CAJ | 학술논문

目的：探讨经肛门内镜微创手术（ transanal endoscopic microsurgery ，TEM）的适应证和并发症。方法回顾2011年5月至2014年5月在我院接受TEM治疗的135例直肠病变患者的临床资料，分析TEM在直肠病变治疗中的主要适应证和常见并发症。结果本组135例患者均成功实施TEM，其中行直肠壁全层切除115例，黏膜下及肌层部分切除20例。平均手术时间（66．5±25．0）min （25～120 min），术中平均失血量（10．5±5．5）ml（3～50 ml）。术后病理学检查确诊：直肠腺瘤60例，直肠腺瘤癌变（pTis期）10例，早期直肠癌（pT1期）11例，进展期直肠癌（pT2期）10例，直肠癌经术前放化疗后病理完全缓解（ ypT0期）2例，直肠类癌或类癌内镜电切后残灶24例，直肠胃肠道间质瘤5例，直肠平滑肌瘤1例，非肿瘤性息肉10例，直肠子宫内膜异位症2例。所有标本切缘均阴性。术中3例上段直肠前壁肿瘤行全层切除时切入腹腔，即刻行腔内缝合修补成功，未并发腹膜炎或盆腔感染。术后继发肛门出血2例，肺部、泌尿系感染和尿潴留各1例。并发症发生率为5．9％（8／135）。术后平均住院日（2．5±1．2）d（2～8 d）。术后平均随访15．5个月（6～36月），未发现肿瘤复发转移。结论适合局部切除的直肠局限性肿瘤是TEM的主要适应证。严格选择没有淋巴结转移证据的直肠癌行TEM 是安全有效的，已成为直肠局部切除术的首选方式。但目前的循证医学证据仍然有限，仍需要进一步研究论证。
목적：탐토경항문내경미창수술（ transanal endoscopic microsurgery ，TEM）적괄응증화병발증。방법회고2011년5월지2014년5월재아원접수TEM치료적135례직장병변환자적림상자료，분석TEM재직장병변치료중적주요괄응증화상견병발증。결과본조135례환자균성공실시TEM，기중행직장벽전층절제115례，점막하급기층부분절제20례。평균수술시간（66．5±25．0）min （25～120 min），술중평균실혈량（10．5±5．5）ml（3～50 ml）。술후병이학검사학진：직장선류60례，직장선류암변（pTis기）10례，조기직장암（pT1기）11례，진전기직장암（pT2기）10례，직장암경술전방화료후병리완전완해（ ypT0기）2례，직장유암혹유암내경전절후잔조24례，직장위장도간질류5례，직장평활기류1례，비종류성식육10례，직장자궁내막이위증2례。소유표본절연균음성。술중3례상단직장전벽종류행전층절제시절입복강，즉각행강내봉합수보성공，미병발복막염혹분강감염。술후계발항문출혈2례，폐부、비뇨계감염화뇨저류각1례。병발증발생솔위5．9％（8／135）。술후평균주원일（2．5±1．2）d（2～8 d）。술후평균수방15．5개월（6～36월），미발현종류복발전이。결론괄합국부절제적직장국한성종류시TEM적주요괄응증。엄격선택몰유림파결전이증거적직장암행TEM 시안전유효적，이성위직장국부절제술적수선방식。단목전적순증의학증거잉연유한，잉수요진일보연구론증。
Objective To investigate the indications and complications of transanal endoscopic microsurgery(TEM).Methods In order to analyze the main indications and frequent complications of TEM in the management of rectal lesions , clinical data of 135 patients with rectal lesions treated using TEM between May 2011 and May 2014 were summarized retrospectively .Results All the 135 patients were performed TEM successfully .Surgical procedures included the full-thickness excision ( 115 cases ) and the submucosal excision with partial muscular layer excision (20 cases).The average operating time was 66.5 ± 25.0 ( range, 25 ~120 ) min.The mean operative blood loss was 10.5 ±5.5 ( range, 3 ~50 ) ml.The postoperative pathological examination identified retcal adenomas in 60,carcinomatous changes of adenomas (pTis) in 10,early rectal adenocarcinomas (pT1) in 11,advanced rectal adenocarcinomas (pT2) in 10, pathological complete response ( ypT0 ) after preoperative chemoradiation in 2, rectal carcinoids or their residual lesions after endoscopic resection in 24,rectal gastrointestinal stromal tumor in 5,leiomyoma in 1, nontumorous polyps in 10,and rectal endometriosis in 2.Surgical margins of all specimens were clear .Three patients with the upper anterior rectal neoplasms happened entrance into the peritoneal cavity during full -thickness excision by TEM , and all peritoneal entries were closed transanally via endoscope without developing peritonitis or pelvic infection .Postoperative complications included anal hemorrhage in 2, pulmonary infection in 1,urinary infection in 1,and urinary retention in 1.The incidence of complications was 5.9%(8/135).The average postoperative stay was 2.5 ±1.2(range,2~8)d.With a mean follow-up period of 15.5(6~36)months,no tumor recurrence or metastasis was observed .Conclusions The localized rectal neoplasms suitable for local excision are the main indications of TEM .TEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement ,but the scientific evidence remains limited at present .As a kind of minimally invasive surgery with fewer complications , TEM is now considered as the first choice of procedure for rectal local excision .