Objective To evaluate the safety and ascendancy of small caliber stapler application for anterior resection in ultra-low rectal cancer with anal sphincter preservation. Methods A retrospective analysis of the data of 60 cases of ultra-low rectal cancer treated by anterior resection with anal sphincter preservation by double stapling technique according to TME principle between June 2006 and June 2009 were undertaken. The 60 patients were divided into two groups, each group included 30 cases. One group adopted 33 mm stapler and another group adopted 29 mm stapler, and then the profiles of medi-operation, post-operation, and prognosis were assessed. Results Time of simple anastomose in operation was (9.0±3.3) min in 33 mm stapler group and (6.0±2.6) min in 29 mm stapler group, and there was significant difference between them (P=0.022 5). There were 6 cases needed to be restored because of lesion during operation or dys-anastomosis in 33 mm stapler group, while 2 cases in 29 mm stapler group, there was significant difference between them (P=0.030 1). No significant differences were observed between the two groups in terms of the time for operation, leakage, bleeding, stenosis, anastomotic recurrence, and fecal incontinence after operation or length of stay. Conclusion The application of 29 mm stapler not only can shorten time for anastomose and step down the degree of difficulty, but also dosen’t increase stenostomia and other complications.
ObjectiveTo understand the incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer, the factors influencing fecal incontinence, the relationship of fecal incontinence to anorectal manometry, and treatment. MethodThe literatures about fecal incontinence after sphincter-preserving operation for middle and low rectal cancer were reviewed. ResultsThe incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer was about 35.3%. Wexner fecal incontinence score was the most popular scale in assessing the severity of fecal incontinence, which had high validity and utility. When Wexner score≥9, the fecal incontinence-related quality of life was seriously damaged. Closer the anastomosis to the anal margin, the fecal incontinence was more likely to happen and much severer if it appeared. Surgeon could improve the anorectal function through some kinds of surgeries, like ultralow anterior resection with levator-sphincter reinforcement when the tumor site was rather low. The effect of chemoradiotherapy on fecal incontinence was uncertain now. Age itself was a risk factor for fecal incontinence, for elderly patients underwent sphincter-preserving operation needed to be careful. The relationship of fecal incontinence to anorectal function was not completely clear. The anal sphincter nerve function was a predicting factor whether neurogenic fecal incontinence was going to happen or not. Even though the retrograde colonic irrigation, sacral nerve stimulation, and biofeedback therapy had been proved to alleviate the symptoms and improve the quality of life after sphincter-preserving operation, much more prospective and controlled studies were needed to validate their efficacy and explore other new solutions. ConclusionsWe still need to come up with the objective criterion to assess fecal incontinence. Much more prospective studies are needed to analyze the influencing factors and to find effective prevention and treatment.
目的 探讨经肛门内镜显微手术(TEM)治疗直肠肿瘤的疗效。方法 回顾性分析2009年1~12月期间我院行TEM治疗7例直肠腺瘤患者的临床资料。结果 7例直肠肿瘤均获完整切除，切缘均阴性。手术时间55～240 min，平均110 min; 术中出血量5～100 ml,平均45 ml。术后病理诊断: 直肠绒毛状腺瘤4例，绒毛管状腺瘤2例，直肠腺癌1例。手术并发症: 术中直肠穿孔1例，肺部感染1例，尿潴留1例。 7例随访6~13个月,平均8个月，肿瘤无复发。结论 TEM治疗直肠肿瘤安全、有效。
目的 探讨老年低位直肠癌经肛门局部切除后加放、化疗的临床意义。方法 对18例年龄≥65岁，肿瘤距肛缘≤6 cm且经病理证实但拒绝Miles术的直肠癌患者行经肛门局部切除； 于术后1个月给予放疗（总剂量50 Gy）； 化疗： 亚叶酸钙200 mg、5-FU 400 mg/m2，第1次于术后第1~5 d，每3~4周重复1次，共3~6次。结果 全部病例无手术死亡，术后均有良好的肛门功能。16例获随访，随访5年，其中3例局部复发，拒绝再次手术，给予放、化疗。死亡12例，其中2例死于远处转移，10例死于其他因素。本组患者1年生存率为77.8%（14/18），5年生存率为38.9%（7/18）。结论 对老年低位直肠癌拒绝Miles术的患者行经肛门局部切除加放、化疗，疗效确切，可提高患者生活质量，延长生存期。
Objective To summarize the assessment methods of anal function after low/ultralow rectal anastomosis in patients with rectal cancer. Methods Domestic and international publications on the study of evaluation of anal function after low/ultralow rectal anastomosis in patients with rectal cancer were collected and reviewed. Results Anal function of patients with rectal cancer was usually evaluated by feeling of discharge, continence, perceptual function of rectum, defecate frequency, and defecation time, anal manometry and three-dimensional vector manometry were used as well. Recovery of anal function in patients with rectal cancer after low/ultralow rectal anastomosis depended on the integrity of anal canal, length of remaining rectum, level of anastomosis, and integrity of mucosa. Conclusions Subjective assessment methods and auxiliary measuring instruments are the common means to evaluate the rectal-anal function. Subjective assessment method is simple and direct, but its accuracy is low; Auxiliary measuring instruments have high accuracy, while their examination costs are high and that of costs are not popular, the new assessment methods are needed for further research.
Objective To study the safety and feasibility of modified laparoscopic Dixon surgery for rectal cancer. Methods In the procedure of modified laparoscopic Dixon surgery, the rectum with tumor was pulled out and cut and colon-rectum anastomosis was performed through anus. The clinical data of patients with rectal cancer between modified laparoscopic Dixon surgery (laparoscopy group) and open Dixon surgery (open group) were compared and analysed prospectively. The clinical data included operative time, volume of bleeding, number of lymph node dissection, volume of abdominal drainage, time to bowel gas passage, hospital stay and relative complications, such as anastomotic leakage, ureteral injury, dysuria and fecal incontinence. Results Fifty-eight cases were selected in this study between September 2007 and July 2008, including 25 laparoscopic surgery in laparoscopy group and 33 open surgery in open group. Patient’s data on gender, age, distance between tumor and anus edge, tumor diameter, tumor pathologic type and Dukes stage were similar between two groups by statistic analysis (Pgt;0.05). All the operations were performed successfully. Two cases experienced anastomotic leakage in laparoscopy group, while 1 case experienced anastomotic leakage in open group. All these patients got recovered by conservative treatment at last. No other complications were experienced, such as ureteral injury, dysuria, fecal incontinence, and so on. There were no significant differences in term of operative time, volume of bleeding and number of lymph node dissection between two groups (Pgt;0.05). The volume of abdominal drainage was less while the time to bowel gas passage and hospital stay were shorter in laparoscopy group than those in open group (P＜0.05). Conclusion This study reveals that it is safe and feasible to perform modified laparoscopic Dixon surgery for rectal cancer, and it presents the character of minimal invasion.
目的：总结吻合器痔上黏膜环切术（PPH）治疗痔病的经验。探讨该术式的有关问题，以便提高疗效。方法：回顾性分析了2001～2006年8月收治痔病541例，其中PPH术42例的临床资料。本组均为Ⅲ度或Ⅳ度痔。局部合并症共22例次：血栓外痔愈合后遗留皮赘14例，肛裂2例。有关全身合并症：前列腺增生7例，慢性泌尿系统感染1例。结果:42例中，35例术后2～5天出院，6例自愿留院到7天，1例慢性尿路感染者术后2～7天多次便血，再次手术后28日痊愈出院。随访13～24个月：32例恢复满意，10例有肛门包块感及包块排粪时轻度脱出，其中3例经进一步处理缓解，另7例观察治疗。结论:(1)PPH手术简单易行，疼痛轻，住院时间短，效果好。(2)为了提高效果术中应注意：①禁忌症为单个痔块脱出和肛管皮肤不平滑并纤维化的Ⅳ度病变者外。我们还发现慢性泌尿系统感染未彻底治愈者也应视为相对禁忌。明显前列腺增生者也应慎重。②术中按经典PPH手术的要求进行操作，扩肛器插入前后，不宜扩肛和下牵痔块。③个别巨大痔块及皮赘性痔块（tag）宜先行切除，再行本术。④重度脱出者，黏膜切除应宽大，必要时切除部分肛垫。
ObjectiveTo investigate the curative effect of C-shaped mucosal resection and anastomosis above the dentate line in the treatment of mixed hemorrhoids and its effect on anal function. MethodsA total of 78 patients with degree Ⅳ mixed hemorrhoids treated in Nanjing Liuhe District People’s Hospital from June 2015 to February 2018 were retrospectively collected. The patients were divided into control group (n=39) and observation group (n=39) according to treatment methods. Patients of the control group received traditional procedure for prolapse and hemorrhoids operation, while patients of the observation group received C-shaped mucosal resection and anastomosis above the dentate line. The perioperative indexes (operation time, intraoperative blood loss, hospital stay, etc.), subjective function evaluation indexes (Wexner constipation score, Kirwan grade, etc.), clinical efficacy and recurrence rate were compared between the two groups. The random walking model was used to evaluate the clinical curative effect. ResultsThe intraoperative blood loss [(27.9±3.4) mL vs. (43.2±5.2) mL, P<0.001], 24 h visual analogue scale score [(4.2±1.5) points vs. (5.6±1.5) points, P<0.001], duration of first defecation pain [(22.1±3.2) min vs. (34.2±5.0) min, P<0.001], the time of carrying blood [(4.1±0.4) d vs. (5.7±0.6) d, P<0.001], and the time of edema [(3.2±0.6) d vs. (4.7±0.9) d, P<0.001] in the observation group were shorter (lower) than those in the control group. The difference between pre-and post-operation of Wexner constipation score [(13.2±2.4) points vs. (11.7±2.1) points, P=0.004], resting pressure [(23.1±4.9) mmHg vs. (17.8±3.4) mmHg, P<0.001] and maximum squeeze pressure [(33.5±7.3) mmHg vs. (23.1±5.6) mmHg, P<0.001] in the observation group were significantly higher than those in the control group. There was a long-term correlation between changes in random fluctuating power rate values of Wexner constipation score, Kirwan grade, rectoanal inhibitory reflex positive rate, resting pressure, maximum squeeze pressure and the surgical procedure received by the patient of the two groups. The total effective rate [97.4% (38/39) vs. 66.7% (26/39)] and non-recurrence rate [92.3% (36/39) vs. 76.9% (29/39)] in the observation group were higher than those in the control group, while there was no significant difference in the incidence of total complications between the two groups [5.1% (2/39) vs. 12.8% (5/39), P=0.235)]. ConclusionCompared with PPH, C-shaped mucosal resection and anastomosis above the dentate line for the treatment of degree Ⅳ mixed hemorrhoids can improve the therapeutic effect, reduce postoperative recurrence, maintain anal function and facilitate the recovery of patients.