论经肛全直肠系膜切除术能否做到真正的全直肠系膜切除术

Whether the transanal total mesorectal excision can achieve a real total mesorectal excision

自20世纪80年代初，Heald报道全直肠系膜切除术（TME），经腹TME已成为中低位直肠癌手术的金标准手术方式。而传统的经腹TME，特别是对于低位直肠癌、肥胖症、男性狭窄骨盆的患者，存在暴露困难的问题。因此，经肛全直肠系膜切除术（TaTME）的提出，旨在克服经腹途径的暴露困难。但是，TaTME能否做到真正的TME？其直肠系膜远切缘是否足够？其远切缘标志在哪里？能否保证手术标本环周切缘及直肠系膜质量？目前尚存在争议。笔者拟对直肠癌的定义、经腹TME的相关原则进行梳理，并对既往发表的TaTME临床研究进行回顾，结合直肠肛管和盆底相关应用解剖和相关指南共识，论述TaTME是否能达到真正的TME原则，并讨论其适用范围。

The total mesorectal excision （TME） developed by Heald in 1982, is the present gold standard treatment of middle and low rectal cancer. However, traditional transabdominal TME remains a technically demanding procedure in patients with a narrow pelvis, bulky tumors, or obesity. To overcome the technical difficulties associated with transabdominal rectal dissection, transanal total mesorectal excision （TaTME） has recently been introduced. However, can TaTME achieve comparable outcomes in comparison with transabdominal TME？ Is the distal margin of the mesorectum sufficient？ Where is the sign of distal margin of mesorectum？ Can the circumferential margin （CRM） and specimen quality be guaranteed？ The aim of this comment was to discuss whether the TaTME can achieve a real TME from the following aspects： the principles of transabdominal TME, current published TaTME clinical trials, and the anorectal and pelvic anatomy.