CAJ | 학술논문

目的探讨经肛内括约肌切除术(ISR)联合经腹全系膜切除术(TME)对超低位直肠肿瘤患者保肛的临床应用.方法对34例无肛门外括约肌受侵的超低位直肠肿瘤患者给予经肛ISR联合经腹TME手术的临床资料进行回顾性分析.结果 34例患者远切缘距肿瘤下缘距离为2.1 cm(1.8～3.0 cm).病理类型:腺癌23例(其中高分化9例,中分化14例),乳头状癌1例,直肠间质瘤2例,绒毛状腺瘤癌变5例,巨大绒毛状腺瘤3例.病理分期(术后):pTNM 1期18例,ⅡA期5例,ⅡB期1例,ⅢA期4例,ⅢB期1例;T分级:T1 15例,T2 5例,T3 8例,T4 1例.全组无手术死亡,发生吻合口狭窄3例,吻合121裂开2例,直肠阴道瘘2例.术后早期大便次数3～12次/d,肛门控便能力明显下降;术后6～12个月肛门功能逐渐恢复,大便次数1～5次/d,部分患者恢复正常.但是内括约肌全切术患者1年后仍然时有粪污发生.术后随访时间平均26个月,术后5个月吻合口复发1例,术后28个月和10个月肝转移各1例,术后26个月心源性猝死1例.结论在严格掌握适应证的前提下经肛ISR符合肿瘤的根治性原则,又能保留肛门功能.
목적 탐토경항내괄약기절제술(ISR)연합경복전계막절제술(TME)대초저위직장종류환자보항적림상응용.방법 대34례무항문외괄약기수침적초저위직장종류환자급여경항ISR연합경복TME수술적림상자료진행회고성분석.결과 34례환자원절연거종류하연거리위2.1 cm(1.8～3.0 cm).병리류형:선암23례(기중고분화9례,중분화14례),유두상암1례,직장간질류2례,융모상선류암변5례,거대융모상선류3례.병리분기(술후):pTNM 1기18례,ⅡA기5례,ⅡB기1례,ⅢA기4례,ⅢB기1례;T분급:T1 15례,T2 5례,T3 8례,T4 1례.전조무수술사망,발생문합구협착3례,문합121렬개2례,직장음도루2례.술후조기대편차수3～12차/d,항문공편능력명현하강;술후6～12개월항문공능축점회복,대편차수1～5차/d,부분환자회복정상.단시내괄약기전절술환자1년후잉연시유분오발생.술후수방시간평균26개월,술후5개월문합구복발1례,술후28개월화10개월간전이각1례,술후26개월심원성졸사1례.결론 재엄격장악괄응증적전제하경항ISR부합종류적근치성원칙,우능보류항문공능.
Objective To study the combination of trans-anal intersphincteric resection and trans- abdominal total mesorectal excision for anus-retained ultra-low rectal tumors. Methods Clinical data of 34 ultra-low rectal tumor patients without external anal sphincter involved, who underwent the combination surgery, were retrospectively analyzed Results The distance from the distal incisal margin of the rectum to the inferior margin of the tumor ranged from 1.8 cm to 3.0 cm on an average of 2. 1 cm. For pathological types, there were 23 cases of adenocarcinoma (9 well differentiated and 14 moderately differentiated), 1 papillary carcinoma, 2 rectal stromal tumor, 5 rectal villous adenoma with canceration and 3 giant villous adenoma. For pathological stages, there were 18 eases at stage pTNM Ⅰ , 5 at Ⅱ A, 1 at Ⅱ B, 4 at ⅢA, 1 at ⅢB and for T grading, there were 15 cases at stage T1, 5 at T2, 8 at T3, 1 at T4. In these 34 patients, there were 3 cases with postoperative anastomotic stenosis, 2 with postoperative anastomotic rupture, 2 with rectovaginal fistula and no operative death. Because of the dysfunction of bowel control, bowel frequency varied from 3 to 12 in the early stage after operation, but with the recovery of anus function, bowel frequency decreased and ranged form 1 to 5 times a day and the time of formed bowel control could be more than 5 min in 6-12 months after operation. However, patients underwent total resection of internal anal sphincter still suffered from incontinence of loose stool after 1 year. After operation, anastomotic recurrence was found in 1 case in 5 months, liver metastasis in 1 case in 10 months and 28 months respectively, cardiac sudden death in 1 case in 26 months. Conclusion The combination of trans-anal ISR and trans-abdominal TME for anus-retained ultra low rectal tumor is not only coincident with radical tumor principle but also retains the function of anus, on the premise of the strict indication.