TaTME直肠癌手术的新突破教学课件

1、经肛全直肠系膜切除术（Transanal total mesorectal excision TaTME）第1页，共17页。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第2页，共17页。第3页，共17页。Current

2、status of trans-anal total 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 rad

3、ial margin rate in laparoscopic 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 inc

4、rease in the surgical morbidity of the procedure 2.1 van der Pas MHGM, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WCJ. Bonjer HJ Laparoscopic versus open surgeryfor rectal cancer (COLOR II): short-term outcomes of a randomised,phase 3 trial. Lancet Oncol 2013; 14: 2108.2 Ito M, Sugito M, Kobayashi

5、A, Nishizawa Y, Tsunoda Y,Saito N. Relationship between multiple numbers of staplerfirings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 2008; 23:7037.第4页，共17页。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第5页，共1

6、7页。Tatme适应证 Trans-anal total 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 obe

7、sity with body mass index (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

8、盆狭小患者的直肠系膜间隙术野显露有一定优势，可能提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。

9、7 aM 开展过程中尤其需注意骶前出血、尿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。第6页，共17页。 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 平台的直肠镜第7页，共17页。 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第8页，

10、共17页。 TaTME手术步骤第9页，共17页。TATME与腹腔镜辅助TME比较肛门脱出避免腹部切口，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第10页，共17页。 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Denovi

11、lliers 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后支）第11页，共17页。Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancerTable1 Patient demographics第12页，共17页。Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal

12、cancer第13页，共17页。Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer第14页，共17页。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.第15页，共17页。Transanal total mesorectal excision: surgical technique description andoutcomes第16页，共17页。Conclusions ：Transanal total mesorectal excision has em