Yin Yefeng, Zhuang Meng, Hu Xiyue, Liu Junguang, Mei Shiwen, Tang Jianqiang
Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, 100021, China.
Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, 065001, China.
Langenbecks Arch Surg. 2023 Jan 18;408(1):41. doi: 10.1007/s00423-023-02801-y.
Laparoscopic total mesorectal excision (LaTME) is a technically challenging for ultralow-lying rectal cancer in obese male patients. Herein, we introduced modified serial techniques "ASTRO" to facilitate LaTME, and the short-term outcomes were presented.
A prospective study (NCT05067413) was conducted between December 2020 and January 2022. The modified serial surgical techniques "ASTRO" included 5 key steps: (1) Anterior peritoneal reflection (APR) dissection at the highest line along with a "n"-shaped membrane bridge; (2) suspending the APR with a purse-string suture through the bladder peritoneum to enlarge the operating space of the anterior rectal wall; (3) traction and counter-traction continuously of the rectum applied with a cotton tape around the rectum; (4) resection of the pelvic rectum on tripartition, followed by the sequence of "posterior > anterior > lateral" principle; and (5) the trans-anterior Obturator nerve gateway was adapted to transect the distal rectum. The operative data and postoperative short-term outcomes were collected.
Twenty-four consecutive patients underwent this procedure successfully. The average body mass index (BMI) was 29.9±1.3. The average of tumor height from anal verge was 4.0 cm (range, 3.0-4.5 cm). The median operating time and blood loss was 217 min (range, 165-420 min) and 50 ml (range, 20-100 ml) respectively. The anterior operation space at the midsagittal plane of the pelvis inlet was increased by 2.0 ± 0.3 cm. The calculated dominant angle was 20 ± 3°. The length of stapling line was 6.8 ± 1.0 cm with 11 cases by one cartridge and 13 cases by 2 cartridges. Eight patients developed postoperative complications including 4 with anastomosis leakage (16.7%), 2 with urinary retention (8.3%), one with anastomotic stenosis (4.2%) and one with ileus (4.2%). All the complications were relatively mild and the patients recovered well.
Modified serial techniques "ASTRO" could expand the operating space and facilitate LaTME in obese male patients, thereby reducing the risk of conversion to open and transanal dissection.
腹腔镜全直肠系膜切除术（LaTME）对于肥胖男性患者的超低位直肠癌来说，在技术上具有挑战性。在此，我们引入改良的系列技术“ASTRO”以促进LaTME，并展示了其短期结果。
于2020年12月至2022年1月进行了一项前瞻性研究（NCT05067413）。改良的系列手术技术“ASTRO”包括5个关键步骤：（1）在最高线处进行前腹膜返折（APR）解剖，同时形成一个“n”形膜桥；（2）通过膀胱腹膜用荷包缝合悬吊APR，以扩大直肠前壁的手术空间；（3）用棉带围绕直肠对直肠进行持续牵引和对抗牵引；（4）将盆腔直肠进行三分切除，遵循“后>前>侧”的顺序原则；（5）采用经前闭孔神经通道横断直肠远端。收集手术数据和术后短期结果。
24例患者连续成功接受了该手术。平均体重指数（BMI）为29.9±1.3。肿瘤距肛缘的平均高度为4.0 cm（范围为3.0 - 4.5 cm）。中位手术时间和失血量分别为217分钟（范围为165 - 420分钟）和50毫升（范围为20 - 100毫升）。盆腔入口矢状面的前方手术空间增加了2.0±0.3 cm。计算得出的优势角为20±3°。吻合器钉合线长度为6.8±1.0 cm，其中11例使用一个钉仓，13例使用2个钉仓。8例患者出现术后并发症，包括4例吻合口漏（16.7%）、2例尿潴留（8.3%）、1例吻合口狭窄（4.2%）和1例肠梗阻（4.2%）。所有并发症均相对较轻，患者恢复良好。
改良的系列技术“ASTRO”可以扩大手术空间，促进肥胖男性患者的LaTME，从而降低中转开腹和经肛解剖的风险。
