Issa Nidal, Fenig Yaniv, Gingold-Belfer Rachel, Khatib Muhammad, Khoury Wisam, Wolfson Lea, Schmilovitz-Weiss Hemda
1 Department of Surgery, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel .
2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .
J Laparoendosc Adv Surg Tech A. 2018 Aug;28(8):977-982. doi: 10.1089/lap.2017.0399. Epub 2018 Apr 18.
Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.
Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.
One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.
Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.
经肛门内镜显微手术（TEM）患者的选择取决于诊断方式；然而，直肠病变的术前诊断仍存在一些局限性，在一些报告中，经TEM切除的腺瘤中高达三分之一被发现为腺癌；因此，挽救性根治性切除术（RR）对于实现肿瘤切除仍然是必要的。挽救性RR可能会遇到一些技术问题，如直肠系膜的侵犯和瘢痕形成。在本研究中，我们旨在报告接受挽救性RR患者的发病率和肿瘤学结果。
回顾性收集2004年至2014年间接受TEM后行RR患者的人口统计学和临床数据。
在研究期间共进行了141例TEM，其中53例（38%）用于直肠恶性病变。TEM的适应证：15例（28%）为良性腺瘤，25例（47%）为早期直肠癌，13例（25%）在新辅助放化疗后临床完全缓解。10例（19%）患者的TEM标本中无残留肿瘤，15例（28%）为T1期，其中2例行挽救性低位前切除术（LAR）。10例（19%）为T2期，4例行LAR，1例行腹会阴联合切除术（APR）。5例（9%）为T3期，3例行LAR，2例行APR。在13例（25%）接受放化疗（CRT）后的患者中，4例行挽救性AR。从TEM到RR的时间为47天（范围32 - 70天）。在16例挽救性手术中，8例（50%）为腹腔镜手术。中位手术时间为210分钟（范围165 - 360分钟）。有5例患者行保护性回肠造口术。2例（12%）患者发生直肠穿孔；均位于后方，其中1例发生在CRT后。发生2例（12%）术后小肠梗阻和3例伤口感染。接受RR的患者中无围手术期死亡。最终病理结果为9例无残留疾病，1例为T3N1，3例为T3N0，1例为T2N1，2例为T2N0。8例（50%）接受辅助化疗。
TEM后腹腔镜全直肠系膜切除术似乎是安全的，且对切除的完整性无负面影响。术中标本穿孔的问题确实存在，应采用精细技术和仔细解剖来处理，尤其是在CRT后。
