Perez Rodrigo Oliva, Julião Guilherme Pagin São, Vailati Bruna Borba
Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil.
Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
Clin Colon Rectal Surg. 2022 Feb 28;35(2):122-128. doi: 10.1055/s-0041-1742112. eCollection 2022 Mar.
Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.
肿瘤对新辅助放化疗（nCRT）的反应，包括肿瘤缩小和降期，显著影响了被认为适合行经肛门局部切除（TLE）的患者数量。一些患者可能存在局限于肠壁的小残留病灶。通过直肠指检、内镜评估和影像学评估显示有主要反应（“近乎完全”）的这些患者，可考虑采用这种方法。尽管TLE术后发病率极低，但仍需提前谨慎评估一些临床后果和肿瘤学结局。在nCRT的情况下，已观察到临床相关伤口裂开的风险较高，这导致因疼痛管理而再次入院的风险相当大。据报道，肛门直肠功能较差（仍优于全直肠系膜切除术后[TME]），TME标本质量恶化，腹部切除术发生率较高（在需要完成TME的病例中）。在TLE区域观察到的增生性瘢痕在这些患者的随访中也是一个具有挑战性的发现。局部切除可能应仅限于原发性肿瘤位于肛门直肠环（磁共振定义）或其以下水平的患者。否则，这些患者是腹会阴切除术或低位前切除术加结肠肛管吻合术的候选者，这些手术常常需要永久性造口或肛门直肠功能相当差。
