直肠癌术中远端直肠冲洗的重要意义及方法

Significance and methods of distal rectal irrigation in rectal cancer surgery

直肠癌术中远端直肠冲洗(IORW)指充分游离直肠后,于肿瘤远端阻断直肠腔并进行冲洗,然后离断远端直肠。长期以来,IORW是直肠癌保肛手术的一个关键步骤,也是直肠肿瘤根治手术中无菌无瘤操作的重要环节。大量研究发现远端直肠冲洗液中含有肿瘤细胞,行IORW可降低直肠癌术后局部复发率。随着结直肠癌根治术全面进入微创时代,IORW的价值受到质疑。IORW应用相关研究多为回顾性,为低质量证据,且腹腔镜辅助直肠癌根治术行IORW难度较大。针对低位直肠癌微创保肛手术行IORW难度较大的问题,可以选择拖出式手术或经肛直肠全系膜切除(taTME)手术解决。taTME手术中进行IORW尤为重要,因为对于该术式来说,经肛操作不仅是完成吻合,而且是完成直肠系膜游离(腹腔镜辅助taTME手术)或所有腹盆腔操作(完全taTME手术)的手术途径。taTME若不进行IORW,不仅可导致局部复发,而且还可能导致腹盆腔种植的严重后果。IORW的关键技术主要包括阻断技术、冲洗液的选择和冲洗量的把握。其中,阻断技术最为重要。针对不同的手术方式,可选择不同的阻断技术。腹腔镜低位直肠癌根治术中最常用的阻断技术是使用两件式阻断钳;拖出式手术可在直视下进行冲洗;taTME可通过荷包缝合阻断肠腔。taTME术中行荷包缝合须可靠,且在整个手术过程中要保持该荷包缝合的完整性。

Intraoperative rectal washout(IORW)refers to irrigation and separation of the distal rectum by blocking the rectal cavity below the distal end of the tumor after full mobilization of the rectum.IORW has long been recognized as a key step in anal preservation surgery for rectal cancer,as well as an important part of aseptic and disease-free operation in radical surgery for rectal cancer.A large number of studies have found the existence of tumor cells in the distal rectal rinse fluid,and IORW can reduce the local recurrence rate of rectal cancer after surgery.Knowing that radical resection for colorectal cancer has entered the era of minimally invasive surgery,some scholars have questioned the value of IORW.As most relevant studies are of retrospective nature with low quality evidence and IORW is difficult to be performed in laparoscopy-assisted radical resection of rectal cancer,we suppose that the difficulty with IORW in low rectal cancer minimally invasive anal preservation surgery and the irrigation problem could be solved by pull-through surgery or taTME surgery.It needs to be emphasized that IORW is even more important in taTME surgery because the purpose of this transanal surgical procedure is not only for the completion of anastomosis but for the completion of mesorectal mobilization via laparoscopic-assisted taTME surgery,or the completion of the entire abdominal and pelvic procedures via pure taTME surgery.Without IORW,taTME surgery may lead to local recurrence or even serious consequences of abdominal and pelvic implants.The core technology of IORW mainly includes the blocking technique,the type of rinse fluid and the rinse volume.Among them,we believe that the blocking technique is the most important.Different blocking techniques can be selected for different surgical methods.The most common blocking technique in laparoscopy-assisted radical resection of low rectal cancer is the use of the two-piece blocking forceps.Irrigation can be performed under direct vision in pullthrough surgery.The bowel cavity is blocked by purse-suturing in taTME operation.It should be emphasized that purse-suturing for taTME surgery must be reliable,and the integrity of the purse must be maintained throughout the entire procedure.