Marks John H, Frenkel Joseph L, Greenleaf Christopher E, D'Andrea Anthony P
Lankenau Medical Center, Wynnewood, Pennsylvania.
Dis Colon Rectum. 2014 Oct;57(10):1176-82. doi: 10.1097/DCR.0000000000000208.
Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome.
We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences.
This single-institution retrospective review uses a prospectively maintained database.
This study was conducted at a tertiary colorectal surgery referral center.
From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity.
Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured.
Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis.
This review was limited by its retrospective nature.
High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).
经肛门内镜显微手术的相对禁忌证包括高位、基于前方的病变行全层切除，因为担心进入腹腔。存在对安全性和肿瘤学结局的担忧。
我们检查了经肛门内镜显微手术切除进入腹腔的结果，并将其与未进入腹腔的结果进行比较，以验证我们的假设，即进入腹腔是安全的，不会产生不良感染或肿瘤学后果。
这项单机构回顾性研究使用了前瞻性维护的数据库。
本研究在一家三级结直肠手术转诊中心进行。
从1997年到2012年，我们确定了303例行经肛门内镜显微手术切除的患者，其中26例进入了腹腔。
围手术期数据、术后发病率、延迟发病率和肿瘤学结局是主要测量的结局。
26例患者中，有8名女性，平均年龄67.5岁。平均体重指数为31kg/m，69%的美国麻醉医师协会（ASA）分级为III或IV级。病变的平均上缘为10.4cm（4.5 - 16）。48%的患者有基于前方的病变。腹腔进入组的前方位置、距肛门直肠环的水平和癌症诊断显著更高（p = 0.003、p = 0.007和p = 0.007）。术前诊断包括16例腺癌、8例息肉和2例类癌肿瘤。13例患者术前行放化疗。估计中位失血量为15mL（5 - 400），3例患者进行了改道手术。中位出院时间为3天（2 - 10）。无围手术期死亡。中位随访时间为21.0个月。有1例局部复发（3.8%），未发生癌性腹膜炎。
本综述受其回顾性性质的限制。
经验丰富的医生应考虑将高位前方直肠病变作为经肛门内镜显微手术切除的候选对象。在获得大量经肛门内镜显微手术经验后，我们在高危患者群体中使用经肛门内镜显微手术，使88%的患者无需进行腹部手术，也无需临时或永久性结肠造口术即可得到明确治疗。未出现脓肿或癌性腹膜炎的理论担忧（见视频，补充数字内容1，http://links.lww.com/DCR/A154）。
