Zuo Zhi-gui, Song Hua-yu, Li Ji, Xu Chang, Zhou Zhen-hua, Ni Shi-chang, Chen Shao-qi
Department of Colorectal Surgery, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou 325000, China.
Zhonghua Zhong Liu Za Zhi. 2009 Dec;31(12):941-4.
To investigate the clinical application of intersphincter resection (ISR) combined with total mesorectal excision (TME) and colon-anal anastomosis in the treatment for ultra-low rectal carcinoma.
To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma (without external anal sphincter involvement) who received treatment of ISR, TME and colon-anal anastomosis.
Partial resection of internal sphincter was performed in the patients with a distal edge of the tumor greater than or equal to 2 cm from the dentate line. Subtotal removal of the rectum was performed between 1 cm and 2 cm. Total resection was performed in less than 1 cm or involvement of dentate line. Reconstruction of digestive tract was done by manual colon-anal anastomosis. The average distance from distal excised margin to the tumor was 2.3 (1.8 - 3.2) cm among 34 patients. The pathological types were as follows: 28 cases of adenocarcinoma (11 were well differentiated, 17 moderately differentiated), 1 case of papillary carcinoma and 5 cases of villous adenoma with malignant change. The postoperative pathological stages were: Dukes stage A in 28 cases, stage B in 1 and stage C in 5 cases. The pTNM staging was 28 cases in phase I, 1 in phase IIa, 4 in phase IIIa and 1 in phase IIIb. The T stages of the patients were as following: 16 Tl, 17 T2 and 1 T3. Postoperative anastomotic stenosis occurred in 3 cases, anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases. The ability of controlling feces of patients decreased significantly in the early postoperative period, and restored gradually at 6 to 12 months after operation. Anastomotic recurrence occurred in 1 case at 5 months after operation and liver metastasis in 1 case at 40 months.
With strictly grasping indications, radical resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis. It is an effective sphincter-preserving operation.
探讨括约肌间切除术（ISR）联合全直肠系膜切除术（TME）及结肠肛管吻合术在超低位直肠癌治疗中的临床应用。
回顾性分析34例接受ISR、TME及结肠肛管吻合术治疗的超低位直肠癌（未累及外括约肌）患者的资料。
肿瘤远端边缘距齿状线大于或等于2 cm的患者行内括约肌部分切除术。直肠切除范围在齿状线上1 cm至2 cm之间的行直肠次全切除术。肿瘤远端边缘距齿状线小于1 cm或累及齿状线的行全直肠切除术。消化道重建采用手工结肠肛管吻合术。34例患者切除标本远端切缘距肿瘤的平均距离为2.3（1.8 - 3.2）cm。病理类型如下：腺癌28例（高分化11例，中分化17例），乳头状癌1例，绒毛状腺瘤恶变5例。术后病理分期：Dukes A期28例，B期1例，C期5例。pTNM分期：Ⅰ期28例，Ⅱa期1例，Ⅲa期4例，Ⅲb期1例。患者的T分期如下：T1 16例，T2 17例，T3 1例。术后吻合口狭窄3例，吻合口裂开2例，直肠阴道瘘2例。术后早期患者的控便能力明显下降，术后6至12个月逐渐恢复。术后5个月吻合口复发1例，术后40个月肝转移1例。
严格掌握适应证，ISR联合TME及结肠肛管吻合术可实现根治性切除并保留肛门括约肌。这是一种有效的保肛手术。
