Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experienceSurgEndosc.2009

姜海軍第一頁，共三十頁。Backgroundpresentexperiencewithrectaladenomasmanagedbytransanalendoscopicmicrosurgery(TEM).Goal:evaluatingmorbidity,mortality,andlocalrecurrencerate.第二頁，共三十頁。PatientsandmethodsEnrolled:402patients,preoperativediagnosisofadenomas.(1993.1-2008.10)Meanage:65years(range22-92)Men:221vsWomen:181第三頁，共三十頁。distanceofadenomasfromtheanalverge0-3cm:28patients3-6cm:58patients6-12cm:251patients12-16cm:54patients>16cm:11patients第四頁，共三十頁。Lesionpositionanteriorwalloftherectum:92patientsposteriorwall:107patientslateralwall:88patientssemicircumferential:98patientscircumferential:17patients第五頁，共三十頁。Preoperativetherapystagingdigitalexaminationtoevaluatetumorfixationtotalcolonoscopyrigidrectoscopy:macrobiopsies;measurethedistancefromtheanalverge;determinethelocationandconsequentlyselecttheposition第六頁，共三十頁。transanalendosonography(EUS)byarotativeprobecomputedtomography(CT)scanormagneticresonanceimaging(MRI):giantandsuspectedlesions第七頁，共三十頁。Patientpreparationwashoutofthecolonshort-termantibioticprophylaxisgeneralanesthesiainthemajorityofpatientsSpinalanesthesiawasusedin65(16.1%)high-riskpatients(ASA4).第八頁，共三十頁。1.supineposition

2.proneposition

3.lateral

position

placethelesionintheinferiorpartof

theoperativefield第九頁，共三十頁。Fullthicknessexcision:379patients(94.3%)1cmminimumofnormalmucosaaroundthelesionMucosectomy:23patients(5.7%)第十頁，共三十頁。Meanoperativetimewas64min(range=22–120).rectaldefectwasclosed:endoluminalrunningsuturewithasilverclipplacedateachendofthesuturetoavoidanintrarectalnode.第十一頁，共三十頁。only15patients(3.7%)requiredtherepeatedadministrationofketorolac30mginthefirst48h.drinkliquidsonthefirstpostoperativedayMeanhospitalstaywas2.5days(range=1–8days).第十二頁，共三十頁。short-termresults:Minimalintraoperativecomplications:

13casesanopeningoftheperitonealcavityandin1patienttherewasanopeningofthevaginaAlllesionswereclosedendoscopicallybyTEMwithoutanyintra-orpostoperativeconsequences.第十三頁，共三十頁。giantadenomas(2cases):impossibletocarryoutacompletesuture.temporaryileostomyclosedafter2monthsOneofthetwopatientshadarectalstenosisrequiredendoscopicdilatation.Atfollow-upof24and30months(thepatientwithrectalstenosis)noothercomplicationswereobserved.第十四頁，共三十頁。DefinitivehistologyNFurthertreatmentadenomas366(91%).NOsitucarcinomaorpT1rectaltumor34(8.4%)NOmucinousT2cancer2(0.5%)laparoscopicanteriorrectalresectionwithtemporaryileostomy第十五頁，共三十頁。Postoperativefollow-up

meanfollow-up:84months(range=1–190months)1monthafterdischarge:①clinicalexamination,②digitalrectalexploration,and③rigidrectoscopyevery6monthsforthefirstyearandthenannually(flexibleendoscopywithbiopsiesofthescar)第十六頁，共三十頁。complications第十七頁，共三十頁。Allleakingsuturesresolvedbylocaltherapy(antibioticsandanalgesicenema)and/orparenteralnutrition.Stoolincontinencewastreatedwithphysiotherapyandanalsphincterbiofeedbackresolvedwithin2monthsoftheoperationThepatientswithhemorrhaging,twoofthemwithcirrhosis,requiredbloodtransfusions第十八頁，共三十頁。第十九頁，共三十頁。Surgicaldrainageandcolostomy(patientisaliveafter1year)LaparoscopicileostomyandanewsuturebyTEM.(patientisaliveafter2yearswithoutothercomplications)第二十頁，共三十頁。Long-termresults第二十一頁，共三十頁。Nopatientshadanewrecurrenceatthenextfollow-upOfthe34patientswithpT1rectalcancer,themeanfollow-upof30months(range=14–70months)revealednolocalrecurrencesordistantmetastases.第二十二頁，共三十頁。Discussionadenomasofthecolonandrectumhavethepotentialtobecomemalignant;relatedtosize,histologicaltype(villousadenoma),andgradeofdysplasia第二十三頁，共三十頁。Endoscopicpolypectomyisnotabletoremovealllargeandsessilepolypsduetotechnicalproblemsinthemiddleorupperrectum,itmaybedifficulttoexciseitcompletely第二十四頁，共三十頁。Sometimes,largeadenomasinthelowerthirdoftherectumaretreatedbyabdominoperinealexcisionorcoloanalanastomosisadenomasintheupperthirdoftherectumareremovedbyanteriorresectionResectionoftherectumisamajorsurgicalprocedureassociatedwithsignificantmorbidity(7–68%)andmortality(0–6.5%)第二十五頁，共三十頁。TEM:minimallyinvasiveandsafecanreachfurtherintotherectumthanotherformsoflocalexcision(upto20cmfromtheanalverge)第二十六頁，共三十頁。Risk:pelvicabscess,Infectionbleedingperforationintotheperitonealcavitysuturedehiscencestoolincontinence(soiling)rectovaginalfistula第二十七頁，共三十頁。indicationBenignlesion:polypsadenomasMalignantlesion:T1N0rectaltumor第二十八頁，共三十頁。Thankyou第二十九頁，共三十頁。內(nèi)容梗概Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experience。Patientsandmethods。Meanage:6