经肛内镜显微外科手术-TEM医学医药.ppt

Treatment of rectal adenomas by transanal endoscopic microsurgery(TEM):15 yearsexperience,Surg Endosc.2009 姜海军,Background,present experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).Goal:evaluating morbidity,mortality,and local recurrence rate.,Patients and methods,Enrolled:402 patients,preoperative diagnosis of adenomas.(1993.1-2008.10)Mean age:65 years(range22-92)Men:221 vs Women:181,distance of adenomas from the anal verge,0-3 cm:28 patients3-6 cm:58 patients6-12 cm:251 patients12-16 cm:54 patients 16 cm:11 patients,Lesion position,anterior wall of the rectum:92 patientsposterior wall:107 patientslateral wall:88 patientssemicircumferential:98 patientscircumferential:17 patients,Preoperative therapy staging,digital examination to evaluate tumor fixationtotal colonoscopyrigid rectoscopy:macrobiopsies;measure the distance from the anal verge;determine the location and consequently select the position,transanal endosonography(EUS)by a rotative probecomputed tomography(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesions,Patient preparation,washout of the colonshort-term antibiotic prophylaxisgeneral anesthesia in the majority of patientsSpinal anesthesia was used in 65(16.1%)high-risk patients(ASA 4).,1.supine position2.prone position 3.lateral position,place the lesion in the inferior part ofthe operative field,Fullthickness excision:379 patients(94.3%)1 cm minimum of normal mucosa around the lesionMucosectomy:23 patients(5.7%),Mean operative time was 64 min(range=22120).rectal defect was closed:endoluminal running suture with a silver clip placed at each end of the suture to avoid an intrarectal node.,only 15 patients(3.7%)required the repeated administration of ketorolac 30 mg in the first 48 h.drink liquids on the first postoperative dayMean hospital stay was 2.5 days(range=18 days).,short-term results:,Minimal intraoperative complications:13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vagina All lesions were closed endoscopically by TEM without any intra-or postoperative consequences.,giant adenomas(2 cases):impossible to carry out a complete suture.temporary ileostomy closed after 2 months One of the two patients had a rectal stenosisrequired endoscopic dilatation.At follow-up of 24 and 30 months(the patient with rectal stenosis)no other complications were observed.,Postoperative follow-up,mean follow-up:84 months(range=1190 months)1 month after discharge:clinical examination,digital rectal exploration,andrigid rectoscopyevery 6 months for the first year and then annually(flexible endoscopy with biopsies of the scar),complications,All leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.Stool incontinence was treated with physiotherapy and anal sphincter biofeedback resolved within 2 months of the operationThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusions,Surgical drainage and colostomy(patient is alive after 1 year)Laparoscopic ileostomy and a new suture by TEM.(patient is alive after 2 years without other complications),Long-term results,No patients had a new recurrence at the next follow-upOf the 34 patients with pT1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.,Discussion,adenomas of the colon and rectum have the potential to become malignant;related to size,histological type(villous adenoma),and grade of dysplasia,Endoscopic polypectomy is not able to remove all large and sessile polyps due to technical problemsin the middle or upper rectum,it may be difficult to excise it completely,Sometimes,large adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosisadenomas in the upper third of the rectum are removed by anterior resection Resection of the rectum is a major surgical procedure associated with significant morbidity(768%)and mortality(06.5%),TEM:minimally invasive and safecan reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge),Risk:,pelvic abscess,Infectionbleedingperforation into the peritoneal cavitysuture dehiscencestool incontinence(soiling)rectovaginal fistula,indication,Benign lesion:polypsadenomasMalignant lesion:T1N0 rectal tumor,Thank you,