Surgical resection of rectal adenoma:A rapid review

Transanal excision (TE), endoscopic transanal resection (ETAR) and transanal endoscopic microsurgery (TEM) can be used to remove adenomatous polyps. However, their use is limited by the size or location of the tumor. TE is limited to the lower rectum, TEM offers better access to lesions in the middle and upper rectum, and ETAR is used less frequently than it deserves for resection of rectal lesions.

CLINICOPATHOLOGICAL ANALYSIS OF 50 RECTAL CANCER CASES DIAGNOSED AS ADENOMA IN BIOPSY

Objective: To evaluate the clinicopathological characteristics of rectal cancer diagnosed as adenoma in biopsy. Methods: 50 rectal cancer cases diagnosed as adenoma in biopsy were analyzed retrospectively in this study by comparing the biopsy and postoperative pathology. Results: Among these 50 patients, biopsy pathology showed 26% (13/50) adenoma with mild dysplasia, 30% (15/50) adenoma with moderate dysplasia, and 44% (22/50) adenoma with severe dysplasia. In 8 cases, the adenomas were smaller than 2cm. On postoperatively surgical pathology, only 10 cases were carcinoma-in-situ, while 40 cases were invasive cancer. Conclusion: Special emphasis should be taken to biopsy-negative rectal adenomas and those smaller than 2cm.

Solitary rectal ulcer syndrome complicating sessile serrated adenoma/polyps: A case report and review of literature

Solitary rectal ulcer syndrome(SRUS) is a rare benign condition, which can mimic many other diseases because of their similarities in clinical, endoscopic and histological features. Sessile serrated adenoma/polyp(SSA/p) is a premalignant lesion in the colon and rectum. The misdiagnosis of SSA/p in SRUS patients has been noted, but the case of SRUS arising secondarily to SSA/p has been rarely reported. We herein report the case of a 59-year-old man who presented with an ulcerative nodular lesion in the rectum, accompanied by the symptoms of blood and mucus in the feces, diarrhea and constipation. Magnetic resonance imagining revealed thickening of the rectal mucosa-submucosa. Histologically, the lesion was characterized by the hyperplastic lamina propria and diffusely serrated crypts. Further immunohistochemical staining showed the loss of HES1 and MLH1 expression in the epithelial cells in the serrated area. The patient with SRUS had histological changes of SSA/p, suggesting a potential of tumor transformation in certain cases. SRUS uncommonly accompanied by serrated lesions should at least be considered by pathologists and clinicians.

脂联素基因多态性与直肠腺瘤切除预后相关性分析

目的:探讨脂联素(APN)基因多态性与直肠腺瘤(RA)切除预后的相关性。方法:选取接受切除手术治疗的RA病人97例,根据预后情况,将复发RA病人52例作为观察组,无复发病人45例作为对照组。通过聚合酶链式反应-限制性片段长度多态性(PCR-RELP)法检测受试者血清中APN基因rs2241766位点多态性基因分布频率,并分析APN单核苷酸多态性各基因型与RA切除预后的相关性。结果:APN基因rs2241766位点基因型有TT野生型、TG杂合子型、GG纯合子型,对照组与观察组APN基因rs2241766位点基因型符合Hardy-Weinberg平衡定律,2组APN基因rs2241766位点基因型及等位基因频率差异均有统计学意义(P<0.01)。突变杂合子TG型、突变纯合子GG型病人的腺瘤数、腺瘤最大径及平均直径均大于野生TT型(P<0.05),纯合子GG型病人腺瘤数、腺瘤最大径及平均直径均大于杂合子TG型(P<0.05)。二元logistic回归分析显示,APN基因rs2241766位点TG型、GG型突变均为RA切除后复发的危险因素(P<0.01)。结论:APN基因rs2241766位点多态性与RA切除预后具有相关性。

Colorectal cancer screening by non-invasive metabolic biomarker fecal tumor M2-PK

AIM: To evaluate the utility of the innovative fecal tumor M2-Pyruvate kinase (M2-PK) test in our daily clinical routine, as a marker for the pre-selection of patients who should subsequently undergo colonoscopy for the diagnosis or exclusion of colorectal cancer. METHODS: Fecal tumor M2-PK was measured in stool samples of 96 study participants (33 patients with colorectal cancer, 21 patients with rectal carcinoma and 42 controls) who all underwent total colonoscopy. RESULTS: In 39 of 42 individuals in the control group, fecal tumor M2-PK was below 4.0 kU/L (93% specificity). Colorectal tumors were accompanied by a highly significant increase (P < 0.001) in fecal tumor M2- PK levels (median: colon carcinoma, 23.1 kU/L; rectal carcinoma, 6.9 kU/L; colorectal carcinoma, 14.7 kU/L), which correlated with Duke’s staging and T-classification. The overall sensitivity was 78% for colorectal cancer, increasing from 60% for stage T1 to 100% for stage T4 and from 60% for Duke’s A to 90% for Duke’s D tumors. CONCLUSION: Fecal tumor M2-PK is an appropriately sensitive tool to pre-select those patients requiring colonoscopy for the further diagnostic confirmation or exclusion of colorectal cancer.

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

Restorative proctocolectomy is the most common surgical option for patients with familial adenomatous polyposis(FAP). However,adenomas may develop in the ileal pouch mucosa over time,and even carcinoma in the pouch has been reported. We therefore reviewed the prevalence,nature,and treatment of adenomas and carcinoma that develop after proctocolectomy in the ileal pouch mucosa in patients with FAP. In 25 reports that were reviewed,the incidence of adenomas in the ileal pouch varied from 6.7% to 73.9%. Several potential factors that favor the development of pouch polyposis have been investigated,but many remain controversial. Nevertheless,it seems certain that the age of the pouch is important. The risk appears to be 7%to 16% after 5 years,35% to 42% after 10 years,and75% after 15 years. On the other hand,only 21 cases of ileal pouch carcinoma have been recorded in the literature to date. The diagnosis of pouch carcinoma was made between 3 to 20 years(median,10 years) after pouch construction. Although the risk of malignant transformation in ileal pouches is probably low,it is not negligible,and the long-term risk cannot presently be well quantified. Regular endoscopic surveillance,especially using chromoendoscopy,is recommended.

Colonoscopy surveillance for high risk polyps does not always prevent colorectal cancer

AIM To determine the frequency and risk factors for colorectal cancer(CRC) development among individuals with resected advanced adenoma(AA)/traditional serrated adenoma(TSA)/advanced sessile serrated adenoma(ASSA). METHODS Data was collected from medical records of 14663 subjects found to have AA, TSA, or ASSA at screening or surveillance colonoscopy. Patients with inflammatory bowel disease or known genetic predisposition for CRC were excluded from the study. Factors associated with CRC developing after endoscopic management of high risk polyps were calculated in 4610 such patients who had at least one surveillance colonoscopy within 10 years following the original polypectomy of the incident advanced polyp. RESULTS84/4610(1.8%) patients developed CRC at the polypectomy site within a median of 4.2 years(mean 4.89 years), and 1.2%(54/4610) developed CRC in a region distinct from the AA/TSA/ASSA resection site within a median of 5.1 years(mean 6.67 years). Approximately, 30%(25/84) of patients who developed CRC at the AA/TSA/ASSA site and 27.8%(15/54) of patients who developed CRC at another site had colonoscopy at recommended surveillance intervals. Increasing age; polyp size; male sex; right-sided location; high degree of dysplasia; higher number of polyps resected; and piecemeal removal were associated with an increased risk for CRC developmentat the same site as the index polyp. Increasing age; right-sided location; higher number of polyps resected and sessile endoscopic appearance of the index AA/TSA/ASSA were significantly associated with an increased risk for CRC development at a different site. CONCLUSION Recognition that CRC may develop following AA/TSA/ASSA removal is one step toward improving our practice efficiency and preventing a portion of CRC related morbidity and mortality.

直肠肿瘤局部切除治疗进展

早期直肠癌的根治性局部切除术目前仍存在争议,而治愈性的直肠息肉局部切除和姑息性的直肠癌局部切除术已经被大家认可。直肠肿瘤的局部切除存在多种手术方式,经肛门局部切除术在临床最常见,与其它的局部切除方式一样其应用还受到一定的限制。经肛门内窥镜下微创外科(TransanalEndoscopicMicrosurgery,TEM)技术是最近几年发展起来的一门新的微创外科技术,这项技术是针对直肠肿瘤的局部切除而设计,与其它局部切除手术相比死亡率和复发率最低,目前国内尚未开展这项技术。本文介绍了各种经肛门进行直肠肿瘤局部切除手术的优缺点,重点介绍了TEM手术的特点。

经肛门内镜微创手术治疗直肠肿瘤76例

目的探讨经肛门内镜微创手术(TEM)治疗直肠肿瘤临床应用的疗效。方法选择76例接受TEM临床治疗的的患者资料,分析TEM在直肠肿瘤治疗中应用效果。直肠病灶平均直径为(2.3±0.5)cm(0.7～5.2cm),距齿线平均距离(4.8±2.1)cm(1.5～15.5cm),病灶在直肠内的部位:前壁23例,后壁16例,左侧壁15例,右侧壁22例。结果 76例患者手术方式包括TEM肠壁全层切除63例,黏膜下及部分肌层切除13例。平均手术时间(65.0±35)min(25～180min),平均失血(15.6±8.5)mL(10～80mL)。术后病理学检查:直肠腺瘤22例,直肠腺瘤癌变和直肠癌20例(其中Tis期12例,T1期7例,T2期5例),直肠类癌12例,直肠间质肿瘤7例,直肠平滑肌瘤2例,炎性息肉13例,标本切缘皆为阴性。术后并发肛门出血2例,泌尿系感染1例,并发症发生率3.9%,术后平均住院日(3.4±1.4)d(2～8d)。平均术后随访14.6个月,未发现肿瘤复发转移。结论 TEM治疗直肠肿瘤具有手术损伤小、疗效好、恢复快、切除精确等优点。对于术前诊断肿瘤性质明确及术后明确为T1期癌变者,TEM是一种治愈性的、安全有效的微创手术方法。

直肠绒毛状腺瘤及腺瘤癌变的外科治疗(附49例临床分析)

目的 探讨直肠绒毛状腺瘤及腺瘤癌变的手术治疗。方法 对 49例手术治疗的直肠绒毛状腺瘤及腺瘤癌变病例进行回顾性研究及随访。经肛门括约肌径路切除（ Mason术） 20例，直肠前切除术 (Dixon术 )11例，经肛门局部切除 (transanal excision， TE) 7例，其他手术 11例。结果 49例患者中术后并发症发生率为 14.3％ ,术后复发率为 16.3％。 Manson术后并发症发生率和术后复发率分别为 10％和 0％。结论 Manson术是切除直肠中下段绒毛状 腺瘤比较理想的术式。

腔内彩色多普勒技术诊断直肠良、恶性肿瘤的价值

目的探讨腔内彩色多普勒超声技术在直肠肿瘤诊断中的应用价值。材料和方法应用腔内彩色多普勒超声技术及彩色血管能量成像(CPA)检测65例直肠癌和13例直肠腺瘤患者,分析肿瘤超声表现及血供,测量瘤内动脉收缩期峰值速度(PSV)、舒张末期流速(EDV)、阻力指数(RI)。结果腺瘤肠壁层次清晰,肿瘤多为高回声,直肠癌正常肠壁层次消失,肿瘤为低回声。直肠癌频谱为高阻型,直肠腺瘤为低阻型。结论直肠肿瘤的超声表现及血液动力学特征有助于良恶性肿瘤的诊断及鉴别。

28例低位直肠绒毛状腺瘤癌变局部切除治疗经验

目的:探讨合理选择治疗低位直肠绒毛状腺瘤癌变的手术方式。方法:回顾性分析我院28例经局部切除治疗的低位直肠绒毛状腺瘤癌变的临床资料,并加以讨论。结果:经肛局部切除(transanalexcision,TE术)20例,经骶局部切除(Kraske术)8例。术后病理高、中分化腺癌27例,低分化腺癌1例;肿瘤浸润粘膜层13例,浸润粘膜下层12例,浸润肌层3例。术后复发4例,转移2例,5年生存率78.6%(22/28)。结论:直肠绒毛状腺瘤癌变恶性程度低,对于病变位于低位直肠的患者,只要符合适应证,则局部切除术既可以达到根治术的疗效,又能保留正常排便功能,提高患者生存质量。

MRI对直肠腺瘤的诊断价值及临床分析

目的探讨直肠腺瘤的MRI影像学特征,提高对直肠腺瘤的诊断水平。方法对26例经手术病理证实的直肠腺瘤病人的临床资料进行回顾性分析。结果26例直肠腺瘤中管状腺瘤4例,管状绒毛状腺瘤17例,绒毛状腺瘤5例。MRI影像特征有:从黏膜层向腔内呈团块状或菜花状生长,肠壁无增厚,宽基底生长;平扫T1WI以低信号为主,T2WI以稍高信号为主,b=800s/mm2时DWI轻度扩散受限呈稍高信号,增强扫描以轻中度强化为主;病灶与直肠壁相贴时留下通气的间隙20例,可作为直肠腺瘤的特征性表现。结论 MRI有助于直肠腺瘤的诊断及鉴别。

经直肠双平面腔内超声在诊断直肠腺瘤局部恶变中的价值

目的探讨经直肠双平面腔内超声在诊断直肠腺瘤局部恶变中的应用价值。方法应用彩色多普勒超声诊断仪经直肠双平面探头,对临床怀疑为直肠腺瘤局部恶变的37例老年患者进行检查,并将诊断结果与术后病理结果进行对比。结果 37例患者中,术后病理诊断直肠腺瘤局部恶变32例,超声诊断直肠腺瘤局部恶变29例。经直肠双平面腔内超声诊断直肠腺瘤局部恶变的准确率、敏感度、特异度、阳性预测值、阴性预测值、假阳性率、假阴性率分别为90.6%、90.6%、100%、100%、62.5%、0%、9.4%。结论经直肠双平面腔内超声对直肠腺瘤局部恶变的诊断准确率较高,可作为指导手术的首选方法。

经肛门内镜显微手术在直肠肿瘤局部切除术中的应用

目的初步评价经肛门内镜显微手术（transanal endoscopic microsurgery，TEM）在直肠肿瘤局部切除术中的应用。方法2006年4月至9月对8例直肠肿瘤患者采用TEM行局部切除术。术前根据直肠腔内超声肿瘤分期：uTo期6例，uTis期和uT1期各1例。肿瘤距肛缘距离平均7（4～9）cm；肿瘤直径平均1．5（1～2．5）cm；肿瘤占据肠腔周径比例平均20％（10％～30％）。结果8例直肠肿瘤均获完整切除（粘膜下切除3例，全层切除5例），各切缘均阴性。手术时间平均50（40～60）min；术中平均出血量30（10～50）ml。术后住院天数平均5（2～7）d。无一例出现手术并发症。术后病理分期：pT0期5例，pTis期、pT1期和pT2期各1例。8例术后随访平均3（1～5）个月，肿瘤无局部复发。结论TEM显露良好、切除精确，手术安全、创伤小，经严格选择病例可用于良性直肠肿瘤和早期直肠癌的彻底切除。

3.0T磁共振动态对比增强及扩散加权成像在绒毛状腺瘤和直肠癌鉴别中的应用

目的评价3.0T磁共振动态对比增强成像(dynamic contrast-enhanced magnetic resonance imaging,DCEMRI)及扩散加权成像(diffusion-weighted imaging,DWI)在绒毛状腺瘤和直肠癌鉴别诊断中的作用。方法收集2015年3月-2016年3月在新疆医科大学附属肿瘤医院经病理证实的10例绒毛状瘤患者和30例直肠癌患者作为实验组,选取14例正常人作为对照组,两组均行3.0T DCE-MRI及DWI检查。比较两组容积转运常数(Volume transfer constant,K^(trans))、速率常数(Rate constant,K_ep)、容积百分数(Volume per unit tissue volume,V_e)及表观扩散系数(Apparent diffusion coefficient,ADC),并分析ADC值对绒毛状腺瘤与直肠癌的诊断效能。结果对照组与实验组患者的K^(trans)、K_ep、V_e及ADC值差异均有统计学意义(P<0.01)。以ADC<0.905×10^(-3)mm^2/s为鉴别直肠癌与绒毛状腺瘤的界值,其敏感性为84.6%,特异性为87.5%。结论 K^(trans)、K_ep、V_e及ADC值对绒毛状腺瘤和直肠癌的鉴别诊断具有参考价值。

直肠管状腺瘤自发破裂1例报告

直肠管状腺瘤自发破裂在临床罕见,死亡率高,因此必须引起临床医生重视.

16例直肠腺瘤的CT影像分析

[目的]探讨直肠腺瘤的CT表现。[方法]对16例经病理证实的直肠腺瘤CT表现进行回顾性分析。[结果]16例腺瘤按病理类型分为绒毛状腺瘤,管状绒毛状腺瘤和管状腺瘤,其中8例恶变。CT征象如下:广基生长有8例,窄基带蒂生长的5例,环壁增厚的有4例;向腔内匍匐式或菜花状生长的有10例;占肠周径比率在1/3以下的9例;病灶与直肠壁相贴时留下通气的间隙7例,可作为直肠腺瘤的特征性表现。[结论]一般直肠腺瘤均具有典型的CT表现,术前明确的腺瘤的CT诊断对于手术方式有重要影响。

大肠腺瘤及癌中细胞凋亡和bcl-2、bax基因的表达

目的：探讨细胞凋亡及其调控基因ｂｃｌ－２和ｂａｘ与大肠癌发生发展之间的关系。方法：采用Ｆｅｕｌｇｅｎ染色、ＴｄＴ酶介导的生物素化ｄＵＴＰ缺口末端标记（ＴＵＮＥＬ）技术和免疫组织化学Ｓ－Ｐ法，分别检测大肠正常粘膜、腺瘤、癌及癌旁非腺瘤性不典型增生中细胞凋亡率和ｂｃｌ－２、ｂａｘ基因的表达。结果：大肠腺瘤及癌细胞凋亡率显著高于正常粘膜（Ｐ＜０．０１）。高分化癌凋亡率显著高于低分化癌（Ｐ＜０．０５）。ｂｃｌ－２在正常粘膜腺窝底部、７８．９％（１５／１９）的腺瘤、７５％（３０／４０）的癌及８９．５％（１７／１９）的癌旁不典型增生中有表达。高分化癌与低分化癌阳性率差异显著（Ｐ＜０．０５）。癌的ｂｃｌ－２表达与凋亡率显著负相关（Ｐ＜０．０５）。ｂｃｌ－２／ｂａｘ与大肠癌细胞凋亡率有关（Ｐ＜０．０５）。结论：大肠癌发生过程中细胞凋亡受到抑制，表现为凋亡的相对不足。ｂｃｌ－２／ｂａｘ是影响细胞凋亡的重要因素。

直肠腺瘤中西医结合临床研究

目的:探讨中西医结合治疗直肠腺瘤的临床疗效。方法:选取2012年1月—2014年1月我院收治的直肠腺瘤患者70例,按照入院编号将患者随机分为观察组和对照组各35例,对照组患者给予手术治疗;观察组患者在手术基础上进行中医辨证治疗,比较两组患者的术后并发症率、术后复发率及癌变率。结果:经上述治疗后,观察组患者的术后并发症率、6个月复发率及癌变率分别为5.6%、8.6%、0,均显著低于对照组水平,上述3项指标的组间差异均有统计学意义(P<0.05)。结论:中西医结合治疗直肠腺瘤,能够明显改善治疗效果,降低术后复发率和癌病率,提高患者的预后质量,值得在临床上推广使用。