Review of transanal total mesorectal excision in the treatment of rectal cancer
-
摘要: 长久以来，结直肠外科医师一直不断探索直肠癌的治疗方法，尽可能地提升患者的生存质量，不断提高直肠癌的治疗效果。其中低中位的直肠癌常见于中国患者，而关于低中位直肠癌的治疗，目前比较成熟的有经肛门全直肠系膜切除(transanal total mesorectal excision，TaTME)、括约肌间切除术(intersphincteric resection，ISR)、Miles术(腹会阴联合切除术，abdominoperineal resection，APR)、Hartmann术(肿瘤切除远端封闭，近端造口)、经肛门的局部切除、Parks术(结肠-肛管吻合术)、腹会阴柱状切除术(extralevator abdominoperineal excision，ELAPE)、Dixon术(低位直肠癌前切除术)、Bacon术(结肠经肛拖出吻合术)、经骶后入路的局部切除等，不同的术式应用于不同症状的直肠癌。而对于肿瘤巨大、系膜肥大、骨盆狭窄等具有“困难骨盆”的低位直肠癌患者，经肛门全直肠系膜切除术(tTaTME)因为能够精确定位患者病灶切缘、肛管内括约肌和中低位直肠膜间隙，有效降低手术并发症的风险，控制复发率，改善生存率，得到了结直肠外科医师的青睐和认可。但是经肛门全直肠系膜切除术(TaTME)需要医师们有足够的腹腔镜和经肛门手术经验，并受限于目前腹腔镜设备和器械的发展。本文就经肛门全直肠系膜切除术(TaTME)的发展起源、运用，优势和劣势及未来展望方面进行综述，期望为这方面研究和实践提供一点理论依据和经验证据。
-
关键词:
- 直肠癌 /
- 经肛门全直肠系膜切除术 /
- 综述
Abstract: For a long time, colorectal surgeons have been continuously exploring the treatment of rectal cancer and improving the quality of life of patients and the therapeutic effect of rectal cancer. Low and median rectal cancer is common in Chinese patients. The current surgical operations used in the treatment of low and median rectal cancer include transanal total mesorectal excision (TaTME), ISR, Miles, APR, Hartmann, Parks, ELAPE and Dixon. Different surgical procedures are used in rectal cancer with different symptoms. For low rectal cancer patients with "difficult pelvis" such as huge tumor, mesangial hypertrophy and pelvic stenosis, TaTME can accurately locate the margin of the lesion, internal sphincter space in the anal canal and middle and low rectal membrane space. It can effectively reduce the risk of surgical complications, control the recurrence rate and improve the survival rate, which has been favoured and recognised by colorectal surgeons. However, TaTME requires doctors to have sufficient experience in laparoscopic and transanal surgery and is limited by the current development of laparoscopic equipment and instruments. In this paper, the developmental origin, application, advantages and disadvantages of TaTME and its future prospects are reviewed to provide some theoretical basis and empirical evidence for this research and practice.-
Key words:
- Rectal cancer /
- Transanal total mesorectal excision /
- Review
-
表 1 TaTME的优势和劣势
项目 内容 优势 1.可确保足够的远切缘和环周切缘。
2.无切口，杜绝并发症。
3.可获得足够的可视化空间。
4.减少手术时间并可保护重要的结构。
5.提高解剖平面能力。劣势 1.学习曲线长。
2.完全TaTME不能彻底探查腹腔。
3.不能先处理结扎供血管根部。
4.操作难度大。
5.腹腔镜辅助TaTME存在CO2栓塞的风险。
下载: 导出CSV
-
[1] 娄彦昂, 高飞, 赵浩永, 等. 示踪剂技术在腹腔镜直肠癌根治术中应用的价值[J]. 医药论坛杂志, 2019, 40(10): 31-33. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX201910009.htm [2] 李兵, 蒋泰君, 黄振国, 等. 超低位直肠癌完全经肛全直肠系膜切除术联合括约肌间切除术术后医院内感染的临床特点及影响因素分析[J]. 癌症进展, 2019, 17(17): 2048-2051. https://www.cnki.com.cn/Article/CJFDTOTAL-AZJZ201917017.htm [3] 范海军, 田大广, 魏晓平, 等. 多学科团队对直肠癌同时性肝转移1例的诊治实践[J]. 中国临床研究, 2020, 33(4): 542-546. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCK202004029.htm [4] 陈弦, 李杰. 中医综合治疗干预Ⅲ-Ⅳ期结直肠癌的临床研究[J]. 中国中医基础医学杂志, 2017, 23(3): 371-374, 383. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYJC201703031.htm [5] 应可明, 燕归如, 孙民昌, 等. 腹腔镜与开腹直肠癌全直肠系膜切除术的安全性及远期临床疗效评估[J]. 中国医药, 2019, 14(7): 1046-1050. doi: 10.3760/j.issn.1673-4777.2019.07.022 [6] 吴海俊, 李辉华, 胡水根, 等. 腹腔镜手术与开腹手术治疗结直肠癌的临床效果比较[J]. 中国基层医药, 2020, 27(14): 1689-1692. doi: 10.3760/cma.j.issn.1008-6706.2020.14.006 [7] 李鑫, 骆成玉, 李海连, 等. 腹腔镜辅助结直肠癌根治术的临床研究[J]. 北京医学, 2017, 39(7): 701-703. https://www.cnki.com.cn/Article/CJFDTOTAL-BJYX201707019.htm [8] 汪明庆, 熊茂明, 陈博, 等. 腹腔镜与传统开放Dixon术治疗直肠癌的临床对照研究[J]. 中华全科医学, 2019, 17(1): 10-13. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201901004.htm [9] 魏志平, 应荣彪, 姚俊, 等. 经肛门微创手术治疗直肠肿瘤疗效分析[J]. 中国基层医药, 2017, 24(12): 1782-1785. doi: 10.3760/cma.j.issn.1008-6706.2017.12.007 [10] 杨永江, 彭涛, 黄迪, 等. 内镜切割吻合器在直肠肿瘤经肛门切除术中的应用[J]. 中国临床研究, 2018, 31(4): 524-526, 530. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCK201804023.htm [11] 徐胜, 黄顺荣. 直肠癌经肛全直肠系膜切除术的临床研究现状[J]. 中国临床新医学, 2019, 12(8): 918-922. doi: 10.3969/j.issn.1674-3806.2019.08.27 [12] BONJER H J, DEIJEN C L, ABIS G A, et al. Randomized trial of laparoscopic versus open surgery for rectal cancer[J]. New Eng J of Med, 2015, 372(14): 1324-1332. doi: 10.1056/NEJMoa1414882 [13] WEXNER S D, BERHO M. Transanal total mesorectal excision of rectal carcinoma: Evidence to learn and adopt the technique[J]. Ann Surg, 2015, 261(2): 234-236. doi: 10.1097/SLA.0000000000000886 [14] DEIJEN C L, VEITHUIS S, TSAI A, et al. COLOR III: A multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer[J]. Surg Endosc, 2016, 30(8): 3210-3215. doi: 10.1007/s00464-015-4615-x [15] 孙瑞彩, 史学文. 经肛门全直肠系膜切除术的研究进展[J]. 中国肛肠病杂志, 2019, 39(2): 71-73. doi: 10.3969/j.issn.1000-1174.2019.02.033 [16] WHIYEFORD M H, DENK P M, SWANSTRÖM L L. Feasibility of radical sigmoid colectomy performed as natural orifice transluminal endoscopic surgery (NOTES) using transanal endoscopic microsurgery[J]. Surg Endosc, 2007, 21(10): 1870-1874. doi: 10.1007/s00464-007-9552-x [17] TELEM D A, HAN K S, KIM M C, et al. Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series[J]. Surg Endosc, 2013, 27(1): 74-80. doi: 10.1007/s00464-012-2409-y [18] SYLLA P, RATTNER D W, DEIGADO S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance[J]. Surg Endosc, 2010, 24(5): 1205-1210. doi: 10.1007/s00464-010-0965-6 [19] 张忠涛, 姚宏伟. 再谈经肛全直肠系膜切除的进展、争议及前景[J]. 中国实用外科杂志, 2018, 38(1): 65-67. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201801018.htm [20] 中华医学会外科学分会, 结直肠外科学组, 中华医学会外科学分会腹腔镜与内镜外科学组. 直肠癌经肛全直肠系膜切除专家共识及手术操作指南(2017版)[J]. 中国实用外科杂志, 2017, 37(9): 978-984. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201709012.htm [21] 姚宏伟, 张忠涛, 郑民华. 直肠癌经肛全直肠系膜切除中国专家共识及临床实践指南(2019版)[J]. 中国实用外科杂志, 2019, 39(11): 1121-1128. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201911001.htm [22] 陈谢平, 余启熠, 古柳根. 腹腔镜辅助TaTME治疗中低位直肠癌的效果观察[J]. 临床医药文献电子杂志, 2019, 6(91): 24-25. https://www.cnki.com.cn/Article/CJFDTOTAL-LCWX201991018.htm [23] 池畔, 陈致奋. 机器人与腹腔镜全直肠系膜切除术的比较[J]. 中华胃肠外科杂志, 2017, 20(6): 610-613. doi: 10.3760/cma.j.issn.1671-0274.2017.06.003 [24] 康亮. 开展经肛全直肠系膜切除术的条件和经验[J]. 中华胃肠外科杂志, 2017, 20(6): 643. doi: 10.3760/j.issn.1671-0274.2017.06.015 [25] KANG L, CHEN W H, LUO S L, et al. Transanal total mesorectal excision for rectal cancer: A preliminary report[J]. Surg Endosc, 2016, 30(6): 2552-2562. doi: 10.1007/s00464-015-4521-2 [26] 尤一舟, 史良会. 经肛门全直肠系膜切除术的发展现状[J]. 沈阳医学院学报, 2018, 20(2): 170-173. https://www.cnki.com.cn/Article/CJFDTOTAL-SYYX201802023.htm [27] 何流, 肖毅. 经肛门全直肠系膜切除术在直肠癌根治中的应用[J]. 中华胃肠外科杂志, 2017, 20(8): 957-960. doi: 10.3760/cma.j.issn.1671-0274.2017.08.034 [28] ATAIIAH S. Transanal minimally invasive surgery for total mesorectal excision[J]. Minim Invasive Ther Allied Technol, 2014, 23(1): 10-16. doi: 10.3109/13645706.2013.833118 [29] LACY A M, TASENDE M M, DEIGADO S, et al. Transanal total mesorectal excision for rectal cancer: Outcomes after 140 patients[J]. J Am Coll Surg, 2015, 221(2): 415-423. doi: 10.1016/j.jamcollsurg.2015.03.046 [30] SIMILLIS C, HOMPES R, PENNA M, et al. A systematic review of transanal total mesorectal excision: Is this the future of rectal cancer surgery?[J]. Colorectal Dis, 2016, 18(1): 19-36. doi: 10.1111/codi.13151 [31] 磨鹏诗, 杨平, 陈应驹. 腹腔镜辅助TaTME术在低位直肠癌患者中的临床效果及安全性研究[J]. 中华普外科手术学杂志(电子版), 2019, 13(2): 155-158. doi: 10.3877/cma.j.issn.1674-3946.2019.02.015 [32] 罗双灵, 康亮. 经肛腔镜手术/经肛TME的国际进展和质量数据[J]. 中国医刊, 2019, 54(1): 1-4. doi: 10.3969/j.issn.1008-1070.2019.01.001 [33] 王世磊, 胡艳瑞. 腹腔镜辅助经腹直肠前切除术治疗高龄低位直肠癌患者的效果观察[J]. 医药论坛杂志, 2019, 40(7): 128-130. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX201907045.htm [34] PENNA M, HOMPES R, ARNOLd S, et al. Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision results from the international TaTME registry[J]. Ann Surg, 2019, 269(4): 700-711. doi: 10.1097/SLA.0000000000002653 [35] 胡金. 直肠癌经肛全直肠系膜切除术的临床研究现状[J]. 中外医学研究, 2020, 18(19): 182-184. https://www.cnki.com.cn/Article/CJFDTOTAL-YJZY202019078.htm [36] 何风国, 师新荣. 腹腔镜直肠癌保肛手术后吻合口瘘的危险因素与对策研究[J]. 中国全科医学, 2019, 22(S2): 123-125. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX2019S2044.htm [37] EMILE S H, LACY F B D, KELLER D S, et al. Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom[J]. World J Gastroint Surg, 2018, 10(3): 28-39. doi: 10.4240/wjgs.v10.i3.28 [38] 张纯博, 张超, 白军伟, 等. 经自然腔道取标本腹腔镜下直肠癌根治术与传统腹腔镜直肠癌根治术的回顾性对比研究[J]. 医药论坛杂志, 2020, 41(7): 10-14. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX202007003.htm [39] 尹鹏, 乔磊, 徐华晓, 等. 快速康复外科理念在腹腔镜结直肠癌经自然腔道标本取出手术中的应用[J]. 中国医药, 2018, 13(6): 891-895. doi: 10.3760/j.issn.1673-4777.2018.06.023 [40] CARMICHAEL H, D'ANDREA A P, SKANCKE M, et al. Feasibility of transanal total mesorectal excision (taTME) using the Medrobotics Flex System[J]. Surg Endo, 2019, 34(1): 485-491. http://www.cascade-fp7.eu/cras2013/proceedings/cras2013_Zenati.pdf -
点击查看大图
表(1)
计量
- 文章访问数: 111
- HTML全文浏览量: 56
- PDF下载量: 5
- 被引次数: 0
