In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and ...In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.展开更多
Background:Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision(h-taTME),a completely incisionless surgical procedure has not ye...Background:Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision(h-taTME),a completely incisionless surgical procedure has not yet been developed.This study was performed to explore the efficacy of pure taTME(p-taTME)without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.Methods:We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018.Relevant patient characteristics and clinical information including the surgical procedure,specimens,pathological characteristics,and patients’post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.Results:Fifty-five patients who had undergone p-taTME were included in this study.They comprised 32(58.2%)men and 23(41.8%)women with a mean age of 65.6610.6 years and mean body mass index of 23.463.3 kg/m^(2).The median surgical time was 180.0(range,130–360)min and estimated blood loss was 25.0(range,15–80)mL.The commonest post-operative complication was varying degrees of faecal incontinence(56.4%).However,such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’quality of life.Conclusions:p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer,especially in those with obesity or a narrow pelvis.However,further studies of the indications and long-termefficacy are needed to verify the suitability of this procedure.展开更多
Background:Although the clinical importance of complete,intact total mesorectal excision(TME)is the widely accepted standard for decreasing local recurrence of rectal cancer,the residual mesorectum still represents a ...Background:Although the clinical importance of complete,intact total mesorectal excision(TME)is the widely accepted standard for decreasing local recurrence of rectal cancer,the residual mesorectum still represents a significant component of resection margin involvement.This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection.Methods:The distal mesorectum end was investigated retrospectively through a review of 124 operative videos at the Union Hospital of Fujian Medical University(Fujian,China)and Cleveland Clinic(Ohio,USA)by two independent surgeons who were blinded to each other.Furthermore,28 cadavers and 44 post-operative specimens were prospectively examined by hematoxylin and eosin(H&E)staining and Masson’s staining to validate and confirm the findings of the retrospective part.Univariate and multivariate analyses were carried out to detect the independent factors that can affect the visualization of the distal mesorectal end.Results:The terminal line(TL)is the distal mesorectal end of the transabdominal and transanal TME(taTME)and appears as a remarkable pearly white fascial structure extending posteriorly from 2 to 10 o’clock.Histopathological examination revealed that the fascia propria of the rectum merges with the presacral fascia at the TL,beyond which the mesorectum ends,with no further downward extension.In the retrospective observation,the TL was seen in 56.6%of transabdominal TME and 56.0%of taTME operations.Surgical approach and tumor distance from the anal verge were the independent variables that directly influenced the detection of the TL(P=0.03 and P=0.01).Conclusion: The TL is a visible sign where the transabdominal TME should end and the taTME should begin. Recognitionof the mesorectal end may impact the certainty of complete mesorectum inclusion. Further clinical trials are needed toconfirm the preliminary findings.展开更多
文摘目的探讨经肛门内镜显微手术(transanal endoscopic microsurgery,TEM)在不同特点的中低位直肠癌器官保留中的应用。方法回顾性分析北京协和医院于2017年1月至2023年10月间收治的81例行TEM术或采用TEM平台行经肛全直肠系膜切除术(transanal total mesorectal excision,taTME)的直肠癌患者资料。结果患者根据临床和病理特征被分为三组:早期直肠癌行TEM术组(A组)、进展期直肠癌新辅助治疗(neoadjuvant chemoradiotherapy,nCRT)后行TEM术组(B组)、进展期直肠癌采用TEM平台行taTME组(C组)。A组32例,临床分期cT1N0,均行TEM术;切除后具有高危因素者追加根治性手术或辅助放化疗。8例为肠镜切除后追加TEM术,术后病理均未见肿瘤。中位随访时间37.5个月(4~84个月),无病生存30例(93.75%)。B组36例,nCRT后达到cCR或near-cCR,行TEM术。术后病理ypT021例(58.3%)、ypT14例(11.1%)、ypT210例(27.8%)、ypT31例(2.8%)。中位随访时间56个月(12~80个月),无病生存26例(72.2%)。C组13例,临床分期为cT3+NanyM0或cTanyN+M0,所有患者nCRT后,采用TEM平台行taTME术。中位随访时间48个月(4~68个月),无病生存11例(84.6%)。三组患者年龄、体质量指数(body mass index,BMI)差异无统计学意义(P=0.818、0.934)。A、B组间肿瘤大小、距肛门距离、ASA差异有统计学意义(P=0.011、0.015、0.001)。B、C组间肿瘤大小、ASA差异有统计学意义(P<0.001、P=0.0276)。三组间5年无进展生存期比较,A、B组间差异有统计学意义(P=0.034),A、C组间差异无统计学意义(P=0.053),B、C组间差异无统计学意义(P=0.534)。结论TEM技术在中低位直肠癌保肛手术中具有重要作用,低危早期直肠癌可完整切除;对于有高危因素者,可在术后追加辅助放化疗。对于局部进展期直肠癌,如行nCRT后肿瘤退缩不明显,可以TEM为平台行taTME术,实现低位保肛,但并发症较多;如达到cCR或near-cCR且患者保肛意愿强烈,可考虑行TEM术,但可能牺牲无进展生存时间。
文摘In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.
文摘Background:Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision(h-taTME),a completely incisionless surgical procedure has not yet been developed.This study was performed to explore the efficacy of pure taTME(p-taTME)without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.Methods:We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018.Relevant patient characteristics and clinical information including the surgical procedure,specimens,pathological characteristics,and patients’post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.Results:Fifty-five patients who had undergone p-taTME were included in this study.They comprised 32(58.2%)men and 23(41.8%)women with a mean age of 65.6610.6 years and mean body mass index of 23.463.3 kg/m^(2).The median surgical time was 180.0(range,130–360)min and estimated blood loss was 25.0(range,15–80)mL.The commonest post-operative complication was varying degrees of faecal incontinence(56.4%).However,such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’quality of life.Conclusions:p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer,especially in those with obesity or a narrow pelvis.However,further studies of the indications and long-termefficacy are needed to verify the suitability of this procedure.
基金supported by the Chinese Scholarship Council(CSC)[grant number 2017DFH010880].
文摘Background:Although the clinical importance of complete,intact total mesorectal excision(TME)is the widely accepted standard for decreasing local recurrence of rectal cancer,the residual mesorectum still represents a significant component of resection margin involvement.This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection.Methods:The distal mesorectum end was investigated retrospectively through a review of 124 operative videos at the Union Hospital of Fujian Medical University(Fujian,China)and Cleveland Clinic(Ohio,USA)by two independent surgeons who were blinded to each other.Furthermore,28 cadavers and 44 post-operative specimens were prospectively examined by hematoxylin and eosin(H&E)staining and Masson’s staining to validate and confirm the findings of the retrospective part.Univariate and multivariate analyses were carried out to detect the independent factors that can affect the visualization of the distal mesorectal end.Results:The terminal line(TL)is the distal mesorectal end of the transabdominal and transanal TME(taTME)and appears as a remarkable pearly white fascial structure extending posteriorly from 2 to 10 o’clock.Histopathological examination revealed that the fascia propria of the rectum merges with the presacral fascia at the TL,beyond which the mesorectum ends,with no further downward extension.In the retrospective observation,the TL was seen in 56.6%of transabdominal TME and 56.0%of taTME operations.Surgical approach and tumor distance from the anal verge were the independent variables that directly influenced the detection of the TL(P=0.03 and P=0.01).Conclusion: The TL is a visible sign where the transabdominal TME should end and the taTME should begin. Recognitionof the mesorectal end may impact the certainty of complete mesorectum inclusion. Further clinical trials are needed toconfirm the preliminary findings.
