切换至 "中华医学电子期刊资源库"
高级检索
中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2019, Vol. 08 ›› Issue (06) : 580 -587. doi: 10.3877/cma.j.issn.2095-3224.2019.06.007

所属专题： 文献；

论著

经肛门内镜显微外科手术（TEM）治疗直肠少见肿瘤
白雪杉1, 林国乐1,†(), 吴昕1, 薛晓强1, 周皎琳1, 邱辉忠1   
  1. 1. 100730　中国医学科学院北京协和医院基本外科
  • 收稿日期:2019-06-25 出版日期:2019-12-25
  • 通信作者: 林国乐
  • 基金资助:
    北京市科技重大专项基金(No.D17110700260000)

Transanal endoscopic microsurgery (TEM) for rare rectal tumors

Xueshan Bai1, Guole Lin1,†(), Xin Wu1, Xiaoqiang Xue1, Jiaolin Zhou1, Huizhong Qiu1   

  1. 1. Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
  • Received:2019-06-25 Published:2019-12-25
  • Corresponding author: Guole Lin
  • About author:
    Corresponding author: Lin Guole, Email:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

白雪杉, 林国乐, 吴昕, 薛晓强, 周皎琳, 邱辉忠. 经肛门内镜显微外科手术（TEM）治疗直肠少见肿瘤[J]. 中华结直肠疾病电子杂志, 2019, 08(06): 580-587.

Xueshan Bai, Guole Lin, Xin Wu, Xiaoqiang Xue, Jiaolin Zhou, Huizhong Qiu. Transanal endoscopic microsurgery (TEM) for rare rectal tumors[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2019, 08(06): 580-587.

目的

探讨经肛门内镜显微外科手术（TEM）在直肠少见肿瘤治疗中的应用。

方法

2006年4月至2018年5月，北京协和医院共收治157例直肠少见肿瘤患者。收集临床资料，建立回顾性准确数据库。其中男性89例,女性68例。平均肿瘤直径（1.2±0.7）cm（0.2~5.3 cm），距肛缘平均距离（6.6±2.3）cm（2~12 cm）。分析人口学特征、手术细节、肿瘤特点、并发症和随访资料。

结果

所有患者均获得全层完全切除，切缘阴性。术中并发症3例，术后并发症21例。病理组织学结果报告神经内分泌肿瘤（NETs）114例；胃肠道间质肿瘤（GISTs）35例，黑色素瘤、淋巴瘤和平滑肌瘤各2例；脂肪瘤和鳞癌各1例。145例患者平均随访（56.25±32.13）个月（19~144个月），2例死亡，1例局部复发，1例出现淋巴结转移。1例在术后1个月出现直肠阴道瘘。其余患者无局部复发、转移、大便失禁。神经内分泌瘤亚组分析中，初次手术组与内镜术后补救组之间比较，手术时长、术中出血量、术后住院天数等方面差异无统计学意义。在间质瘤亚组分析中，新辅助治疗组与直接手术组之间，同样在手术时长、术中出血量、术后住院天数等方面差异无统计学意义。

结论

TEM是治疗直肠少见肿瘤的可靠方法。并发症发生率低，疗效满意。

关键词: 肛管, 直肠肿瘤, 经肛门内镜显微外科手术（TEM）, 直肠少见肿瘤, 神经内分泌肿瘤, 胃肠道间质肿瘤, 全层切除
Objective

The purpose of this article is to discuss the application of TEM in the treatment of rare rectal tumors.

Methods

From April 2006 to May 2018, 157 patients with rare rectal tumors were treated in Peking Union Medical College Hospital. To collect clinical data and establish a retrospective and accurate database. There were 89 males and 68 females. The average diameter of the tumors was (1.2±0.7) cm, (0.2~5.3 cm) and the average distance from the anal margin was (6.6±2.3) cm, (2~12 cm). The demographic characteristics, surgical details, tumor characteristics, complications and follow-up data were analyzed.

Results

All patients were completely resected with negative incision margin. There were 3 intraoperative complications and 21 post-operative complications. Histopathological findings were reported in 114 cases of neuroendocrine tumors (NETs), thirty-five cases of gastrointestinal stromal tumors (GISTs), two cases of melanoma, two cases of lymphoma and 2 cases of leiomyoma, one case of lipoma and 1 case of squamous cell carcinoma. 145 patients were followed up for (56.25±32.13) months (19~144 months). Two patients died, one had local recurrence and one had lymph node metastasis. One case developed rectovaginal fistula one month after operation. No local recurrence, metastasis or fecal incontinence occurred in the other patients. In the analysis of neuroendocrine tumor subgroup, there was no significant difference in operation time, intraoperative bleeding and postoperative hospital stay between first operation group and the second surgery failed group. In gastrointestinal stromal tumor subgroup, there was also no significant difference between the neoadjuvant therapy group and without neoadjuvant therapy group in operation time, intraoperative bleeding and postoperative hospital stay.

Conclusion

TEM is a reliable `treatmentfor rare rectal tumors. The incidence of complications is low and the curative effect is satisfactory.

Key words: Anal canal, Rectal neoplasms, Transanal endoscopic microsurgery (TEM), Rare rectal tumors, Neuroendocrine tumors, Gastrointestinal stromal tumors, Full-thickness resection
表1 整体患者临床特征和肿瘤特点分析
术中项目 统计数据
性别（男/女例） 89/68
年龄（岁，±s） 52.1±12.5
肿瘤直径（cm，±s） 1.2±0.7
距肛缘距离（cm，±s） 6.6±2.3
肿瘤位置（例） ?
? 　前壁 61
? 　后壁 71
? 　侧壁 25
手术时间（min，±s） 60.2±20.4
术中出血量（ml，±s） 11.4±6.5
术后平均住院时间（d，±s） 2.8±1.6
图1 TEM术具体手术过程。1A：病灶形态；1B：针形电刀在病灶周围烧灼出一圈拟切除线；1C-D：电刀加深切口至肠外脂肪层，即全层切除；1E-F：创面可用可吸收滑线横向连续缝合
图2 应用TEM平台切除的少见肿瘤病理标本图片。2A：直径1.2 cm的NETs；2B：直径1.8 cm GISTs ；2C：直径1.2 cm的黑色素瘤；2D：直径2.0 cm的平滑肌瘤
表2 患者术后及随访项目分析
术后项目 统计数据
术后并发症（例） 21
Clavien系统分级（例） ?
? Ⅰ级 15（发热12例、直肠出血2例、尿潴留1例）
? Ⅱ级 4（腹泻3例、肺炎1例）
? Ⅲ级 2（直肠出血1例、直肠阴道瘘1例）
术后住院时间（d，±s） 2.8±1.6（1~12）
随访人数（例） 145
随访时间（m，±s） 56.25±32.13（19~144）
术后复发（例） 1（鳞癌）
术后转移（例） 3（黑色素瘤2例、NETs淋巴结转移1例）
表3 NETs亚组初次手术组和内镜术后补救组的详细数据
? 总数（n=114） 初次手术组（n=82） 内镜术后补救组（n=32） t/χ2值 P值
性别（男/女） 68/46 50/32 18/14 0.152 0.833
年龄（岁） 52.37±11.81 52.29±11.75 51.81±10.92 0.209 0.835
肿瘤大小（cm） 1.02±0.48 1.03±0.48 0.81±0.21 2.791 0.006
距肛缘距离（cm） 7.41±1.83 7.38±1.81 8.03±1.84 0.838 0.404
手术时长（min） 53.51±13.65 54.69±12.87 52.71±14.91 2.405 0.018
出血量（mL） 11.64±6.12 11.71±6.11 10.85±6.72 1.886 0.062
术后住院时间（天） 2.72±1.47 2.82±1.49 2.72±1.34 0.370 0.712
侵犯深度（黏膜层/肌层/浆膜层） 43/48/8 38/36/8 5/12/0 - -
分级（G1/G2） 70/19 55/17 15/2 - -
表4 间质瘤亚组是否进行新辅助治疗的详细数据
? 总数（n=35） 行新辅助治疗（n=12） 未行新辅助治疗（n=23） t/χ2值 P值
性别（男/女） 18/17 4/8 14/9 2.394 0.164
年龄（岁） 49.31±13.32 47.63±15.74 50.21±12.23 -0.541 0.592
肿瘤大小（cm） 1.81±1.12 3.14±1.25a 1.55±0.86 4.737 >0.001
? ? 2.6±1.2b ? 3.408 0.002
距肛缘距离（cm） 4.02±1.80 3.81±1.14 4.16±2.13 -0.465 0.645
手术时长（min） 82.42±21.13 76.71±24.83 85.42±18.84 -1.172 0.250
出血量（mL） 11.72±7.53 12.43±7.61 11.36±7.62 0.397 0.694
术后住院时间（天） 2.72±1.21 3.23±1.54 2.42±0.84 1.950 0.060
分级（G1/G2） 31/4 10/2 21/2 - -
[1]
Reickert CA. Uncommon colorectal neoplasms [J]. Clin Colon Rectal Surg, 2011, 24(3): 127-128.
[2]
José Errasti Alustiza, Eloy Espín Basany, ángel Reina Duarte. Rare tumors of the rectum. Narrative Review [J]. Cirugía Española, 2014, 92(9): 579-588.
[3]
Young DO, Kumar AS. Local excision of rectal cancer [J]. Surg Clin North Am,2017, 97(3): 573-585.
[4]
Buess GF, Raestrup H. Transanal endoscopic microsurgery [J]. Surg Oncol Clin N Am, 2001, 10(3): 709-731.
[5]
Ortenzi M, Ghiselli R, Cappelletti Trombettoni MM, et al. Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience [J]. World Journal of Gastrointestinal Endoscopy, 2016, 8(17):623-627.
[6]
中国抗癌协会大肠癌专业委员会TEM学组. 经肛门内镜微创手术(TEM)技术专家共识(2016) [J]. 中华胃肠外科杂志，2016，19(7)：731-733.
[7]
de Graaf EJ, Burger JW, van Ijsseldijk AL, et al. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas [J]. Colorectal Dis, 2011, 13(7): 762-767.
[8]
林国乐，邱辉忠，周皎琳, 等. 经肛门内镜微创手术的适应证与并发症[J/CD].中华结直肠疾病电子杂志, 2015, 4(5): 63-67.
[9]
Ramwell A, Evans J, Bignell M, et al. The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications [J]. Colorectal Disease, 2010, 11(9): 964-966.
[10]
Dulskas A, Kilius A, Petrulis K, et al. Transanal endoscopic microsurgery for patients with rectal tumors: A single institution′s experience [J]. Ann Coloproctol, 2017, 33(1): 23-27.
[11]
Gourtsoyianni S, Papanikolaou N. Role of magNETsic resonance imaging in primary rectal cancer-standard protocol and beyond [J]. Seminars in Ultrasound Ct & Mri, 2016, 37(4): 323-330.
[12]
Ishii N, Horiki N, Itoh T, et al. Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors [J]. Surgical Endoscopy, 2010, 24(6): 1413-1419.
[13]
Tsikitis VL, Wertheim BC, Guerrero MA. Trends of incidence and survival of gastrointestinal neuroendocrine tumors in the United States: A seer analysis [J]. J Cancer, 2012, 3: 292-302.
[14]
Caplin M, Sundin A, Nillson O, et al. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: Colorectal neuroendocrine neoplasms [J]. Neuroendocrinology, 2012, 95(2): 88-97.
[15]
Oberg K, Akerstrom G, Rindi G, et al. Neuroendocrine gastroenteropancreatic tumours: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up [J]. Annals of Oncology, 2010, 21(Supplement 5): v223-v227.
[16]
de Mestier L, Brixi H, Gincul R, et al. Updating the management of patients with rectal neuroendocrine tumors [J]. Endoscopy, 2013, 45(12): 1039-1046.
[17]
Shields CJ, Tiret E, Winter DC,et al. Carcinoid tumors of the rectum: A multi-institutional international collaboration [J]. Annals of Surgery, 2010, 252(5): 750-755.
[18]
Scherübl H, de Mestier L, Cadiot G. Therapy of rectal carcinoids of 11 to 19mm: A matter of debate [J]. Gastrointest Endosc, 2014, 80(3): 532-533.
[19]
Ramage JK, De Herder WW, Fave GD, et al. ENETS consensus guidelines update for colorectal neuroendocrine neoplasms [J]. Neuroendocrinology, 2016, 103(2): 139-143.
[20]
杨小云，钟芸诗，时强, 等. 改良金属夹丝线联合牵引技术在内镜治疗结直肠神经内分泌肿瘤中的应用 [J]. 中华消化内镜杂志, 2018, 35(8): 595-596.
[21]
林国乐，邱辉忠. 经肛门内镜显微手术的病例选择和手术规范[J]. 中华胃肠外科杂志, 2015, 18(5): 427-429.
[22]
Kwaan MR, Goldberg JE, Bleday R. Rectal carcinoid tumors: Review of results after endoscopic and surgical therapy [J]. Arch Surg, 2008, 143(5): 471-475.
[23]
Chen WJ, Wu N, Zhou JL, et al. Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors [J]. World J Gastroenterol, 2015, 21(30): 9142-9149.
[24]
Kirsch R, Gao ZH, Riddell R. Gastrointestinal stromal tumors: Diagnostic challenges and practical approach to differential diagnosis [J]. Adv Anat Pathol, 2007, 14(4): 261-285.
[25]
Rossi CR, Mocellin S, Mencarelli R, et al. Gastrointestinal stromal tumors: From a surgical to a molecular approach [J]. International Journal of Cancer, 2003, 107(2): 171-176.
[26]
Arezzo A, Verra M, Morinom. Transanal endoscopic microsurgery after neoadjuvant therapy for rectal GISTs [J]. Dig Liver Dis, 2011, 43(11): 923-924.
[27]
Blesius A, Cassier PA, François Bertucci, et al. Neoadjuvant imatinib in patients with locally advanced non metastatic GISTs in the prospective BFR14 trial [J]. BMC Cancer, 2011, 11(1):72.
[28]
Yasui M, Tsujinaka T, Mori M, et al. Characteristics and prognosis of rectal gastrointestinal stromal tumors: an analysis of registry data [J]. Surg Today, 2017, 47(10): 1188-1194.
[29]
Buissin D, Sterle A, Schmiegelow P, et al. Primary anorectal malignant melanoma: A rare but aggressive tumor: Report of a case [J]. World J Surg Oncol, 2015, 13(1): 1-3.
[30]
Nam S, Kim CW, Baek SJ,et al. The clinical features and optimal treatment of anorectal malignant melanoma [J]. Ann Surg Treat Res, 2014, 87(3): 113-117.
[31]
Kelley SR. Mucosa-associated lymphoid tissue (MALT) variant of primary rectal lymphoma: A review of the English literature [J]. Int J Colorectal Dis, 2017, 32(3): 295-304.
[32]
Nakamura S, Matsumoto T, Iida M, et al. Primary gastrointestinal lymphoma In Japan: a clinicopathologic analysis of 455 patients with special reference to its time trends [J]. Cancer, 2003, 97(10): 2462-2473.
[33]
Khoury W, Igov I, Issa N, et al. Transanal endoscopic microsurgery for upper rectal tumors [J]. Surg Endosc, 2014, 28(7): 2066-2071.
[1] 代莉, 邓恢伟, 郭华静, 黄芙蓉. 术中持续输注艾司氯胺酮对腹腔镜结直肠癌手术患者术后睡眠质量的影响[J]. 中华普通外科学文献(电子版), 2023, 17(06): 408-412.
[2] 王得晨, 杨康, 杨自杰, 归明彬, 屈莲平, 张小凤, 高峰. 结直肠癌微卫星稳定状态和程序性死亡、吲哚胺2,3-双加氧酶关系的研究进展[J]. 中华普通外科学文献(电子版), 2023, 17(06): 462-465.
[3] 唐旭, 韩冰, 刘威, 陈茹星. 结直肠癌根治术后隐匿性肝转移危险因素分析及预测模型构建[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 16-20.
[4] 张生军, 赵阿静, 李守博, 郝祥宏, 刘敏丽. 高糖通过HGF/c-met通路促进结直肠癌侵袭和迁移的实验研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 21-24.
[5] 张焱辉, 张蛟, 朱志贤. 留置肛管在中低位直肠癌新辅助放化疗后腹腔镜TME术中的临床研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 25-28.
[6] 李婷, 张琳. 血清脂肪酸代谢物及维生素D水平与结直肠癌发生的关系研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 661-665.
[7] 付振保, 曹万龙, 刘富红. 腹腔镜直肠癌低位前切除术中不同缝合方法的回肠双腔造口术临床效果研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 684-687.
[8] 贺亮, 王松林, 周业江. 两种预防性回肠造口在腹腔镜ISR术治疗超低位直肠癌的效果对比研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 697-700.
[9] 关旭, 王锡山. 基于外科与免疫视角思考结直肠癌区域淋巴结处理的功与过[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 448-452.
[10] 顾睿祈, 方洪生, 蔡国响. 循环肿瘤DNA检测在结直肠癌诊治中的应用与进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 453-459.
[11] 卢艳军, 马健, 白鹏宇, 郭凌宏, 刘海义, 江波, 白文启, 张毅勋. 纳米碳在腹腔镜直肠癌根治术中253组淋巴结清扫的临床效果[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 473-477.
[12] 倪文凯, 齐翀, 许小丹, 周燮程, 殷庆章, 蔡元坤. 结直肠癌患者术后发生延迟性肠麻痹的影响因素分析[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 484-489.
[13] 范小彧, 孙司正, 鄂一民, 喻春钊. 梗阻性左半结肠癌不同手术治疗方案的选择应用[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 500-504.
[14] 杨红杰, 张智春, 孙轶. 直肠癌淋巴结转移诊断研究进展[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 512-518.
[15] 马慧颖, 凡新苓, 覃仕瑞, 陈佳赟, 曹莹, 徐源, 金晶, 唐源. 磁共振加速器治疗局部晚期直肠癌的初步经验[J]. 中华结直肠疾病电子杂志, 2023, 12(06): 519-523.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号