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经内镜切除直肠恶性息肉后行经肛门内镜微创手术:一种对根治性治疗有指导意义的有用技术。

Transanal endoscopic microsurgery after endoscopic resection of malignant rectal polyps: a useful technique for indication to radical treatment.

机构信息

Department of Surgical Sciences, University of Torino, Corso A. M. Dogliotti 14, 10126, Turin, Italy,

出版信息

Surg Endosc. 2014 Apr;28(4):1136-40. doi: 10.1007/s00464-013-3290-z. Epub 2013 Oct 30.

Abstract

BACKGROUND

Management of malignant rectal polyps (MRPs) after endoscopic polypectomy (EP) is still debated. It is sometimes difficult to decide whether to simply follow-up (FU) or to treat such a removed lesion. Transanal endoscopic microsurgery (TEM) could have a role both in T staging and in treating MRPs after EP.

METHODS

Patients who underwent a full-thickness TEM within 3 months after an EP between January 2008 and October 2012 were retrospectively analyzed. If post-TEM histology showed locally advanced rectal cancer, patients underwent a total mesorectal excision (TME) within 4-6 weeks. Patients without malignant disease or pT1sm1 cancers at post-TEM histology were followed up every 3 months for 2 years with clinical examination, flexible rectal endoscopy, and neoplastic markers monitoring.

RESULTS

A total of 39 patients were included. Post-EP histology was adenocarcinoma in 27/39 cases (69.2 %) and adenoma in 12/39. Mean operative time was 64.2 min; no 30-day mortality occurred; 30-day morbidity was 2.7 % (rectal bleeding in 1/39 cases). Post-TEM histology showed a T2 cancer in 5/39 patients, four with and one without a previous cancer diagnosis, who were further treated by TME (four RARs and one APR) and are disease free with a mean FU of 24.2 months. Post-TEM histology showed adenoma in 10/39 cases and fibrosis in 24/39. These patients are disease free with a mean FU of 13 months.

CONCLUSIONS

A full-thickness TEM after EP of MRPs can establish the presence of residual malignant disease and its depth of invasion, precisely defining the indication to TME. In event of benign post-EP histology, TEM must be performed in presence of macroscopic residual disease, in order to obtain an RO resection and finally exclude cancer, while, in absence of macroscopic residual disease, only close FU is required.

摘要

背景

直肠息肉恶变(MRPs)内镜下息肉切除术(EP)后的处理仍存在争议。有时难以决定单纯随访(FU)还是治疗切除的病变。经肛门内镜微创手术(TEM)在 EP 后的 T 分期和治疗中均有作用。

方法

回顾性分析 2008 年 1 月至 2012 年 10 月期间 EP 后 3 个月内行全层 TEM 的患者。如果 TEM 术后组织学显示局部进展期直肠癌,在 4-6 周内行全直肠系膜切除术(TME)。TEM 术后组织学无恶性疾病或 pT1sm1 癌的患者,前 2 年每 3 个月进行临床检查、直肠软镜检查和肿瘤标志物监测。

结果

共纳入 39 例患者。EP 术后组织学为腺癌 27/39 例(69.2%),腺瘤 12/39 例。手术时间平均为 64.2 分钟;无 30 天内死亡;30 天发病率为 2.7%(1/39 例直肠出血)。TEM 术后组织学显示 5/39 例 T2 癌,其中 4 例有、1 例无先前癌症诊断,进一步行 TME(4 例 RARs,1 例 APR)治疗,无病生存,平均 FU 为 24.2 个月。TEM 术后组织学显示腺瘤 10/39 例,纤维化 24/39 例。这些患者无病生存,平均 FU 为 13 个月。

结论

MRPs EP 后全层 TEM 可明确残留恶性疾病及其浸润深度,准确确定 TME 的适应证。EP 术后组织学为良性时,若存在肉眼残留病变,必须行 TEM 以获得 RO 切除,最终排除癌症;而无肉眼残留病变时,只需密切 FU。

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