经肛内镜显微外科手术TEM医学医药

经肛内镜显微外科手术TEM医学医药第1页/共30页Treatmentof

rectaladenomas

by

transanalendoscopicmicrosurgery(TEM):

15years’experience第2页/共30页Backgroundpresentexperiencewithrectaladenomasmanagedbytransanalendoscopicmicrosurgery(TEM).Goal:evaluatingmorbidity,mortality,andlocalrecurrencerate.第3页/共30页PatientsandmethodsEnrolled:402patients,preoperativediagnosisofadenomas.(1993.1-2008.10)Meanage:65years(range22-92)Men:221vsWomen:181第4页/共30页distanceofadenomasfromtheanalverge0-3cm:28patients3-6cm:58patients6-12cm:251patients12-16cm:54patients>16cm:11patients第5页/共30页Lesionpositionanteriorwalloftherectum:92patientsposteriorwall:107patientslateralwall:88patientssemicircumferential:98patientscircumferential:17patients第6页/共30页Preoperativetherapystagingdigitalexaminationtoevaluatetumorfixationtotalcolonoscopyrigidrectoscopy:macrobiopsies;measurethedistancefromtheanalverge;determinethelocationandconsequentlyselecttheposition第7页/共30页transanalendosonography(EUS)byarotativeprobecomputedtomography(CT)scanormagneticresonanceimaging(MRI):giantandsuspectedlesions第8页/共30页Patientpreparationwashoutofthecolonshort-termantibioticprophylaxisgeneralanesthesiainthemajorityofpatientsSpinalanesthesiawasusedin65(16.1%)high-riskpatients(ASA4).第9页/共30页1.supineposition

2.proneposition

3.lateral

position

placethelesionintheinferiorpartof

theoperativefield第10页/共30页Fullthicknessexcision:379patients(94.3%)1cmminimumofnormalmucosaaroundthelesionMucosectomy:23patients(5.7%)第11页/共30页Meanoperativetimewas64min(range=22–120).rectaldefectwasclosed:endoluminalrunningsuturewithasilverclipplacedateachendofthesuturetoavoidanintrarectalnode.第12页/共30页only15patients(3.7%)requiredtherepeatedadministrationofketorolac30mginthefirst48h.drinkliquidsonthefirstpostoperativedayMeanhospitalstaywas2.5days(range=1–8days).第13页/共30页short-termresults:Minimalintraoperativecomplications:

13casesanopeningoftheperitonealcavityandin1patienttherewasanopeningofthevaginaAlllesionswereclosedendoscopicallybyTEMwithoutanyintra-orpostoperativeconsequences.第14页/共30页giantadenomas(2cases):impossibletocarryoutacompletesuture.temporaryileostomyclosedafter2monthsOneofthetwopatientshadarectalstenosisrequiredendoscopicdilatation.Atfollow-upof24and30months(thepatientwithrectalstenosis)noothercomplicationswereobserved.第15页/共30页DefinitivehistologyNFurthertreatmentadenomas366(91%).NOsitucarcinomaorpT1rectaltumor34(8.4%)NOmucinousT2cancer2(0.5%)laparoscopicanteriorrectalresectionwithtemporaryileostomy第16页/共30页Postoperativefollow-up

meanfollow-up:84months(range=1–190months)1monthafterdischarge:①clinicalexamination,②digitalrectalexploration,and③rigidrectoscopyevery6monthsforthefirstyearandthenannually(flexibleendoscopywithbiopsiesofthescar)第17页/共30页complications第18页/共30页Allleakingsuturesresolvedbylocaltherapy(antibioticsandanalgesicenema)and/orparenteralnutrition.Stoolincontinencewastreatedwithphysiotherapyandanalsphincterbiofeedbackresolvedwithin2monthsoftheoperationThepatientswithhemorrhaging,twoofthemwithcirrhosis,requiredbloodtransfusions第19页/共30页第20页/共30页Surgicaldrainageandcolostomy(patientisaliveafter1year)LaparoscopicileostomyandanewsuturebyTEM.(patientisaliveafter2yearswithoutothercomplications)第21页/共30页Long-termresults第22页/共30页Nopatientshadanewrecurrenceatthenextfollow-upOfthe34patientswithpT1rectalcancer,themeanfollow-upof30months(range=14–70months)revealednolocalrecurrencesordistantmetastases.第23页/共30页Discussionadenomasofthecolonandrectumhavethepotentialtobecomemalignant;relatedtosize,histologicaltype(villousadenoma),andgradeofdysplasia第24页/共30页Endoscopicpolypectomyisnotabletoremovealllargeandsessilepolypsduetotechnicalproblemsinthemiddleorupperrectum,itmaybedifficulttoexciseitcompletely第25页/共30页Sometimes,largeadenomasinthelowerthirdoftherectumaretreatedbyabdominoperinealexcisionorcoloanalanastomosisadenomasintheupperthirdoftherectumareremovedbyanteriorresectionResectionoftherectumisamajorsurgicalprocedureassociatedwithsignificantmorbidity(7–68%)andmortality(0–6.5%)第26页/共30页TEM:minimallyinvasiveandsafecanreachfurtherintotherectumthanotherformsoflocalexcision(upto20cmfromtheanalverge)第27页/共30页Risk:pelvicabscess,