经肛内镜显微外科手术TEM医学医药

Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experienceBackgroundpresentexperiencewithrectaladenomasmanagedbytransanalendoscopicmicrosurgery(TEM).Goal:evaluatingmorbidity,mortality,andlocalrecurrencerate.PatientsandmethodsEnrolled:402patients,preoperativediagnosisofadenomas.(1993.1-2008.10)Meanage:65years(range22-92)Men:221vsWomen:181distanceofadenomasfromtheanalverge0-3cm:28patients3-6cm:58patients6-12cm:251patients12-16cm:54patients>16cm:11patientsLesionpositionanteriorwalloftherectum:92patientsposteriorwall:107patientslateralwall:88patientssemicircumferential:98patientscircumferential:17patientsPreoperativetherapystagingdigitalexaminationtoevaluatetumorfixationtotalcolonoscopyrigidrectoscopy:macrobiopsies;measurethedistancefromtheanalverge;determinethelocationandconsequentlyselectthepositiontransanalendosonography(EUS)byarotativeprobecomputedtomography(CT)scanormagneticresonanceimaging(MRI):giantandsuspectedlesionsPatientpreparationwashoutofthecolonshort-termantibioticprophylaxisgeneralanesthesiainthemajorityofpatientsSpinalanesthesiawasusedin65(16.1%)high-riskpatients(ASA4).1.supineposition

2.proneposition

3.lateral

position

placethelesionintheinferiorpartof

theoperativefieldFullthicknessexcision:379patients(94.3%)1cmminimumofnormalmucosaaroundthelesionMucosectomy:23patients(5.7%)Meanoperativetimewas64min(range=22–120).rectaldefectwasclosed:endoluminalrunningsuturewithasilverclipplacedateachendofthesuturetoavoidanintrarectalnode.only15patients(3.7%)requiredtherepeatedadministrationofketorolac30mginthefirst48h.drinkliquidsonthefirstpostoperativedayMeanhospitalstaywas2.5days(range=1–8days).short-termresults:Minimalintraoperativecomplications:

13casesanopeningoftheperitonealcavityandin1patienttherewasanopeningofthevaginaAlllesionswereclosedendoscopicallybyTEMwithoutanyintra-orpostoperativeconsequences.giantadenomas(2cases):impossibletocarryoutacompletesuture.temporaryileostomyclosedafter2monthsOneofthetwopatientshadarectalstenosisrequiredendoscopicdilatation.Atfollow-upof24and30months(thepatientwithrectalstenosis)noothercomplicationswereobserved.DefinitivehistologyNFurthertreatmentadenomas366(91%).NOsitucarcinomaorpT1rectaltumor34(8.4%)NOmucinousT2cancer2(0.5%)laparoscopicanteriorrectalresectionwithtemporaryileostomyPostoperativefollow-up

meanfollow-up:84months(range=1–190months)1monthafterdischarge:①clinicalexamination,②digitalrectalexploration,and③rigidrectoscopyevery6monthsforthefirstyearandthenannually(flexibleendoscopywithbiopsiesofthescar)complicationsAllleakingsuturesresolvedbylocaltherapy(antibioticsandanalgesicenema)and/orparenteralnutrition.Stoolincontinencewastreatedwithphysiotherapyandanalsphincterbiofeedbackresolvedwithin2monthsoftheoperationThepatientswithhemorrhaging,twoofthemwithcirrhosis,requiredbloodtransfusionsSurgicaldrainageandcolostomy(patientisaliveafter1year)LaparoscopicileostomyandanewsuturebyTEM.(patientisaliveafter2yearswithoutothercomplications)Long-termresultsNopatientshadanewrecurrenceatthenextfollow-upOfthe34patientswithpT1rectalcancer,themeanfollow-upof30months(range=14–70months)revealednolocalrecurrencesordistantmetastases.Discussionadenomasofthecolonandrectumhavethepotentialtobecomemalignant;relatedtosize,histologicaltype(villousadenoma),andgradeofdysplasiaEndoscopicpolypectomyisnotabletoremovealllargeandsessilepolypsduetotechnicalproblemsinthemiddleorupperrectum,itmaybedifficulttoexciseitcompletelySometimes,largeadenomasinthelowerthirdoftherectumaretreatedbyabdominoperinealexcisionorcoloanalanastomosisadenomasintheupperthirdoftherectumareremovedbyanteriorresectionResectionoftherectumisamajorsurgicalprocedureassociatedwithsignificantmorbidity(7–68%)andmortality(0–6.5%)TEM:minimallyinvasiveandsafecanreachfurtherintotherectumthanotherformsoflocalexcision(upto20cmfromtheanalverge)R