Pappalardo Giuseppe, Spoletini Domenico, Nunziale Aldo, Manna Elena, De Lucia Francesca, Frattaroli Fabrizio Maria
Dipartimento P. Stefanini I Facoltà di Medicina e Chirurgia, Università La Sapienza, Roma Azienda Policlinico Umberto I.
Ann Ital Chir. 2010 Jul-Aug;81(4):255-63; discussion 283.
To value the results of "open" surgery with sphincter preservation, TME nerve-sparing, fast-track, without a protective stoma in a consecutive series of patients with subperitoneal rectal cancer (s.p.r.c.).
In January 1989, we started a prospective, non-randomized study designed to assess when a primary derivative stoma was warranted in a series of consecutive patients electively treated with open low and ultralow AR. The inclusion criteria were: all patients with middle and low rectal cancer who underwent elective low and ultralow AR, including those treated with neoadjuvant therapy. The exclusion criteria were: urgent surgery, incomplete rings in the stapler, a positive hydropneumatic test, preoperative involvement of the external sphincter and/or surrounding structures by the tumor as demonstrated by CT-scan and endorectal MR and/or transrectal ultrasound. Anastomoses between 7 cm and 4 cm from the pectinate line were defined as low colo-rectal anastomoses, while anastomoses lower than 4 cm from the pectinate line were defined as ultralow anastomoses. A fistula or anastomotic dehiscence was suspected when pelvic and/or peritoneal pain, fever, leucocytosis, fecaloid liquid in the drainage and/or perianal erythematosus swelling were present. An anastomotic leak was confirmed by means of angio-CT and/or endoscopy and/or contrast enema depending on the procedure available most promptly. Signs of peritoneal reaction were considered to be indicative of a major dehiscence, regardless of the diameter of the fistula; when diagnosed, a transverse colostomy was immediately performed. Clinically less serious cases were defined as minor dehiscences, for which a "wait and see" strategy or a transcutaneous CT or ultrasound guided drainage of an abscess were used. Sixty-five patients were treated according to a fast-track postoperative protocol.
Between 1998 and 2007, 89 patients with s.p.r.c. were treated according to a prospective protocol. One hundred and nineteen patients (69.6%) underwent low anastomoses and 52 patients (30.4%) underwent ultra low anastomoses. Forty-two (24.6%) were treated with traditional AR, 129 (75.4%) with AR and nerve-sparing TME. Forty-six (26.9%) patients underwent neoadjuvant therapy. One hundred and two patients underwent a mechanical end-to-end anastomosis, 67 a double stapled anastomosis, and 2 a colo-anal anastomosis at the pectinate line performed according to our technique. All 6 patients with major dehiscences underwent a protective colostomy within hours of the onset of clinical symptoms immediately after the radiologically- or endoscopically-confirmed diagnosis. The 7 minor dehiscences were successfully treated with conservative therapy (antibiotic and enteral feeding) using an out-patient regimen. Two (28.6%) required percutaneous drainage: one pelvic CT-guided drainage and the other (an ultralow dehiscence) perineal drainage. The 72.6% of the patients survived at 5-years follow-up. The incidence of local recurrences in 2-years followup was 3.2% (on 124 patients). We had no deaths in patients treated with fast-track protocol.
Open, TME nerve-sparing A.R. with selective use of neoadjuvant therapy, can be successfully performed without a protective stoma in more than 80% of the patients. Fast-track protocol seems to increase quality of p.o. period and decrease hospital stay
评估对一系列连续的腹膜下直肠癌（s.p.r.c.）患者行保留括约肌、保留TME神经、快速康复且不做保护性造口的“开放”手术的效果。
1989年1月，我们启动了一项前瞻性、非随机研究，旨在评估在一系列接受开放性低位和超低位直肠肛管切除术（AR）的连续患者中，何时需要行一期衍生造口。纳入标准为：所有接受择期低位和超低位AR的中低位直肠癌患者，包括接受新辅助治疗的患者。排除标准为：急诊手术、吻合器钉合环不完整、气腹试验阳性、CT扫描、直肠内磁共振成像和/或经直肠超声显示术前肿瘤侵犯外括约肌和/或周围结构。距齿状线7 cm至4 cm之间的吻合口定义为低位结直肠吻合口，距齿状线低于4 cm的吻合口定义为超低位吻合口。当出现盆腔和/或腹膜疼痛、发热、白细胞增多、引流液中有粪样液体和/或肛周红斑性肿胀时，怀疑有吻合口漏或吻合口裂开。根据最快捷可用的检查方法，通过血管造影CT和/或内镜检查和/或造影灌肠确认吻合口漏。无论瘘管直径大小，腹膜反应迹象均被视为严重裂开的指标；一经诊断，立即行横结肠造口术。临床症状较轻的病例定义为轻度裂开，对此采用“观察等待”策略或经皮CT或超声引导下的脓肿引流。65例患者按照快速康复术后方案进行治疗。
1998年至2007年期间，89例s.p.r.c.患者按照前瞻性方案进行治疗。119例（69.6%）患者行低位吻合，52例（30.4%）患者行超低位吻合。42例（24.6%）患者接受传统AR治疗，129例（75.4%）患者接受AR联合保留神经的TME治疗。46例（26.9%）患者接受了新辅助治疗。102例患者行机械端端吻合，67例患者行双吻合器吻合，2例患者按照我们的技术在齿状线处行结肠肛管吻合。所有6例严重裂开的患者在经影像学或内镜确诊后数小时内，临床症状出现后立即行了保护性结肠造口术。7例轻度裂开患者采用门诊保守治疗方案（抗生素和肠内营养）成功治愈。2例（28.6%）患者需要经皮引流：1例为盆腔CT引导下引流，另1例（超低位裂开）为会阴引流。72.6%的患者在5年随访期内存活。2年随访期内局部复发率为3.2%（124例患者）。接受快速康复方案治疗的患者无死亡病例。
开放性、保留TME神经的AR联合选择性使用新辅助治疗，超过80%的患者可以成功实施且无需保护性造口。快速康复方案似乎提高了术后康复质量并缩短了住院时间
