Saito Norio, Ono Masato, Sugito Masanori, Ito Masaaki, Morihiro Masato, Kosugi Chihiro, Sato Kazunori, Kotaka Masahito, Nomura Satoru, Arai Manabu, Kobatake Takaya
Colorectal Surgery Division, Department of Surgical Oncology, National Cancer Center, Hospital East, Kashiwa, Japan.
Dis Colon Rectum. 2004 Apr;47(4):459-66. doi: 10.1007/s10350-003-0088-4. Epub 2004 Feb 25.
Abdominoperineal resection has been the standard surgery for very low rectal cancer located within 5 cm of the anal verge. However, permanent colostomy exerts serious limitations on quality of life. The present study aimed to investigate curability and functional results of intersphincteric resection and additional partial external sphincteric resection for carcinoma of the anorectal junction.
Thirty-five patients were prospectively studied from November 1999 to September 2002. All patients displayed adenocarcinoma (T3: n = 26; T2: n = 7; T1: n = 2) located between 0 and 2 cm above the dentate line. Abdominotransanal rectal resection with total mesorectal excision was performed in all patients (total intersphincteric resection: n = 14; subtotal intersphincteric resection: n = 5; additional partial external sphincteric resection: n = 6). All patients underwent diverting colostomy, which was closed at a median of six months postoperatively. Twenty patients received preoperative radiochemotherapy.
All patients had curative intent with microscopic safety margins (mean surgical cut end: 4 mm; mean distal cut end: 10 mm). No postoperative mortality was encountered. Morbidity was identified in 13 patients (perianastomotic abscess: n = 4; anastomotic leakage and fistula: n = 4; postoperative bleeding: n = 2; wound infection: n = 1; anastomotic stenosis: n = 1; anovaginal fistula: n = 1). One of these patients received a permanent colostomy. Five patients developed recurrence (liver: n = 1; lung: n = 2; local and lung: n = 1; abdominal wall: n = 1) during the median observation period (23 months). Two of these patients underwent curative resection of liver or lung metastases. Twenty-one patients have received stoma closure, and although continence was satisfactory in all, 5 displayed occasional minor soiling 12 months after stoma closure. Anal canal manometry demonstrated significant reduction in maximum resting pressure (median: 50 cmH(2)O at 12 months after stoma closure), but acceptable function results were obtained.
Curability and anal function were achieved by means of intersphincteric resection without or with additional partial external sphincteric resection. These procedures can be recommended for low rectal cancer patients who are candidates for abdominoperineal resection.
腹会阴联合切除术一直是距肛缘5 cm以内的极低位直肠癌的标准手术方式。然而，永久性结肠造口术对生活质量有严重限制。本研究旨在探讨括约肌间切除术及附加部分外括约肌切除术治疗肛管直肠癌的根治性及功能效果。
对1999年11月至2002年9月期间的35例患者进行前瞻性研究。所有患者均为腺癌（T3：26例；T2：7例；T1：2例），位于齿状线以上0至2 cm之间。所有患者均行腹会阴经肛门直肠切除术并完整切除直肠系膜（全括约肌间切除术：14例；次全括约肌间切除术：5例；附加部分外括约肌切除术：6例）。所有患者均行转流性结肠造口术，术后中位6个月关闭造口。20例患者接受了术前放化疗。
所有患者均有根治性切除意愿，切缘镜下安全（平均手术切端：4 mm；平均远端切端：10 mm）。无术后死亡病例。13例患者出现并发症（吻合口周围脓肿：4例；吻合口漏及瘘：4例；术后出血：2例；伤口感染：1例；吻合口狭窄：1例；肛门阴道瘘：1例）。其中1例患者接受了永久性结肠造口术。中位观察期（23个月）内5例患者出现复发（肝转移：1例；肺转移：2例；局部及肺转移：1例；腹壁转移：1例）。其中2例患者接受了肝或肺转移灶的根治性切除。21例患者已关闭造口，尽管所有患者的控便情况均令人满意，但5例患者在造口关闭12个月后偶尔出现轻微便污。肛管测压显示最大静息压显著降低（造口关闭后12个月时中位值为50 cmH₂O），但功能结果尚可接受。
通过括约肌间切除术（无论是否附加部分外括约肌切除术）可实现根治性切除及肛门功能保留。对于适合腹会阴联合切除术的低位直肠癌患者，可推荐采用这些手术方式。
