Zerz Andreas, Müller-Stich Beat P, Beck Joachim, Linke Georg R, Tarantino Ignatio, Lange Jochen
Department of Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
Dis Colon Rectum. 2006 Jun;49(6):919-24. doi: 10.1007/s10350-005-0305-4.
The rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone.
We operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005.
It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4-20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4-60) months, there was no evidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively.
Radical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.
保留直肠的经肛门局部切除术是治疗直肠下1/3 T1期癌的一种成熟方法。由于经腹直肠切除术存在较高的发病率和死亡率风险，因此该手术潜在的局部区域复发率增加是可以接受的。背侧后腹膜外盆腔镜检查使得在保留直肠的内镜下直肠系膜后切除术的意义上，能够以微创方式切除直肠下1/3的相关淋巴引流。与单纯经肛门局部切除术相比，内镜下直肠系膜后切除术联合经肛门局部切除术在T1期直肠下1/3癌中是否能实现局部根治性切除和充分的肿瘤分期，从而进行更有针对性的治疗规划，这是需要考虑的问题。
1998年至2005年期间，我们对11例连续的直肠下1/3 T1期癌患者采用经肛门局部切除术联合内镜下直肠系膜后切除术，分两阶段进行手术。
所有病例均能完整切除原发灶并切除直肠系膜后部。术后并发症包括两例短暂性神经并发症和一例肺栓塞。无死亡病例。组织学分析显示中位淋巴结数为8个（范围4 - 20个）。两名诊断为淋巴结转移的患者接受了辅助放化疗。中位随访48个月（范围4 - 60个月）后，无局部区域复发证据。一名患者术后8个月检测到肝转移。
经肛门局部切除术和内镜下直肠系膜后切除术似乎能够实现直肠下1/3 T1期癌的原发肿瘤根治性切除和充分的肿瘤分期。
