经肛内外括约肌间切除术治疗超低位直肠癌的保肛效果观察

Clinical application of intersphincteric resection in the anal-preserving operation for ultra-low rectal carcinoma

目的探讨经肛内外括约肌间切除术（ISR）联合经腹全直肠系膜切除术（TME）及经肛结肠肛管吻合术治疗超低位直肠癌的保肛效果。方法经肛ISR联合经腹TME及经肛结肛吻合术治疗34例无肛门外括约肌受侵的超低位直肠癌患者，术后进行肛门功能训练及功能评价。结果34例患者远切缘距肿瘤下缘的中位距离为2．3cm。病理类型为腺癌28例（其中高分化11例，中分化17例），乳头状癌1例，绒毛状腺瘤癌变5例。病理TNM分期Ⅰ期28例，Ⅱa期1例，Ⅲa期4例，Ⅲb期1例。术后吻合口狭窄3例，吻合口裂开2例，直肠阴道瘘2例。术后早期肛门控便能力明显下降，术后6—12个月肛门功能逐渐恢复。术后5个月吻合口复发1例，术后40个月肝转移1例。结论在严格掌握适应证的前提下，经肛ISR联合经腹TME及经肛结肠肛管吻合术符合肿瘤根治性原则，并保留了肛门功能，是一种超低位直肠癌保肛的有效手术方法。

Objective To investigate the clinical application of intersphincter resection （ISR） combined with total mesorectal excision （TME） and colon-anal anastomosis in the treatment for uhra-low rectal carcinoma. Methods To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma （without external anal sphincter involvement） who received treatment of ISR, TME and colon-anal anastomosis. Results Partial resection of internal sphincter was performed in the patients with a distal edge of the tumor greater than or equal to 2 cm from the dentate line. Subtotal removal of the rectum was performed between 1 cm and 2 cm. Total resection was performed in less than 1 cm or involvement of dentate line. Reconstruction of digestive tract was done by manual colon-anal anastomosis. The average distance from distal excised margin to the tumor was 2.3 （1.8-3.2） cm among 34 patients. The pathological types were as follows： 28 cases of adenocarcinoma （11 were well differentiated, 17 moderately differentiated） , 1 case of papillary carcinoma and 5 cases of villous adenoma with malignant change. The postoperative pathological stages were ： Dukes stage A in 28 cases,stage B in 1 and stage C in 5 cases. The pTNM staging was 28 cases in phase Ⅰ, 1 in phase Ⅱ a, 4 in phase Ⅲ a and 1 in phase Ⅲ b. The T stages of the patients were as following： 16 T1, 17 T2 and 1 T3. Postoperative anastomotic stenosis occurred in 3 cases, anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases. The ability of controlling feces of patients decreased significantly in the early postoperative period, and restored gradually at 6 to 12 months after operation. Anastomotic recurrence occurred in 1 case at 5 months after operation and liver metastasis in 1 case at 40 months. Conclusion With strictly grasping indications, radical resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis. It is an effective sphincterpreserving operation.