肛门内括约肌切除术治疗T1～2期超低位直肠癌的疗效评价

Efficacy evaluation of anal intersphincteric resection with direct coloanal anastomosis for T1-2 ultralow rectal cancer

目的评价在全直肠系膜切除术（TME）的基础上采取肛门内括约肌切除术（ISR）治疗T1和T2期超低位直肠癌患者的临床疗效和生存结果。方法对2000年3月至2007年3月间实施ISR的40例超低位直肠癌患者的临床资料进行回顾性分析。结果40例患者术前的肿瘤分期为T1-2N0-1M0。实施完全ISR者5例，部分ISR者23例，改良的部分ISR（保留部分齿状线）12例。术后3例患者出现并发症，其中吻合口瘘1例，伤口感染2例：无围手术期死亡。全组术后5年生存率97％，5年无瘤生存率86％。术后12个月时，接受部分ISR者和改良的部分ISR者的肛门功能优于完全ISR者（分别P=0．008和P=0．004）；接受预防性造口患者的肛门功能优于未接受造口者（P=0．043）。结论ISR选择性治疗超低位直肠癌安全可行。在保证根治的前提下尽可能保留齿状线和部分内括约肌以及行预防性造口可能有助于改善术后肛门功能。

Objective To evaluate the oncological and functional outcomes of intersphincteric resection （ISR） in T1-2 uhra-low rectal cancer. Methods From March 2000 to March 2007, ISR with total mesorectal excision （TME） was performed in 40 patients with very low rectal cancer,among whom total ISR in 5 patients, partial ISR in 23 patients, and partial ISR with partial dentate line preservation （modified partial ISR） in 12 patients. The preoperative tumor staging was T1-2N0-1M0. Results Morbidity was identified in 3 patients including anastomotic leakage in 1 patient and wound infection in 2 patients, and there was no postoperative mortality. The 5-year overall surival rate was 97%, and 5- year disease-free survival rate was 86%. Both patients with modified partial ISR （P=0.004） and patients with partial ISR （P=0.008） had significantly better continence than those with total ISR, and patients with a diverting stoma had significantly better continence （P=0.043） than those without a stoma at 12 months after surgery. Conclusions ISR is a safe procedure for sphincter-saving rectal surgery in selected patients with very low rectal tumors. A temporary diverting stoma may be beneficial to the improvement of anal function. Modified partial ISR under the precondition of radical resection shows better anal function and lower rate of incontinence.