hong;Wu Kaiqiang;Fan Qingwen;Zheng Wei;Zhang Hui;Bai Junwei;Li Junmeng;Chen Jiaqi;Zhang Chao(Department of Gastrointestinal Surgery,Henan Provincial People's Hospital,People's Hospital of Zhengzhou University,Zhengzhou 450006,China;Department of Medical Imaging,Henan Provincial People's Hospital,People's Hospital of Zhengzhou University,Zhengzhou 450006,China)

机构地区：[1]河南省人民医院胃肠外科、郑州大学人民医院胃肠外科,郑州450006 [2]河南省人民医院影像科、郑州大学人民医院影像科,郑州450006

出　　处：《中华胃肠外科杂志》2024年第3期283-286,共4页Chinese Journal of Gastrointestinal Surgery

基　　金：河南省医学科技攻关计划联合共建项目(LHGJ20220062);河南省卫生计生科技英才海外研修工程(HWYX2019116)。

摘　　要：目的探讨腹腔镜下双离断-双吻合器技术联合直肠外翻体外切除术(LDER)在低位直肠癌保肛治疗中的应用价值。方法LDER法适应证:(1)年龄18~70岁;(2)肿瘤下缘距离肛缘4~5 cm;(3)原发肿瘤直径≤3 cm;(4)cTNM分期T1~2N1~2M0;(5)“困难骨盆”(坐骨结节间径<10 cm或体质指数>25 kg/m^(2));(6)患者保留肛门括约肌意愿强烈;(7)术前未接受放化疗或免疫及靶向治疗;(8)术前影像资料未发现侧方淋巴结肿大;(9)既往无肛肠手术史;(10)基础情况良好、可耐受手术的患者。禁忌证:(1)既往曾罹患消化道恶性肿瘤或现罹患非消化道恶性肿瘤;(2)术前肛门功能差(Wexner评分≥10分)、排便失禁者。其手术关键步骤如下:内外括约肌间游离直肠远端,腹腔镜下线型切割闭合器离断肿瘤之近端直肠,再将远端直肠经肛门翻转拖出,离断肿瘤之远端直肠,手工全层缝合加固残端,残端回纳入盆腔后,腹腔镜监视下采用双吻合器技术行结肠直肠端端吻合。本文采用描述性病例系列研究方法,回顾性分析2020年1月至2022年12月期间,河南省人民医院采用LDER治疗的12例T1~2期低位直肠癌患者的术中术后资料和随访数据,观察其疗效。结果12例患者均顺利完成LDER,均保留肛门,无中转开腹或手术方式变更。中位手术时间272(155~320)min,中位出血量100(50~200)ml,手术中肛门括约肌保留率100%,均未行预防性造口,所有患者均进行R0切除,术后中位住院时间为9(7~15)d,3例患者出现术后发热(Clavien-DindoⅠ级),无术后吻合口漏或围手术期死亡者。12例患者中位随访12(6~36)个月,术后6个月中位Wexner评分8(5~14)分,随访期间无肿瘤复发转移。结论腹腔镜下双离断-双吻合器技术联合直肠外翻体外切除术治疗低位直肠癌安全可行的。Objectives To investigate the application value of laparoscopic double stapler firings and double stapling technique combined with rectal eversion and total extra-abdominal resection(LDER)in the anal preservation treatment of low rectal cancer.Methods Inclusion criteria:(1)age was 18-70;(2)the distance of the lower tumor edge from the anal verge was 4-5 cm;(3)primary tumor with a diameter≤3 cm;(4)preoperative staging of T1~2N1~2M0;(5)"difficult pelvis",defined as ischial tuberosity diameter<10 cm or body mass index>25 kg/m^(2);(6)patients with strong intention for sphincter preservation;(7)no preoperative treatment(e.g.,chemotherapy,radiotherapy,molecular targeted therapy,or immunotherapy);(8)no lateral lymph node enlargement;(9)no previous anorectal surgery;(10)patients with good basic condition who could tolerate surgery.Exclusion criteria:(1)previously suffered from malignant tumors of the digestive tract or currently suffering from malignant tumors out of the digestive tract;(2)patients with preoperative anal dysfunction(Wexner score≥10),or fecal incontinence.The specific surgical steps are as follows:the distal end of the rectum was dissected to the level of the interspace between internal and external sphincters of anal canal.Five centimeters proximal to the tumor,the mesorectum was ligated,and a liner stapler was used to transect the rectum.The distal rectum with the tumor were then everted and extracted through the anus.The rectum was transected 0.5-1.0 cm distal to the tumor with a linear stapler.Full thickness suture was used to reinforce the stump of the rectum,which was then brought back into the pelvic cavity.Finally,an end-to-end anastomosis between the colon and the rectum was performed.A retrospective descriptive study was performed of the clinical and pathological data of 12 patients with T1-T2 stage low rectal cancer treated with LDER at Henan Provincial People's Hospital from January 2020 to December 2022.Results All 12 patients successfully completed LDER with sphincter preservation,withou

关 键 词：直肠肿瘤 腹腔镜手术 消化道重建 

分 类 号：R735.37[医药卫生—肿瘤]