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World Journal of Gastroenterology 2018年第11期24卷 1278-1284页

作者： Ping-Tian Xia Maimaiti Yusofu Hai-Feng Han Chun-Xiao Hu San-Yuan Hu Wen-Bin Yu Shao-Zhuang Liu Department of General Surgery Qilu Hospital of Shandong University

AIM To evaluate the safety and feasibility of a new technology combining low-pressure pneumoperitoneum(LPP) and abdominal wall lift(AWL) in laparoscopic total mesorectal excision(TME) for rectal cancer.METHODS From November 2015 to July 2017,26 patients underwent laparoscopic TME for rectal cancer using LPP(6-8 mm Hg) with subcutaneous AWL in Qilu Hospital of Shandong University,Jinan,China.Clinical data regarding patients' demographics,intraoperative monitoring indices,operation-related indices andpathological outcomes were prospectively collected.RESULTS Laparoscopic TME was performed in 26 cases(14 anterior resection and 12 abdominoperineal resection) successfully,without conversion to open or laparoscopic surgery with standard-pressure pneumoperitoneum.Intraoperative monitoring showed stable heart rate,blood pressure and paw airway pressure.The mean operative time was 194.29 ± 41.27 min(range:125-270 min) and 200.41 ± 20.56 min(range:170-230 min) for anterior resection and abdominoperineal resection,respectively.The mean number of lymph nodes harvested was 16.71 ± 5.06(range:7-27).There was no positive circumferential or distal resection margin.No local recurrence was observed during a median follow-up period of 11.96 ± 5.55 mo(range:5-23 mo).CONCLUSION LPP combined with AWL is safe and feasible for laparoscopic TME.The technique can provide satisfactory exposure of the operative field and stable operative monitoring indices.

关键词： Laparoscopic surgery Abdominal wall lift Low-pressure pneumoperitoneum Rectal cancer Total mesorectal excision

Evolution of transanal total mesorectal excision for rectal cancer:From top to bottom

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World Journal of Gastrointestinal Surgery 2018年第3期10卷 28-39页

作者： Sameh Hany Emile F Borja de Lacy Deborah Susan Keller Beatriz Martin-Perez Sadir Alrawi Antonio M Lacy Manish Chand Department of General Surgery Mansoura Faculty of Medicine Department of Surgery Hospital Clinic University of Barcelona GENIE Centre University College London Department of Surgery and Interventional Sciences University College London Hospitals NHS Trusts Department of Surgical Oncology Alzahra Cancer Center Al Zahra Hospital

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision(TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life(QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision(TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending.As evidence for safety and feasibility accumulates,structured training programs to standardize teaching,training, and safe expansion will aid the safe spread of the TaTME.

关键词： Rectal cancer Total mesorectal excision Transanal total mesorectal excision Sphincter sparing surgery Colorectal surgery

Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery

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World Journal of Gastroenterology 2016年第13期22卷 3602-3610页

作者： Francesco Feroci Andrea Vannucchi Paolo Pietro Bianchi Stefano Cantafio Alessia Garzi Giampaolo Formisano Marco Scatizzi Department of General and Oncological Surgery Santo Stefano Hospital Department of General and Minimally Invasive Surgery Misericordia Hospital

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision(TME) with curative intent between January 2008 and December 2014(robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage?Ⅰ-Ⅲ disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME(L-TME) and 342 min for robotic TME(R-TME)(P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. Thepatients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients(8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group(18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients(1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups.CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.

关键词： Robotic surgery Laparoscopic surgery Rectal cancer Total mesorectal excision Minimally invasive surg

The quality of total mesorectal excision specimen: A review of its macroscopic assessment and prognostic significance

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Chronic Diseases and Translational Medicine 2018年第1期4卷 51-58页

作者： Shi-Bo Song Guo-Ju Wu Hong-Da Pan Hua Yang Mao-Lin Hu Qiang Li Qiu-Xia Yan Gang Xiao Department of Gastrointestinal Surgery Beijing HospitalNational Center of GerontologyBeijing 100730China Peking University Fifth School of Clinical Medicine Beijing 100730China

As a surgical procedure which could significantly lower the recurrence rate of cancers, total mesorectal excision (TME) has been the gold standard for middle and lower rectal cancer treatment. However, previous studies have shown that the procedure did not achieve the ideal theoretical local recurrence rates of rectal cancers. Some researchers pointed out it was very likely that not all so-called TME treatments completely removed the mesorectum, implying that some of these TME surgical treatments failed to meet oncological quality standards. Therefore, a suitable assessment tool for the surgical quality of TME is necessary. The notion of 'macroscopic assessment of mesorectal excision (MAME)' was put forward by some researchers as a better assessment tool for the surgical quality of TME and has been confirmed by a series of studies. Besides providing rapid and accurate surgical quality feedbacks for surgeons, MAME also effectively assesses the prognosis of patients with rectal cancer. However, as a new assessment tool used for TME surgical quality, MAME has an only limited influence on the current guidelines and is yet to be widely applied in most countries. The aims of this review are to provide a detailed introduction to MAME for clinical practice and to summarize the current prognostic significance of MAME.

关键词： Macroscopic assessment of mesorectal excision (MAME) Quality control Total mesorectal excision (TME) Coning

Technical feasibility of laparoscopic extended surgerybeyond total mesorectal excision for primary or recurrentrectal cancer

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World Journal of Gastroenterology 2016年第2期22卷 718-726页

作者： Takashi Akiyoshi Gastroenterological Center Department of Gastroenterological SurgeryCancer Institute HospitalJapanese Foundation for Cancer ResearchTokyo 135-8550Japan

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer.Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.

关键词： Rectal cancer Total mesorectal excision Laparoscopic surgery Extended surgery Lateral pelviclymph node dissection Pelvic exenteration

Transanal total mesorectal excision: Myths and reality

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World Journal of Clinical Oncology 2016年第5期7卷 337-339页

作者： Nicolas C Buchs Marta Penna Alexander L Bloemendaal Roel Hompes Division of Visceral Surgery Department of Surgery University Hospitals of Geneva Department of Colorectal Surgery Churchill Hospital Oxford University Hospitals

Transanal total mesorectal excision(TaTME) is a new and promising approach for the treatment of rectal cancer. Whilst the experience is still limited, there are growing evidences that this approach might overcome the limits of standard low anterior resection. TaTME might help to decrease the conversion rate especially in difficult patients, and to improve the pathological results, while preserving the urogenital function. Evaluation of data from large registries and randomized studies should help to draw firmer conclusions. Beyond these technical considerations, the next challenge seems to be clearly the safe introduction of this approach, motivating the development of dedicated courses.

关键词： Transanal total mesorectal excision Bottom up TAMIS Laparoscopy Robotic Outcomes Rectal cancer

Rectal cancer staging: Multidetector-row computed tomography diagnostic accuracy in assessment of mesorectal fascia invasion

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World Journal of Gastroenterology 2016年第20期22卷 4891-4900页

作者： Davide Ippolito Silvia Girolama Drago Cammillo Talei Franzesi Davide Fior Sandro Sironi School of Medicine University of Milano-Bicocca Department of Diagnostic Radiology H. San Gerardo Hospital

AIM: To assess the diagnostic accuracy of multidetectorrow computed tomography(MDCT) as compared with conventional magnetic resonance imaging(MRI), in identifying mesorectal fascia(MRF) invasion in rectal cancer patients.METHODS: Ninety-one patients with biopsy proven rectal adenocarcinoma referred for thoracic and abdominal CT staging were enrolled in this study. The contrast-enhanced MDCT scans were performed on a 256 row scanner(ICT, Philips) with the following acquisition parameters: tube voltage 120 KV, tube current 150-300 m As. Imaging data were reviewed as axial and as multiplanar reconstructions(MPRs) images along the rectal tumor axis. MRI study, performed on 1.5 T with dedicated phased array multicoil, included multiplanar T2 and axial T1 sequences and diffusion weighted images(DWI). Axial and MPR CT images independently were compared to MRI and MRF involvement was determined. Diagnostic accuracy of both modalities was compared and statistically analyzed.RESULTS: According to MRI, the MRF was involved in 51 patients and not involved in 40 patients. DWI allowed to recognize the tumor as a focal mass with high signal intensity on high b-value images, compared with the signal of the normal adjacent rectal wall or with the lower tissue signal intensity background. The number of patients correctly staged by the native axial CT images was 71 out of 91(41 with involved MRF; 30 with not involved MRF), while by using the MPR 80 patients were correctly staged(45 with involved MRF; 35 with not involved MRF). Local tumor staging suggested by MDCT agreed with those of MRI, obtaining for CT axial images sensitivity and specificity of 80.4% and 75%, positive predictive value(PPV) 80.4%, negative predictive value(NPV) 75% and accuracy 78%; while performing MPR the sensitivity and specificity increased to 88% and 87.5%, PPV was 90%, NPV 85.36% and accuracy 88%. MPR images showed higher diagnostic accuracy, in terms of MRF involvement, than native axial images, as compared to the reference magnetic resonance images. The

关键词： Magnetic resonance Multi detector computed tomography Rectal cancer mesorectal fascia Multiplanar re

Laparoscopic total mesorectal excision with natural orifice specimen extraction

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World Journal of Gastroenterology 2013年第5期19卷 750-754页

作者： Quan Wang Chao Wang Dong-Hui Sun Punyaram Kharbuja Xue-Yuan Cao Department of Gastric and Colorectal Surgery Jilin University First Hospital

AIM:To introduce transvaginal or transanal specimen extraction in laparoscopic total mesorectal excision surgery to avoid an abdominal incision. METHODS:Between January 2009 and December 2011,21 patients with rectal cancer underwent laparoscopic radical resection and the specimen was retrieved by two different ways:transvaginal or transanal rectal removal.Transvaginal specimen extraction approach was strictly limited to elderly post-menopausal women who need hysterectomy.Patients aged between 30 and 80 years,with a body mass index of less than 30 kg/m2, underwent elective surgery.The surgical technique and the outcomes related to the specimen extraction,such as duration of surgery,length of hospital stay,and the complications were retrospectively reviewed. RESULTS:Laparoscopic resection using a natural orifice removal approach was successful in all of the 21 patients.Median operating time was 185 min(range,122-260 min)and the estimated blood loss was 48 mL. The mean length of hospital stay was 7.5 d(range,2-11 d).One patient developed postoperative ileus and had an extended hospital stay.The patient complained of minimal pain.There were no postoperative complications or surgery-associated death.The mean size of the lesion was 2.8 cm(range,1.8-6.0 cm),and the mean number of lymph nodes harvested was 18.7(range, 8-27).At a mean follow-up of 20.6 mo(range,10-37 mo),there were no functional disorders associated with the transvaginal and transanal specimen extraction. CONCLUSION:Transvaginal or transanal extraction in L-TME is a safe and effective procedure.Natural orifice specimen extraction can avoid the abdominal wall incision and its potential complications.

关键词： Laparoscopic total mesorectal excision Natural orifice specimen extraction Rectum cancer Transvaginal Transanal

Routine defunctioning stoma after chemoradiation and total mesorectal excision:A single-surgeon experience

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World Journal of Gastroenterology 2013年第11期19卷 1797-1804页

作者： Shao-Chieh Lin Po-Chuan Chen Chung-Ta Lee Hong-Ming Tsai Peng-Chan Lin Helen HW Chen Yuan-Hwa Wu Bo-Wen Lin Wen-Pin Su Jenq-Chang Lee Division of Colorectal Surgery Department of SurgeryNational Cheng Kung University HospitalCollege of Medicine National Cheng Kung University Tainan 704Taiwan Department of Pathology National Cheng Kung University HospitalCollege of Medicine Department of Radiology National Cheng Kung University HospitalCollege of Medicine Department of Oncology National Cheng Kung University HospitalCollege of Medicine Department of Radiation Oncology National Cheng Kung University HospitalCollege of Medicine

AIM:To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution.METHODS:From Oct 1998 to Feb 2009,we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge.All patients received neoadjuvant chemoradiation(CRT) for 6 wk.Among them,85% of the patients received 225 mg/m2/d 5-fluorouracil using a portable infusion pump.The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk.The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk.Total mesorectal excision(TME) and routine defunctioning stoma construction were performed by one surgeon.The distal resection margin,circumferential resection margin,tumor regression grade(TRG) and other parameters were recorded.We used TRG to evaluate the tumor response after neoadjuvant CRT.We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma.RESULTS:The median distance from the lower margin of rectal cancer to the anal verge was 5 cm:6 cm in 9 patients,5 cm in 32 patients,4 cm in 10 patients,and 3 cm in 11 patients.Before receiving neoadjuvant CRT,45 patients(72.6%) had a cT3-4 tumor,and 21(33.9%) patients had a cN1-2 lymph node status.After CRT,30 patients(48.4%) had a greater than 50% clinical reduction in tumor size.The final pathology reports revealed that 33 patients(53.2%) had a ypT3-4 tumor and 12(19.4%) patients had ypN1-2 lymph node involvement.All patients completed the entire course of neoadjuvant CRT.Most patients developed only Grade 1-2 toxicities during CRT.Thirteen patients(21%) achieved a pathologic complete response.Few post-operative complications occurred.Nearly 90% of the defunctioning stomas were closed within 6 mo.The local recurrence rate was 3.2%.Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence(36.5% vs 76.5%,P = 0.006).Nea

关键词： Rectal cancer Neoadjuvant chemoradiation Total mesorectal excision Pathologic complete response Defunctioning stoma

直肠癌全系膜切除及双吻合器术后吻合口瘘的相关因素分析与防治对策

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临床军医杂志 2010年第5期38卷 708-710页

作者：毛岸荣黄河陈立兵胡剑平崔小红种锦贵蒋晓解放军第85医院普外科上海200052

目的探讨直肠癌行全系膜切除及双吻合器手术切除后吻合口瘘的相关原因及预防、诊断、治疗措施.方法回顾性分析我院2001年1月-2009年6月252例(男159例,女93例)直肠癌患者,行直肠全系膜切除及双吻合器术后吻合口瘘的发生率及治疗情况.结... 详细信息

目的探讨直肠癌行全系膜切除及双吻合器手术切除后吻合口瘘的相关原因及预防、诊断、治疗措施.方法回顾性分析我院2001年1月-2009年6月252例(男159例,女93例)直肠癌患者,行直肠全系膜切除及双吻合器术后吻合口瘘的发生率及治疗情况.结果该组病例吻合口瘘的发生率为5.6%(14/252);确诊吻合口瘘发生时间为4～9 d,平均为6.8 d.其中8例高流量瘘采用早期横结肠造瘘与腹腔冲洗引流手术;6例低流量瘘采用非手术治疗,骶前双腔管冲洗与肛管固定引流术.2次治疗至出院时间为28～80 d,平均为48.6 d.术后吻合口瘘发生与患者的全身情况、吻合技术、吻合口位置,肿瘤Dukes分期、术前放化疗、是否行预防性造瘘等有相关性.结论术前充分的评估,术中细致的操作及选择性预防性造瘘的应用和围术期合理的处理是预防术后吻合口瘘的关键;术后及时正确的判断,恰当的手术时机的把握,充分的引流、营养支持等综合性措施是治疗吻合口瘘的必要手段.

关键词：直肠癌直肠全系膜切除双吻合器术后吻合口瘘相关因素分析防治对策 treatment total mesorectal excision anastomotic leakage 非手术治疗预防性造瘘引流手术发生率原因及预防双腔管冲洗术前放化疗回顾性分析 Dukes分期治疗情况治疗措施