TME经括约肌间切除术在超低位直肠癌根治性保肛中的作用

TME Plus Intersphincteric Resection as the Sphincter-saving Procedure for the Ultra-low Rectum Cancer

目的探讨直肠全系膜切除术（TME）加经括约肌间切除术治疗低位直肠癌的手术经验和效果。方法对31例癌灶下缘距离齿状线≤2cm的直肠低位肿瘤进行术前评估，对其中18例进展期直肠癌患者行术前放射疗法和化学疗法。腹部手术施行直肠全系膜切除，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，沿外括约肌环和肠壁（内括约肌）之间再向下分离1—2cm。肛门手术于癌灶下缘2cm、齿状线下方垂直于肛管处长轴切开内括约肌全层，然后沿内外括约肌间向上游离至腹部，将近端结肠或结肠袋与肛管或肛管一齿状线端端吻合。结果全组无手术死亡，31例病人平均随访24月，26例患者无复发和转移，1例患者出现复发和转移，1例患者糖链抗原19-9（CA19-9）增高，但未见转移灶。30例患者手术后肛门功能恢复较满意。结论经括约肌间切除术可用于超低位直肠癌的保肛手术治疗，具有良好的根治性，并能较好保留肛门功能。对较早期或对术前放、化疗敏感的超低位直肠癌、直肠间质瘤、基底广泛息肉和骨盆狭窄的低位直肠癌患者，是一种可选择的根治性保肛方法。

Objective To report the experiences and preliminary results of TIME plus intersphincteric resection as the sphinctersaving procedure for ultra-low rectal cancer. Methods 31 rectal neoplasm patients whose distal tumour edges were ≤2 cm from the dentate line were evaluated preoperatively. Eighteen patients with advanced rectal cancer received preoperative chemoradiotherapy. The TIME were performed by abdominal operation group and then the puborectal ligament and partial levator ani were dissected approaching to the upper edge of external sphincter ring. It was possible to go down further to dissect 1 ～ 2 cm between the external sphincter ring and the rectum inner sphincter wall. The surgeon of anal operative group dissected all layer of rectum inner sphincter vertically to the longitude axis of the anal canal 2 cm below the lower edge of malignancy and then further mobilized ascending to meet with the abdominal group. Colon or colon pouch were anastomosed to distal anal wall. Results There was no operative death and no evidence of recurrence or metastasis in twenty-six patients. The rectum cancer recurred 1 year after operation in one patient, another one had rised level of CA19-9 but without documents of metastasis. 30 patients were satisfied with their fecal control. The average-time of follow-up is 24 months. Conclusion Radical resection could be attained and anal sphincter could be saved by TME plus intersphincteric resection. It is an alternative sphincter-saving method to early stage rectal cancer, or some advanced rectal cancer which were sensitive to preoperative chemoradiotherapy, or ultra-low rectal parenchamal tumour, or wide based polyps, and for patients with extremely strictured pelvis.