经肛内镜显微外科手术TEM概要课件

1、经肛内镜显微外科手术TEM概要课件经肛内镜显微外科手术TEM概要课件Backgroundpresent experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).Goal:evaluating morbidity, mortality, and local recurrence rate.Backgroundpresent experience wPatients and methodsEnrolled:402 patients, preoperative diagnosis of ade

2、nomas.(1993.1-2008.10)Mean age:65 years(range22-92)Men:221 vs Women:181Patients and methodsEnrolled:4distance of adenomas from the anal verge0-3 cm: 28 patients3-6 cm: 58 patients6-12 cm: 251 patients12-16 cm: 54 patients 16 cm: 11 patientsdistance of adenomas from the Lesion positionanterior wall o

3、f the rectum:92 patientsposterior wall:107 patientslateral wall:88 patientssemicircumferential:98 patientscircumferential:17 patientsLesion positionanterior wall oPreoperative therapy stagingdigital examination to evaluate tumor fixationtotal colonoscopyrigid rectoscopy:macrobiopsies; measure the di

4、stance from the anal verge; determine the location and consequently select the positionPreoperative therapy stagingditransanal endosonography (EUS) by a rotative probecomputed tomography (CT) scan or magnetic resonance imaging (MRI):giant and suspected lesionstransanal endosonography (EUS)Patient pr

5、eparationwashout of the colonshort-term antibiotic prophylaxisgeneral anesthesia in the majority of patientsSpinal anesthesia was used in 65 (16.1%) high-risk patients(ASA 4).Patient preparationwashout of 1.supine ne position 3.lateral positionplace the lesion in the inferior part ofthe

6、 operative field 1.supine position2.prFullthickness excision: 379 patients (94.3%) 1 cm minimum of normal mucosa around the lesionMucosectomy: 23 patients(5.7%)Fullthickness excision: 379 paMean operative time was 64 min (range = 22120).rectal defect was closed: endoluminal running suture with a sil

7、ver clip placed at each end of the suture to avoid an intrarectal node.Mean operative time was 64 minonly 15 patients (3.7%) required the repeated administration of ketorolac 30 mg in the first 48 h.drink liquids on the first postoperative dayMean hospital stay was 2.5 days (range = 18 days).only 15

8、 patients (3.7%) requirshort-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.short-term results:Minimal i

9、ntgiant adenomas(2 cases):impossible to carry out a complete suture. temporary ileostomy closed after 2 months One of the two patients had a rectal stenosisrequired endoscopic dilatation. At follow-up of 24 and 30 months (the patient with rectal stenosis) no other complications were observed.giant a

10、denomas(2 cases):impossDefinitive histologyNFurther treatmentadenomas366 (91%).NOsitu carcinoma or pT1 rectal tumor34 (8.4%) NOmucinous T2 cancer2(0.5%)laparoscopic anterior rectal resection with temporary ileostomyDefinitive histologyNFurther tPostoperative follow-up mean follow-up :84 months (rang

11、e = 1190 months)1 month after discharge : clinical examination, digital rectal exploration, andrigid rectoscopyevery 6 months for the first year and then annually (flexible endoscopy with biopsies of the scar)Postoperative follow-up mean fcomplicationscomplicationsAll leaking sutures resolved by loc

12、al therapy (antibiotics and analgesic enema) and/or parenteral nutrition.Stool incontinence was treated with physiotherapy and anal sphincter biofeedback resolved within 2 months of the operationThe patients with hemorrhaging, two of them with cirrhosis, required blood transfusionsAll leaking suture

13、s resolved b经肛内镜显微外科手术TEM概要课件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)Surgical drainage and colostomLong-term resultsLong-term resultsNo patients had a new recurrence at t

14、he next follow-upOf the 34 patients with pT1 rectal cancer, the mean follow-up of 30 months (range = 1470 months) revealed no local recurrences or distant metastases.No patients had a new recurrenDiscussionadenomas of the colon and rectum have the potential to become malignant; related to size, hist

15、ological type (villous adenoma),and grade of dysplasiaDiscussionadenomas of the coloEndoscopic polypectomy is not able to remove all large and sessile polyps due to technical problemsin the middle or upper rectum,it may be difficult to excise it completelyEndoscopic polypectomy is not Sometimes, lar

16、ge adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosisadenomas 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 (06.5%)Sometimes, large adenomas in tTEM:minimally invasive and safecan reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge)TEM:minimally invasive and safRisk:pelvic abscess ,Infectio