经肛内镜显微外科手术TEM医学医药

1、北京世纪坛医院多媒体网络室 2007 临床类模板 Background present experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM). Goal:evaluating morbidity, mortality, and local recurrence rate. 北京世纪坛医院多媒体网络室 2007 临床类模板 Patients and methods Enrolled:402 patients, preoperative diagnosis of adenomas.(199

2、3.1- 2008.10) Mean age:65 years(range22-92) Men:221 vs Women:181 北京世纪坛医院多媒体网络室 2007 临床类模板 distance of adenomas from the anal verge 0-3 cm: 28 patients 3-6 cm: 58 patients 6-12 cm: 251 patients 12-16 cm: 54 patients 16 cm: 11 patients 北京世纪坛医院多媒体网络室 2007 临床类模板 Lesion position anterior wall of the rect

3、um:92 patients posterior wall:107 patients lateral wall:88 patients semicircumferential:98 patients circumferential:17 patients 北京世纪坛医院多媒体网络室 2007 临床类模板 Preoperative therapy staging digital examination to evaluate tumor fixation total colonoscopy rigid rectoscopy:macrobiopsies; measure the distance

4、from the anal verge; determine the location and consequently select the position 北京世纪坛医院多媒体网络室 2007 临床类模板 transanal endosonography (EUS) by a rotative probe computed tomography (CT) scan or magnetic resonance imaging (MRI):giant and suspected lesions 北京世纪坛医院多媒体网络室 2007 临床类模板 Patient preparation wash

5、out of the colon short-term antibiotic prophylaxis general anesthesia in the majority of patients Spinal anesthesia was used in 65 (16.1%) high-risk patients(ASA 4). 北京世纪坛医院多媒体网络室 2007 临床类模板 1.supine position 2.prone position 3.lateral position place the lesion in the inferior part of the operative

6、field 北京世纪坛医院多媒体网络室 2007 临床类模板 Fullthickness excision: 379 patients (94.3%) 1 cm minimum of normal mucosa around the lesion Mucosectomy: 23 patients(5.7%) 北京世纪坛医院多媒体网络室 2007 临床类模板 Mean operative time was 64 min (range = 22120). rectal defect was closed: endoluminal running suture with a silver clip

7、placed at each end of the suture to avoid an intrarectal node. 北京世纪坛医院多媒体网络室 2007 临床类模板 only 15 patients (3.7%) required the repeated administration of ketorolac 30 mg in the first 48 h. drink liquids on the first postoperative day Mean hospital stay was 2.5 days (range = 18 days). 北京世纪坛医院多媒体网络室 200

8、7 临床类模板 short-term results: Minimal intraoperative complications: 13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vagina All lesions were closed endoscopically by TEM without any intra- or postoperative consequences. 北京世纪坛医院多媒体网络室 2007 临床类模板 giant adenomas(2

9、 cases):impossible to carry out a complete suture. temporary ileostomy closed after 2 months One of the two patients had a rectal stenosis required endoscopic dilatation. At follow-up of 24 and 30 months (the patient with rectal stenosis) no other complications were observed. 北京世纪坛医院多媒体网络室 2007 临床类模

10、板 Definitive histology N Further treatment adenomas 366 (91%). NO situ carcinoma or pT1 rectal tumor 34 (8.4%) NO mucinous T2 cancer 2(0.5%) laparoscopic anterior rectal resection with temporary ileostomy 北京世纪坛医院多媒体网络室 2007 临床类模板 Postoperative follow-up mean follow-up :84 months (range = 1190 months

11、) 1 month after discharge : clinical examination, digital rectal exploration, andrigid rectoscopy every 6 months for the first year and then annually (flexible endoscopy with biopsies of the scar) 北京世纪坛医院多媒体网络室 2007 临床类模板 complications 北京世纪坛医院多媒体网络室 2007 临床类模板 All leaking sutures resolved by local t

12、herapy (antibiotics and analgesic enema) and/or parenteral nutrition. Stool incontinence was treated with physiotherapy and anal sphincter biofeedback resolved within 2 months of the operation The patients with hemorrhaging, two of them with cirrhosis, required blood transfusions 北京世纪坛医院多媒体网络室 2007

13、临床类模板 北京世纪坛医院多媒体网络室 2007 临床类模板 Surgical drainage and colostomy (patient is alive after 1 year) Laparoscopic ileostomy and a new suture by TEM.(patient is alive after 2 years without other complications) 北京世纪坛医院多媒体网络室 2007 临床类模板 Long-term results 北京世纪坛医院多媒体网络室 2007 临床类模板 No patients had a new recurre

14、nce at the next follow-up Of the 34 patients with pT1 rectal cancer, the mean follow-up of 30 months (range = 1470 months) revealed no local recurrences or distant metastases. 北京世纪坛医院多媒体网络室 2007 临床类模板 Discussion adenomas of the colon and rectum have the potential to become malignant; related to size

15、, histological type (villous adenoma),and grade of dysplasia 北京世纪坛医院多媒体网络室 2007 临床类模板 Endoscopic polypectomy is not able to remove all large and sessile polyps due to technical problems in the middle or upper rectum,it may be difficult to excise it completely 北京世纪坛医院多媒体网络室 2007 临床类模板 Sometimes, larg

16、e adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosis adenomas in the upper third of the rectum are removed by anterior resection Resection of the rectum is a major surgical procedure associated with significant morbidity (768%) and mortality (0

17、6.5%) 北京世纪坛医院多媒体网络室 2007 临床类模板 TEM:minimally invasive and safe can reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge) 北京世纪坛医院多媒体网络室 2007 临床类模板 Risk: pelvic abscess ,Infection bleeding perforation into the peritoneal cavity suture dehiscence stool incont

18、inence (soiling) rectovaginal fistula 北京世纪坛医院多媒体网络室 2007 临床类模板 indication Benign lesion: polyps adenomas Malignant lesion: T1N0 rectal tumor 北京世纪坛医院多媒体网络室 2007 临床类模板 Thank you 北京世纪坛医院多媒体网络室 2007 临床类模板 Fullthickness excision: 379 patients (94.3%) 1 cm minimum of normal mucosa around the lesion Mucose

19、ctomy: 23 patients(5.7%) 北京世纪坛医院多媒体网络室 2007 临床类模板 Definitive histology N Further treatment adenomas 366 (91%). NO situ carcinoma or pT1 rectal tumor 34 (8.4%) NO mucinous T2 cancer 2(0.5%) laparoscopic anterior rectal resection with temporary ileostomy 北京世纪坛医院多媒体网络室 2007 临床类模板 Postoperative follow-u

20、p mean follow-up :84 months (range = 1190 months) 1 month after discharge : clinical examination, digital rectal exploration, andrigid rectoscopy every 6 months for the first year and then annually (flexible endoscopy with biopsies of the scar) 北京世纪坛医院多媒体网络室 2007 临床类模板 All leaking sutures resolved by local therapy (antibiotics and analgesic enema) and/or parenteral nutrition. Stool incontinence was treated with physiotherapy and anal sphincter biofeedback resolved within 2 mo