经肛门内镜微创手术治疗老年人结直肠腺瘤

Transanal endoscopic microsurgery for the elderly patients with colorectal adenoma

目的探讨经肛门内镜微创手术（TEM）治疗老年人结直肠腺瘤的临床价值。方法2007年12月至2010年9月我院开展TEM治疗老年人结直肠腺瘤21例，肿瘤距肛缘距离为4～20cm，平均8．9cm，肿瘤直径为1．1～3．5cm，平均1．9cm。术前均行全结肠镜和直肠腔内超声检查（EUS），术前病理诊断：管状腺瘤12例，绒毛状腺瘤9例。全麻下根据肿瘤位置选择合适的体位，经肛门插入特殊的手术直肠镜，保持CO2充气状态，在立体视镜和腔镜系统下，采用5mm超声刀将肿瘤（黏膜下或全层）完整切除，手术创口在腔内连续缝合。结果21例肿瘤均获完整切除（12例黏膜下切除，9例全层切除），切缘均阴性；手术时间40～100min，平均76min；术中出血量10～80ml，平均50ml；术后住院时间2～10d，平均4．5d；术后病理分期：pT0 16例，pTis 5例；病理诊断：管状腺瘤9例，绒毛状腺瘤12例，其中低级别上皮内瘤变5例，高级别上皮内瘤变5例；20例随访2～20个月，平均11个月，肿瘤无原位复发。结论TEM微创并发症少，是治疗老年结直肠腺瘤的一种安全、有效的手术方法，术前EUS检查对TEM非常重要。

Objective To investigate the clinical value of transanal endoscopic microsurgery （TEM） for the treatment of elderly patients with colorectal adenoma. Methods Totally 21 patients with colorectal villous adenoma underwent TEM from Dec. 2007 to Sep. 2010. The distance of adenoma from the anal verge was 4-20 cm （average 8.9 cm） and tumor size was 1.1-3.5 cm （average 1.9 cm）. There were 12 cases with tubular adenoma and 9 cases with villous adenoma according to pre-operative diagnosis by colonoscopy and endoanal ultrasonography （EUS）. Appropriate position and posture were dictated by the location of the tumor under general anesthesia. A special rectoscopy was inserted into the anus with CO2 insufflation to keep the rectum open. Under the stereoscopy and lapaoscopytype instruments, the tumor was completely resected （submucosal or full thickness excision） using a 5 mm ultrasonic dissector. The operative wound was closed with intra-lumen continuous sutures. Results The tumor was completely removed with negative resection margins in all the 21 patients （submueosal excision in 12 cases and full-thickness excision in 9 cases）. The operating time was 40-100 rain （average 76 rain） and the intraoperative blood loss was 10-80 ml （average 50 ml）. The post-operative stay was 2-10 d （average 4.5 d）. The postoperative pathological stages were pT0 in 16 cases and pTis in 5 cases. The postoperative pathological diagnosis were tubular adenoma in 12 cases, villous adenoma in 9 cases, low-grade intraepithelial neoplasia （IN） in 5 cases and high-grade IN in 5 cases. Follow-up checkups in the 20 patients for 2-20 months （average 11 months） revealed no local recurrence. Conclusions TEM is safe and effective with little complication for the treatment of elderly patients with colorectal adenoma. Pre-operative EUS is very important for TEM.