Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Surg Endosc. 2010 May;24(5):1205-10. doi: 10.1007/s00464-010-0965-6. Epub 2010 Feb 26.
The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases.
Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis.
The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins.
NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.
经自然腔道内镜外科（NOTES）经肛门内镜微创手术（TEM）行经肛门内镜直肠乙状结肠切除术的可行性和安全性此前已在人体标本和猪存活模型中得到证实。我们报告首例由巴塞罗那和波士顿的外科医生团队使用 TEM 和腹腔镜辅助进行的 NOTES 经肛门直肠切除术治疗直肠癌的临床病例，该团队在NOTES 和结直肠疾病的微创方法方面拥有丰富的经验。
对一名接受术前放化疗的 T2N2 期直肠腺癌 76 岁女性患者进行 TEM 平台辅助的经肛门内镜直肠切除术和全直肠系膜切除术。腹腔镜可视化和直肠乙状结肠游离时的牵拉和显露辅助通过一个 5mm 端口进行，该端口随后被用作造口部位，以及两个 2mm 针孔端口，其中一个被用作引流部位。标本经肛门内切断，然后进行手工结直肠吻合。
手术顺利完成，手术时间为 4 小时 30 分钟。直肠系膜切除完整。术后过程顺利，患者于术后第 4 天出院。最终病理显示 pT1N0，23 个淋巴结阴性，近端、远端和放射状切缘均为阴性。
使用 TEM 和腹腔镜辅助的 NOTES 经肛门内镜直肠乙状结肠切除术是可行且安全的。在广泛临床应用之前，需要仔细选择患者并改进 NOTES 器械，以优化这种方法。
