KeyPort通路在经肛门内镜微创手术中的应用

Application of KeyPort access to transanal endoscopic mircrosurgery

目的探讨KeyPort通路在经肛门内镜微创手术(TEM)中应用的有效性。方法采用描述性病例系列研究的方法。回顾性收集2016年12月至2018年4月期间,首都医科大学附属北京朝阳医院行KeyPort通路经肛门微创手术的20例患者临床资料。KeyPort通路经肛门内镜微创手术步骤:扩肛,安置KeyPort通路,连接TEM气腹机、光源和成像设备;置入5 mm专用内镜,充气CO2,压力1.6~2.0 kPa(12~15 mmHg);冲洗肠腔,针形电刀环形标记切除范围,使用电凝或者超声刀沿标记线行全层切除。采用KeyPort通路经肛门微创手术适应证:(1)广基无蒂、内镜切除困难的良性病变;(2)直径<2 cm的黏膜下病变;(3)无淋巴结转移的Tis和T1期直肠癌;(4)无淋巴结转移的T2期直肠癌姑息切除者。禁忌证:(1)伴随全身严重疾病无法耐受麻醉和手术;(2)病变距离肛缘20 cm以上。结果全组患者男性10例,女性10例,年龄(63±15)岁,体质指数(24.5±3.3)kg/m^2。病变直径(2.0±1.3)cm,肿瘤距肛缘距离(6.2±2.2)cm。其中有1例患者直肠不同位置3处病变,直径分别为0.5 cm、0.5 cm和1.0 cm。所有患者均通过KeyPort通路完成手术,无中转其他方式手术。手术中位时间75(30~220)min,术中中位失血量10(0~30)ml。术中2例患者直肠前壁病变肠壁全层切除达腹膜反折以上,发生穿孔进入腹腔,即刻缝合关闭;有3处病变的患者,直径1.0 cm的病灶行全层切除,其余2处病变行黏膜下切除。均无术后并发症发生。术后病理提示,慢性炎性病变1例,良性肿瘤4例,原位癌3例,神经内分泌肿瘤4例,pT1期直肠癌6例,pT2期直肠癌2例(均侵犯浅肌层)。术后中位住院时间6(3~7)d。术后随访(7.2±3.8)月,均无肿瘤复发和远期并发症发生。结论TEM平台下采用KeyPort通路行经肛门内镜微创手术快捷有效。

Objective To explore the effectiveness of KeyPort access in transanal endoscopic mircrosurgery(TEM).Methods A descriptive case series study was performed.Clinicopathological data of 20 patients undergoing KeyPort access TEM in Beijing Chaoyang Hospital of Capital Medical University from December 2016 to April 2018 were collected and analyzed retrospectively.Procedure of KeyPort access TEM:general anesthesia or combined spinal epidural anesthesia(CSEA);lithotomy or prone jack-knife position;anal dilation;placement of the KeyPortaccess;connection of TEM pneumoperitoneum device,light source and imaging equipment;placement of 5 mm dedicated endoscope;insufflation of CO2 with pressure of 1.6-2.0 kPa(12-15 mmHg);after rinsing the intestinal lumen,circular resection marginlabeled by the needle-shaped electrocautery;electric coagulation or ultrasonic knife used to perform a full-thickness resection with a 0.5 cm-1 cm margin along the marking line.Indications of KeyPort access TEM:(1)benign large sessile polyps which were difficult to resect under colonoscopy;(2)submucosal lesions with diameter<2 cm;(3)Tis and T1 stage rectal carcinoma without lymph node metastasis;(4)palliative resection of T2 stage rectal carcinoma without lymph node metastasis.Contraindications:(1)accompanying serious diseases without the tolerance of anesthesia and operation;(2)distance from lesion to anal verge>20 cm.Results There were 10 males and 10 females with age of(63±15)years old and BMI of(24.5±3.3)kg/m^2.The diameter of the lesions was(2.0±1.3)cm,and the distance from lesion to anal verge was(6.2±2.2)cm.One patient had 3 lesions at different positions in rectum with diameters of 0.5 cm,0.5 cm,and 1 cm,respectively.All operations were accomplished through the KeyPort access TEM and no case was transferred to other methods.The duration of surgery was 75(30-220)minutes;intraoperative blood loss was 10(0-30)ml.Two patients with rectal anterior wall lesions underwent full-thickness resection of the intestine wall reaching the peritoneal reflex with penetration into the peritonealcavity,and received suture closure immediately.For the patient with 3 rectal lesions,the 1.0 cm lesion received a full-thickness resection and the other 2 lesions received submucosal resection.No postoperative complication occurred.Postoperative pathology showed that there were 1 case of chronic inflammatory lesion,4 cases of benign tumor,3 cases of carcinoma in situ,4 cases of neuroendocrine tumor,6 cases of pT1 rectal cancer,2 cases of pT2 rectal cancer(both invading the superficial muscle layer).The median hospital stay was 6(3-7)days.The postoperative follow-up was(7.2±3.8)months.No postoperative complication or recurrence was observed.Conclusion TEM with KeyPort access is safe,rapid and effective in the treatment of rectal tumors.