TaTME-直肠癌手术的新突破

1、经肛全直肠系膜切除术（Transanal total mesorectal excision TaTME）,腹腔镜TME手术的肿瘤根治效果（腹腔镜手术3 年局部复发率、无病存活率、总存活率）与开放手术相似。 Bonjer HJ, Deijen CL, Abis GA. A randomized trial of laparoscopic laparoscopicvesus open surgery for rectal cancerJ. N Engl J Med,2015,372(14):1324-1332.,直肠肿瘤的手术方式,Current status of trans-anal tot

2、al mesorectal excision(TaTME) following the Second International Consensus Conference published in Colorectal Disease think: The challenge of operating in the deep pelvis is confirmed by results of a recent randomized controlled trial showing a 10% positive circumferential radial margin rate in lapa

3、roscopic and open TME and in particular a concerning 22% positive circumferential radial margin rate in the lower rectum in the open arm of the trial 1. Furthermore, the need for multiple firings of linear stapling devices in low rectal division has been associated with an increase in the surgical m

4、orbidity of the procedure 2. 1 van der Pas MHGM, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WCJ. Bonjer HJ Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised,phase 3 trial. Lancet Oncol 2013; 14: 2108. 2 Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsun

5、oda Y,Saito N. Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 2008; 23: 7037.,经自然腔道手术NOTES,腹腔镜技术平台,全直肠系膜切除原则,经肛全直肠系膜切除术（TaTME）,经肛门直肠内拖出术TATA,腹腔镜辅助TaTME,完全TaTME,Tatme适应证,Trans-anal total

6、 mesorectal excision(TaTME) following the Second International Consensus Conference： Rectal cancer include: (i) male gender (ii) rectal cancer less than 12 cm from the anal verge, including very low cancers, (iii) narrow and/or deep pelvis, (iv) visceral obesity and/or obesity with body mass index (

7、BMI) 30 kg/m2, (v) prostatic hypertrophy, (vi)tumour diameter 4 cm, (vii) distorted tissue planes due to neoadjuvant radiotherapy, and (viii) impalpable,low primary tumour requiring accurate placement of the distal resection margin.,直肠癌经肛门全直肠系膜切除术专家意见 1 aM 对于中低位直肠癌尤其是男性、肥胖、骨盆狭小患者的直肠系膜间隙术野显露有一定优势，可能提

8、高手术质量和降低副损伤，具有一定的应用前景 2.aM 实施初期建议选择适当病例， 如术前分期小于或等于3期、肿瘤体积不宜过大的中低位直肠癌患者。 3 临床开展aM 手术前须经专业培训， 建议在有腹腔镜直肠癌手术和经肛门手术经验的中心开展； 有条件的中心可先进行动物实验或尸体实验。 4 实施aM 手术需进行必要的术前评估， 如：MI、超声等，并经M 讨论。 5 根据各个中心的操作经验，aM 手术可以采用M 或M 平台进行。 6 完全aM 可行，但是技术难度相对较大，学习曲线较长；腹腔镜辅助的aM 可发挥经腹和经肛各自优势，学习曲线相对短，可能更易推广。 7 aM 开展过程中尤其需注意骶前出血、尿

9、道损伤和盆神经损伤等相关并发症。 8 aM 手术是否行保护性造口， 可依据患者术中情况和术者经验选择。 9 aM 手术目前尚处起步阶段，仍有待于多中心、大样本和长期随访的临床数据为其安全性、有效性和适应证选择等提供循证医学证据。,TaTME操作平台经肛门微创手术（M）平台商品化的经肛门单孔通道和经肛门内镜显微手术（M）平台的直肠镜,注：（a）；（）；（）；（）M 平台的直肠镜,TEM与TAMIS平台的比较,经肛门全直肠系膜切除手术（aM）时，经肛门微创手术（M）平台与经肛门内镜显微手术（M）平台相比，操作角度大237,TaTME手术步骤,TATME与腹腔镜辅助TME比较,肛门脱出避免腹部切口，

10、杜绝切口感染、切口疝及肿瘤切口种植转移等并发症，减少因多次钉合而出现吻合口并发症，直视下可加固缝合吻合口,Heald认为tatme的最大优势之一是解决了既往TME术中对中下段直肠系膜周围间隙暴露不佳而造成的盆腔神经副损伤。 Heald RJ. A new solution to some old problems: transanal TMEJ. Tech Coloproctol，2013，17(3):257-258.,taTME 术中直肠前壁游离（黑色箭头示前壁Denovilliers 筋膜游离层面）,taTME 术中直肠中下段系膜侧后壁游离（黑色箭头示通向直肠和肛门 内扩约肌的下腹下神经丛

11、后支）,Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer,Table1 Patient demographics,Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer,Transanal TATA/TME: a case-matched study of taTME versus laparoscopi

12、c TME surgery for rectal cancer,Conclusions：We demonstrated no differences in perioperative/postoperative outcomes or pathologic TME outcomes of transanal or bottoms-up TME compared to standard laparoscopic TME. TaTME is a promising progressive approach to NOTES and deserves additional evaluation.,Transanal total mesorectal excision: surgical technique description andoutcomes,Conclusions ：Transanal total mesorectal excision has