Angelita & Joaquim Gama Institute, São Paulo, Brazil.
Dis Colon Rectum. 2011 May;54(5):545-51. doi: 10.1007/DCR.0b013e3182083b84.
Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation.
Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54 Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups.
Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02).
Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.
经肛门内镜微创手术（TEM）可能是新辅助放化疗后低位直肠癌患者的一种合适的诊断和治疗方法。尽管该手术术后并发症发生率较低，但接受新辅助放化疗的患者似乎有更高的缝合线裂开风险。在这种情况下，我们比较了接受 TEM 手术的患者是否接受新辅助放化疗的临床结局。
36 例连续患者在一家机构接受经肛门内镜微创手术治疗。23 例患者在新辅助放化疗治疗直肠腺癌后接受局部切除，13 例患者在没有任何新辅助治疗的情况下接受直肠良恶性肿瘤的局部切除。放化疗包括 50.4 至 54 Gy 和 5-氟尿嘧啶为基础的化疗。所有患者均行经肛门内镜微创手术，直肠缺损行一期缝合。比较两组患者的并发症（即刻和迟发）和再入院率。
总体而言，中位住院时间为 2 天。即刻（30 天）并发症发生率为 44%，为 2/3 级并发症。接受新辅助放化疗的患者更有可能发生 2/3 级即刻并发症（56%比 23%；P=0.05）。总体而言，30 天再入院率为 30%。新辅助放化疗组的切口裂开发生率明显较高（70%比 23%；P=0.03）。新辅助放化疗组患者再入院风险明显较高（43%比 7%；P=0.02）。
经肛门内镜微创手术治疗可能导致显著的术后发病率、切口裂开和再入院率，尤其是由于切口裂开导致的直肠疼痛。在这种情况下，这种微创方法的益处，无论是出于诊断还是治疗目的，对于那些可能避免大手术但仍面临明显更具侵袭性和痛苦的手术的高度选择患者来说，都受到了显著限制。
