经肛管括约肌间径路切除低位直肠癌保肛手术临床研究

Clinical study of intersphincteric resection in the sphincter-saving operation for ultra-low rectal cancer

目的探讨经肛门内外括约肌间径路切除超低位直肠癌保肛手术的安全可行性，并评价肿瘤根治效果及术后肛门功能。方法分析2000—2004年华中科技大学同济医学院附属协和医院经选择的经肛门内外括约肌间径路切除超低位直肠癌保肛手术病人42例的临床资料。结果腹部手术遵循TME原则，肛门手术在直视下距病灶下缘2cm切断直肠黏膜和肛门内括约肌，经括约肌间隙向上游离达肛管外括约肌环上方与腹部手术会合，近端结肠与肛管完成端端吻合。前瞻性随访术后病人肿瘤复发与肛门排便功能状况。37例病人完成手术，并发症包括发生急性肺栓塞并死亡1例，盆底肌肉出血1例，吻合口漏3例。36例病人获得随访，平均随访时间为40（24～60）个月。3例（8．33％）吻合口复发，其中1例死亡；1例同时肺、腹膜转移于术后24个月死亡；2例因肝转移分别于术后16、24个月死亡；1例腹腔内淋巴结、腹股沟淋巴结转移于术后16个月死亡。术后6个月肛门括约肌功能已比较满意。结论经肛门内外括约肌间径路切除术治疗超低位直肠癌的手术方法是一种可选择的安全性高、根治效果好的保肛术式。

Objective To explore the safety, feasibility,oncological outcomes and anal function of intersphincteric resection （ISR） in the sphincter-saving operation for ultra-low rectal cancer. Methods The clinical data of 42 selected patients with ultra-low rectal cancer performed intersphincteric resection between 2000 and 2004 in Union Hospital of Huazhong University of Science and Technology was analyzed. Results Abdominal operation was performed according to the TME principles. The rectum and internal anal sphincter were transected through intersphincteric plane at the level 2 cm below the lower edge of tumor via anus under direct vision. The further intersphincteric mobilization was made proximally above the level of external anal sphincter, then coloanal anastomosis was performed after removal of specimen. All cases were followed up to obtain the data of tumor recurrence and anal function prospectively. Thirty-seven patients were performed operation successfully. Perioperative complications occurred in 5 cases, including acute pulmonary embulization （ n = 1 ）, pelvic muscular bleeding （ n = 1 ） and anastomotic leakage （ n = 3 ）. Thirty-six patients were followed up and the median follow-up duration was 40 （rang,24 -60） months. Anastomotic recurrence occurred in 3 patients （8. 33% ） and one of them died. One died of synchronous lung and peritoneal metastasis in 24 months. Two died of liver metastasis in 16,24 months postoperatively. One died of abdominal and inguinal lymph node metastasis in 16 months postoperatively. A satisfactory sphincter function was obtained in most cases in 6 months postoperatively. Conclusion Intersphincteric resection is an alternative sphincter-saving operation for most patients with ultra-low rectal cancer.