经肛门内镜微创手术治疗32例直肠腺瘤

Analysis of 32 patients with rectal adenoma undergoing transanal endoscopic microsurgery

目的 评估经肛门内镜微创手术（TEM）治疗直肠腺瘤临床应用的安全性及疗效.方法 2006年9月至2010年2月共32例术前诊断为直肠腺瘤的患者接受TEM治疗,总结其治疗结果.结果 全组患者肿瘤直径0.6～10.0（2.31.2）cm.手术时间为20～180（平均70）min,术中平均出血量小于10 ml,无中转开腹手术.22例（68.8%）行创面缝合,其中全层切除14例;有2例上段直肠肿瘤行全层切除时切穿至腹膜腔,予腔内连续缝合修补破损,术后均未发生肠漏.R0切除31例（96.9%）.术后病理示单纯腺瘤12例;腺瘤伴低级别上皮内瘤变10例;腺瘤伴高级别上皮内瘤变5例;腺瘤局灶癌变5例,均为T1期.术后并发肛门出血、急性尿潴留和肺部感染各1例.术后平均住院时间为4.5（3～8）d;平均随访23（2～43）个月,2例出现复发.结论 TEM手术创伤小、切除精确,是一种对直肠较大腺瘤安全有效的微创手术方法.

Objective To evaluate the safety and outcomes after transanal endoscopic microsurgery （TEM）for rectal adenoma. Methods Data of 32 patients undergoing TEM for rectal adenoma between September 2006 and February 2010 in the Ruijin Hospital were reviewed. Results The adenoma diameter ranged from 0.6 to 10.0（2.3±1.2） cm. The mean operative time was 70（range,20-180） min. The estimated blood loss was less than 10 ml. There were no conversions to transabdominal procedure. Twenty-two （68.8%） patients underwent suturing of the wound, of whom 14 had fullthickness resection. Two patients had perforation into peritoneal cavity during full-thickness resection,which were repaired by continuous suturing and no postoperative leak occurred. R0 resection was achieved in 31（96.9%） patients. Postoperative pathology showed 12 simple adenomas, 10 adenomas with low grade intraepithelial neoplasia, 5 adenomas with high grade intraepithelial neoplasia, and 5 T1 focal carcinomas. Complications included rectal bleeding in 1 patient, acute urinary retention in 1 patient, and pulmonary infection in 1 patient. The postoperative stay was 4.5 （3-8） days. The patients were followed-up for a period of 23 months （range, 2-43 months）. There were 2 tumors recurred.Conclusion TEM is a safe and effective minimally invasive surgical technique for large rectal adenomas.