经肛门拖出吻合器吻合法在腹腔镜直肠癌根治术中的应用

Application of Transanal Anastomosis with Stapler in Laparoscopic Radical Resection for Rectal Cancer

目的探讨经肛门拖出吻合器吻合在腹腔镜直肠癌根治术中应用的可行性及临床疗效。方法 2010年6月~2013年1月,采用腹腔镜辅助经肛门拖出吻合器吻合法治疗30例中低位直肠癌。22例≤T2期,8例T3期,均为N0,M0。电子结肠镜检查显示肿瘤下缘距肛缘的距离4.0~10.0 cm,(7.6±1.5)cm;肿瘤直径2~6 cm,(3.8±1.3)cm。先在腹腔镜下进行直肠全系膜切除,于耻骨联合上做下腹部正中辅助切口,直视下切断近端结肠,经肛门拖出切除直肠标本,应用双荷包、单吻合器技术,以国产管型消化道吻合器(31.5 mm或28.5 mm)行结-直肠端端吻合。结果 30例手术均顺利完成。手术时间170~280 min,(216.3±25.9)min。术中出血量50~700 ml,(273.3±160.1)ml。术后肛门排气时间1~4 d,(2.5±0.8)d。术后住院时间8~30 d,(12.2±4.2)d。肠管远端切缘距肿瘤的距离2.0~6.0 cm,(3.9±0.9)cm。远近切缘均未见癌残留。术后发生吻合口漏1例(3.3%),腹腔积液并感染1例(3.3%),均经非手术治疗治愈,无腹腔内出血、肠梗阻、吻合口出血等并发症。随访6~24个月,(11.8±3.9)月,术后3个月大便次数1~5次/d;1例吻合口瘢痕收缩狭窄,排便困难,予以扩肛等处理后好转;1例术后16个月局部肿瘤复发,行腹-会阴联合直肠癌根治术(Miles手术)。结论经肛门拖出吻合器吻合联合腹腔镜手术治疗中低位直肠癌安全可行,值得推广应用。

Objective To investigate the feasibility and clinical effect of transanal anastomosis with stapler in laparoscopic radical resection for rectal caneer. Methods The clinical data of 30 patients undergoing transanal anastomosis with stapler during laparoscopic radical resection for middle-low rectal cancer from June 2010 to January 2013 in our hospital were retrospectively analyzed, cTNM stage of the cases included 22 cases of T1 or T2 and 8 cases of T3;all the 30 cases were NO and M0. Electronic colonoscopy showed the distance from anal edge to the tumor was 4.0 - 10.0 cm （ mean, 7.6 ± 1.5 cm）. The diameter of tumor was 2- 6 cm （mean, 3.8 ± 1.3 cm）. The surgery was performed under laparoscopy with the standard total mesorectal excision （TME） technique first and a lower abdominal midline incision was made afterwards. The proximal colon was cut off under direct gaze, and the rectal stump was pulled out through the anus. The anastomosis was performed u^ing a double ring suture and single stapling technique, with a 31.5 mm or 28.5 mm circular stapler in diameter made in China. Results All the 30 surgeries were successfully completed. The operative time was 170 - 280 （216.3 ± 25.9） min and the intraoperative blood loss was 50 - 700 （273.3 ± 160.1 ） ml. Intestinal function recovery time was 1 -4 （2.5±0.8） d, and postoperative hospital stay was 8 - 30 （ 12.2±4.2） d. The lengths of distal resection margin was 2.0 - 6.0 （3.9 ± 0.9） cm, and no residual tumor was found in the margin. Anastomotic leakage occurred in 1 case （3.3 % ）, and peritoneal effusion and infection in 1 case （3.3 % ）. The 2 cases were treated by non-surgical treatment. No intraabdominal bleeding, intestinal obstruction,or anastomotic bleeding occurred. During the follow-up of 6 - 24 months （ mean, 11.8 ± 3.9 months）, the defecation frequency was 1 to 5 times per day, 1 case had anastomotic stenosis with difficult defecation due to scar contraction, which improved after anal dilatation, and one case had local recurrence of tumor 16 months after the surgery and treated by Miles operation. Conclusion Transanal anastomosis with stapler in laparoscopic radical resection for middle-low rectal cancer is safe and feasible.