Minim Invasive Ther Allied Technol. 2004 Dec;13(5):347-61. doi: 10.1080/13645700410006616.
Abdominoperineal resection (APR) is still the standard surgical treatment of anorectal cancers close to the dentate line. Unfortunately, a permanent iliac colostomy is a severe limitation of the quality of life. Attempts to construct a continent perineal colostomy after anorectal excision have been made over the last 15 years with uncertain benefits. We report on our early results of two different procedures consisting of a laparoscopic approach to abdominoperineal rectal excision, fashioning a perineal colostomy with dynamic graciloplasty or implant of an artificial sphincter. Between 2000 and 2004, a total of six patients underwent laparoscopic abdominoperineal resection or reversal of Miles' procedure and construction of perineal colostomy with dynamic graciloplasty (three cases) or implant of an artificial bowel sphincter (three cases). A diverting loop ileostomy was constructed in all patients to prevent contamination. Data concerning the perioperative management, postoperative morbidity and mortality and function after total anorectal reconstruction at the time of discharge, at postoperative month 1 and after ileostomy closure were collected and evaluated in a prospective non-randomised fashion. No early postoperative complications occurred in both groups. No late complication occurred in the dynamic graciloplasty group, whilst one patient of the artificial sphincter group had an ulceration of the tubing and the control pump through the suprapubic skin and the labium skin respectively on postoperative day 35. Another patient in this group, with an erosion of the transposed colon wall, died of myocardial infarction on postoperative day 75 after removal of the prosthesis. Postoperative stay after artificial sphincter implant and dynamic graciloplasty ranged from 12 to 27 days and 16 to 24 days, respectively. The loop ileostomy was closed at postoperative month 3 in all remaining patients except for one in the dynamic graciloplasty group, who died one day before hospitalization for ostomy closure because of an accidental, not disease/operation related reason. Follow-up of patients of the dynamic graciloplasty and artificial sphincter groups ranged from 3 to 24 months and 2.5 to 9.5 months, respectively. Patients in the dynamic graciloplasty group had no complications and follow-up showed satisfactory continence (SF36 form). All patients in the artificial sphincter group had late local complications with erosion of the prosthesis through the wall, its consequent removal and construction of a permanent iliac colostomy. Laparoscopic APR has been reported to be as safe as open APR. There are no published, available data on laparoscopic APR and laparoscopic reversal of Miles' procedure with total anorectal reconstruction with either dynamic graciloplasty or implant of artificial sphincter. Preliminary results showed that laparoscopic APR and APR reversal with continent perineal colostomy and dynamic graciloplasty may be a possible option in selected patients whilst the implant of an artificial sphincter should not be considered as a safe surgical option in such patients.
腹会阴联合切除术（APR）仍是齿状线附近肛管直肠癌的标准外科治疗方法。不幸的是，永久性髂骨结肠造口术严重限制了生活质量。在过去15年里，人们尝试在肛管直肠切除术后构建可控性会阴结肠造口术，但效果并不确定。我们报告了两种不同手术方法的早期结果，这两种方法包括腹腔镜下腹会阴直肠切除术，通过动态股薄肌成形术或植入人工括约肌来构建会阴结肠造口术。2000年至2004年期间，共有6例患者接受了腹腔镜腹会阴切除术或Miles手术的逆转，并通过动态股薄肌成形术（3例）或植入人工肠括约肌（3例）构建会阴结肠造口术。所有患者均行转流性回肠造口术以防止污染。以非随机前瞻性方式收集并评估了围手术期管理、术后发病率和死亡率以及全肛管直肠重建术后出院时、术后1个月及回肠造口关闭后的功能数据。两组均未发生早期术后并发症。动态股薄肌成形术组未发生晚期并发症，而人工括约肌组有1例患者分别于术后第35天经耻骨上皮肤和阴唇皮肤出现人工括约肌导管及控制泵溃疡。该组另1例患者，因移植结肠壁糜烂，在取出假体后术后第75天死于心肌梗死。人工括约肌植入术和动态股薄肌成形术后的住院时间分别为12至27天和16至24天。除动态股薄肌成形术组1例患者因意外（与疾病/手术无关）原因在计划关闭回肠造口住院前一天死亡外，其余所有患者均于术后3个月关闭回肠造口。动态股薄肌成形术组和人工括约肌组患者的随访时间分别为3至24个月和2.5至9.5个月。动态股薄肌成形术组患者无并发症，随访显示控便情况良好（SF36量表）。人工括约肌组所有患者均出现晚期局部并发症，假体侵蚀肠壁，随后取出假体并构建永久性髂骨结肠造口术。据报道腹腔镜APR与开放性APR一样安全。目前尚无关于腹腔镜APR以及腹腔镜下Miles手术逆转并通过动态股薄肌成形术或植入人工括约肌进行全肛管直肠重建的公开可用数据。初步结果表明，对于部分患者，腹腔镜APR以及行可控性会阴结肠造口术和动态股薄肌成形术的APR逆转术可能是一种选择，而对于此类患者，植入人工括约肌不应被视为一种安全的手术选择。
