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目的探讨全直肠系膜切除(TME)+经肛门内括约肌切除术(ISR)治疗超低位直肠癌和直肠肛管癌保肛手术的安全性及可行性,并评价近期肿瘤根治效果及术后肛门功能。方法回顾性分析2009年1月至2010年12月期间四川大学华西医院胃肠外科中心行TME+ISR治疗的超低位直肠癌和直肠肛管癌86例患者的临床及随访资料。结果 86例患者均成功完成手术,肿瘤下缘距肛门1～5 cm(平均1.63 cm);肿瘤直径2～7 cm,平均3.4 cm。肿瘤系高分化4例,中分化60例,低分化22例;pTNM分期为Ⅰ期12例,ⅡA期11例,ⅡB期15例,ⅢA期2例,ⅢB期23例,ⅢC期16例,Ⅳ期7例。术后发生吻合口漏3例,肛周感染2例(其中1例因肛周严重感染引起盆腔、腹膜感染再次手术行永久性造口),吻合口出血及吻合口狭窄各2例,直肠阴道瘘、炎性肠梗阻、尿潴留和腹腔感染各1例。86例患者均获随访,平均随访时间为18个月(12～24个月)。1例于术后7个月发现肝转移,2例分别于术后7个月和12个月因肿瘤广泛浸润、转移死亡;术后1年局部复发3例(3.5%),1年生存率为97.7%(84/86),排便次数1～5次/d,控便功能按Kirwan评分标准可达1～2级。结论 TME+ISR治疗超低位直肠癌和直肠肛管癌是一种可行的、安全的、能达到根治的保肛术式,近期疗效满意。
Objective To investigate the safety and feasibility of total mesorectal excision (TME) + transanal sphincterotomy (ISR) in the treatment of anorectal surgery in ultra-low rectal cancer and rectum anal canal and to evaluate the recent radical curative effect and postoperative anal function . Methods The clinical and follow-up data of 86 patients with ultra-low rectal cancer and rectal cancer treated with TME + ISR at West China Hospital of Sichuan University from January 2009 to December 2010 were retrospectively analyzed. Results All the 86 patients were successfully operated. The lower edge of the tumor was 1 ~ 5 cm (average 1.63 cm) from the anus. The diameter of the tumor was 2 ~ 7 cm (average 3.4 cm). There were 4 cases of well-differentiated tumor, 60 cases of moderate differentiation and 22 cases of poor differentiation. There were 12 cases of pTNM stage Ⅰ, 11 cases of stage ⅡA, 15 cases of stage ⅡB, 2 cases of stage ⅢA, 23 cases of stage ⅢB, 16 cases of stage ⅢC, Ⅳ period in 7 cases. Anastomotic leakage occurred in 3 cases, 2 cases of perianal infection (1 case of pelvic peritoneal infection caused by severe infection, peritoneal re-operation of permanent ostomy), anastomotic bleeding and anastomotic stenosis in 2 cases, rectovaginal Fistula, inflammatory bowel obstruction, urinary retention and abdominal infection in 1 case. All 86 patients were followed up for an average of 18 months (range, 12-24 months). One patient had liver metastasis at 7 months after operation, and 2 patients died of extensive tumor invasion and metastasis at 7 and 12 months after operation. Local recurrence occurred at 1 year after operation in 3 patients (3.5%) and 1-year survival rate 97.7% (84/86), defecation frequency was 1 ~ 5 times / d, and the stool control function was up to 1 ~ 2 according to Kirwan score standard. Conclusion TME + ISR is a viable, safe and reassuring anal sphincter for the treatment of ultralow rectal cancer and rectal anal cancer. The short-term curative effect is satisfactory.