Clinica Chirurgica, Università Politecnica delle Marche, Ancona, Italy.
Surg Endosc. 2018 Apr;32(4):2020-2025. doi: 10.1007/s00464-017-5898-x. Epub 2017 Oct 19.
The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM.
All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR).
Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%).
In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.
经肛门内镜微创手术（TEM）治疗早期直肠癌的成功取决于正确的适应证和严格的患者选择。当 TEM 手术后发现不利的病理特征时，建议行全直肠系膜切除术，以最大限度地降低复发风险。本研究通过回顾性系列患者收集数据，以确定 TEM 后腹腔镜再次手术的结果。
所有患者均行直肠指诊和经肛门内镜超声、CT 和/或 MRI 进行临床肿瘤分期。组织学检查包括评估切缘是否游离、肿瘤浸润深度（根据国际抗癌联盟指南）、肿瘤分化程度以及有无脉管和神经周围侵犯。当发现高危肿瘤时，在 TEM 后 6 周内行再次手术。根据所行手术将患者分为两组：腹腔镜前切除术（LAR）或腹腔镜腹会阴联合切除术（LAPR）。
68 例（5.3%）患者行再次手术：38 例行 LAR，30 例行 LAPR。手术时间的平均值为 148.24 分钟（±35.8，p=0.62）。同时，TEM 疤痕距肛门缘的平均距离在两组间存在统计学差异（p=0.003），且在多因素分析中与腹会阴联合切除术呈统计学相关（p=0.0001）。LAR 组中有 6 例（15.7%）和 LAPR 组中有 3 例（10%）患者需要转为开放性手术（p=0.38）。组织学检查显示 3 例（3 例 pT2N0）和 1 例（1 例 pT3N0）分别有残留癌细胞，4 例有淋巴结转移。在其余 60 例（88.3%）患者中未发现残留肿瘤。平均随访 108 个月后，总无病生存率为 98%（95%CI 88-99%）。
根据我们的经验，经腹腔镜行 TEM 后再次手术是可行且安全的，转化率低，术后效果理想。
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