直肠系膜全切除术的合理实施

On rationality of total mesorectal excision for rectal cancer

目的 从直肠癌术后局部复发形式探讨直肠系膜全切除 (TME)的合理实施及临床意义。方法 分析 2 0 7例局部复发直肠癌患者的复发形式、治疗情况及治疗效果。结果 吻合口复发71例 ,直肠系膜复发 6 5例 ,会阴部复发 5 0例 ,淋巴结复发 5 9例 ,多部位复发 89例 ,其他部位少见。第 1次行前切除术 (AR)的 81例患者中 ,改行腹会阴联合切除术 (APR)者 5 8例 ;第 1次行APR者 10 2例 ,改行会阴部肿块切除者 38例 ;行全盆及后盆器官切除者 15例 ,补充行淋巴结清除者 18例。手术切除率为 6 6 .2 % (137/2 0 7) ,其中根治性切除率为 4 6 .0 % (6 3/137)。 172例有完整随访资料的患者中 ,病灶切除者的 5年生存率为 2 3.4 % (32 /137) ,根治切除者的 5年生存率为 34.9% (2 2 /6 3)。结论 从局部复发形式来看 ,TME是中低位直肠癌手术必须遵循的原则 ,复发患者只要全身条件允许 ,应再行手术治疗。

Objective To discuss the rationality and clinical significance of total mesorectal excision (TME) assessed by the pattern of local recurrence of rectal cancer. Methods 207 rectal cancer patients treated by surgery from 1975 to 2001 who developed local recurrence were retrospectively studied as to the option of treatment based on their outcome. 172 of these 207 patients had complete record of follow up with a follow up rate of 83.0%. Results The local recurrent sites of 207 patients were: anastomotic stoma 71, mesorectum 65, perineum 50, lymph nodes 59, multiple recurrences 89 and others sites rare. Among 81 patients who had been first treated by anterior resection (AR), 58 were again treated by abdomino perineal resection (APR). Among 102 patients who had been treated by APR, 38 were treated by perineal tumor resection, 15 were treated by total and posterior pelvic organ resection, and 18 were supplemented with lymph node resection. By all modalities, the resection rate was 66.1%(137/207),in which the curable resection rate was 46%(63/137). The 5 year survival rate of patients with tumor resection was 23.3% (32/137), those treated by curable resection was 34.9% (22/63). Conclusion From the pattern of local recurrence, the operation for middle lower rectal cancer must follow the principle of total mesorectum excision(TME). Patients with local recurrence should be energetically treated in the second operation if tolerable. [