经肛门内外括约肌间延伸平面辅助实施全直肠系膜切除术

A procedure to assist achievement of total mesorectal excision through the extending intersphinctericplane

目的探讨经肛门内外括约肌问延伸平面辅助实施全直肠系膜切除术（TME）的应用价值。方法回顾性分析2006年2月至2010年4月65例采用经肛直视下在内外括约肌间的延伸平面辅助实施TME并成功保肛的低位直肠癌患者的临床资料，随访患者的术后并发症情况及肿瘤学结果。结果患者平均手术时间（245±42）min，平均出血量（114±76）ml。无围手术期死亡病例。术后发生吻合口漏2例，吻合口狭窄13例。术后早期炎性肠梗阻2例，泌尿道感染1例，切口感染1例。所有标本环周切缘及远切缘皆为阴性。病理分期TNMI期26例，TNMII期17例，TNMm期22例。平均随访时间（48±19）个月，失访10例。远处转移与局部复发共15例，8例死于肿瘤转移复发。局部复发转移3例，分别于术后35、36、52个月发现骶前复发、左侧盆腔淋巴结转移、骶骨转移。无吻合121复发病例。TNMI、Ⅱ、Ⅲ期患者5年累积生存率分别为100％、93．3％、63．1％，5年累积无病生存率分别为96．2％、83．3％、44．8％。结论经肛门内外括约肌间延伸平面辅助实施TME是解决经腹实施全直肠系膜切除术操作困难的有效技术手段，具有良好的手术安全性和肿瘤根治效果。

Objective To investigate the value of assisted achievement total mesorectal excision （TME） through the extending intersphincterie plane. Methods From February 2006 to April 2010, 65 patients with low rectal cancer underwent assisted implementing TME through the extending intersphincteric plane under direct vision and achieved sphincter preservation. The clinical data was summarized and analyzed retrospectively. Follow-up visits were conducted on complications and oneological outcomes. Results The mean operation time was （245 ±42） minutes, and the mean intraoperative blood loss was （114 ± 76） ml. There was no postoperative mortality. Postoperative complications included 2 cases of anastomotic leak, 13 cases of anastomotie stenosis, 2 cases of early postoperative inflammatory ileus, 1 case of urinary tract infection, and 1 case of incision infection. Distal margins and circumferential resection margin of all specimens were negative. For pathological stage, there were 26 cases at stage pTNM I , 17 cases at stage pTNM H and 22 cases at stage pTNMIII. The mean follow-up time was （47.9 ± 18.9） months. 10 patients were lost to follow up, 15 cases had distant metastasis or local recurrence in, and 8 cases died of tumor metastasis at the latest follow up. Local recurrence occurred in 3 cases, including recurrence in presacral region, metastasis of lymph node at the left side in pelvis cavity, and metastasis at the sacrum at 35, 36, and 52 months postoperatively. There was no anastomotic recurrence. Log-rank survival analysis showed 5-year cumulative survival rate was 100%, 93.3%, and 63.1% in TNM stage I , II, and III, respectively. The cumulative disease-free survival rate was 96. 2%, 83.3% , 44. 8% in TNM stage I ,I]I , and m, respectively. Conclusion It has a good oncological effect and was an advantageous procedure to assist achievement total mesorectal excision （TME） through the extending intersphincteric plane as surgeons encountered with difficulties from transabdominal TME.