Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium.
Surg Endosc. 2012 Feb;26(2):312-22. doi: 10.1007/s00464-011-1869-9. Epub 2011 Sep 5.
This study aimed to review the authors' 16-year experience with transanal endoscopic microsurgery (TEM). Mortality, morbidity, recurrence rate, and functional outcome were assessed. New indications and technical improvements are presented.
From November 1991 to August 2008, 123 patients (72 men and 51 women; median age, 68 years; range, 21-91 years) underwent TEM for excision of 105 adenomas with low- or high-grade dysplasia, 9 invasive adenocarcinomas (5 curative and 4 palliative resections), 2 neuroendocrine tumors, and 2 extramucosal lesions. Five additional patients had excisional biopsies, allowing staging after previous endoscopic resection. Most of the resections were full-thickness rectal resections using electrocautery or, more recently, the Harmonic scalpel. The latest mucosectomies were performed using the endoscopic submucosal dissection (ESD) technique. In addition, nontumoral indications included pelvic abscess (7 patients) and rectal strictures, which were either anastomotic or chemical. Pelvic abscesses were drained transrectally, whereas rectal stenoses were treated by strictureplasty. Foreign object retrieval and collagen plug placement for anal fistulas were performed using TEM in three patients.
No mortality occurred. One intraoperative rectal perforation required conversion to laparotomy. The postoperative complications included one pneumoperitoneum, which was treated medically, and one rectal perforation requiring Hartmann's procedure. In the polyp subgroup, six patients (6/91, 7%) experienced local recurrence. Pelvic abscesses were successfully treated, and stenosis did not recur after strictureplasty. Anorectal manometry showed functional alterations without significant clinical impact.
The findings showed TEM to be a safe and effective procedure for local excision of rectal lesions with a low recurrence rate and minimal consequences in terms of anorectal function. In addition, TEM proved to be feasible and effective for pelvic abscess drainage and rectal stenosis treatment. New technologies such as the Harmonic scalpel and ESD increase the precision already offered by this approach.
本研究旨在回顾作者 16 年的经肛门内镜微创手术（TEM）经验。评估死亡率、发病率、复发率和功能结果。提出新的适应证和技术改进。
从 1991 年 11 月至 2008 年 8 月，123 例患者（72 例男性和 51 例女性；中位年龄 68 岁；范围 21-91 岁）接受 TEM 切除 105 例低级别或高级别异型增生的腺瘤、9 例浸润性腺癌（5 例根治性和 4 例姑息性切除术）、2 例神经内分泌肿瘤和 2 例粘膜外病变。另外 5 例患者接受了切除性活检，允许在先前的内镜切除后进行分期。大多数切除是使用电烙术或最近的 Harmonic 刀进行全层直肠切除。最近的粘膜切除术采用内镜粘膜下剥离术（ESD）技术进行。此外，非肿瘤适应证包括盆腔脓肿（7 例）和直肠狭窄，包括吻合口或化学性狭窄。盆腔脓肿经直肠引流，而直肠狭窄则采用狭窄成形术治疗。3 例患者使用 TEM 取异物和放置胶原塞治疗肛瘘。
无死亡病例。1 例术中直肠穿孔需要转为剖腹手术。术后并发症包括 1 例气腹，经内科治疗，1 例直肠穿孔需要行 Hartmann 手术。在息肉亚组中，6 例患者（91 例中的 6 例，7%）出现局部复发。盆腔脓肿得到成功治疗，狭窄成形术后无复发。肛门直肠测压显示功能改变，但无明显临床影响。
结果表明 TEM 是一种安全有效的直肠病变局部切除方法，复发率低，对肛门直肠功能影响最小。此外，TEM 还被证明对盆腔脓肿引流和直肠狭窄治疗是可行和有效的。新技术如 Harmonic 刀和 ESD 增加了该方法已经提供的精度。
