日本机构一项对123名连续患者的短期和长期结果的研究

经肛门自下而上切除远端直肠作为一种可行的方法在肛门附近的直肠癌腹腔镜保括约肌手术中实现全直肠系膜切除术：日本机构一项对123名连续患者的短期和长期结果的研究

背景
在直肠癌 (RC) 手术中，肛门附近 RC 的腹腔镜括约肌保留手术 (lap-SPS) 中全直肠系膜切除术 (TME) 的复杂性一直是一个关键问题。 最近，通过肛门技术协助完成 TME 受到关注。 本研究旨在阐明在肛门附近的 RC 的 lap-SPS 中实现 TME 的经肛门自下而上解剖的可行性。

方法
评估了总共 123 名连续接受经肛门直肠切除术 (TARD) 的患者的手术和肿瘤学结果，这些患者在直视下通过肛门操作 TME 最困难的部分或使用内窥镜系统 (TaTME) 实现 TME 的经肛门 TME 2006 年 1 月至 2021 年 2 月期间，在肛门附近进行了 RC 的 lap-SPS。

结果
总共包括 123 名中位年龄为 66 岁（范围 33-86 岁）的连续患者（83 名男性）。 分别对 50 名 (40.7%) 和 73 名 (59.3%) 患者进行了 TARD 和 TaTME。 对 40 名 (32.5%) 患者进行了术前治疗，导致 5 名 (12.5%) 患者出现完全病理反应。 TARD 组的括约肌间切除术明显更多 (p<0.001)。 尽管 TaTME 组在经肛门部分需要更长的手术时间 (p<0.001)，但中位失血量较低 (p<0.001)。 52 例 (42.3%) 患者出现 Clavien-Dindo 分级≥2 级的术后并发症。 排尿功能障碍和与造口相关的并发症最常见。 TARD 组发现更多因排尿功能障碍需要药物治疗的患者，但未观察到显著差异（10.0% 对 6.8%，p=0.526）。 几乎所有患者的 TME 质量都很好。 18 名 (14.6%) 患者出现复发。 123 例患者的 5 年总生存率 (OS) 和无复发生存率 (RFS) 分别为 95.8% 和 88.8%。 两组之间的 5 年 OS 和 RFS 具有可比性。

结论
的数据表明，远端直肠经肛门自下而上的解剖可能是肛门附近 RC 的 lap-SPS 可行方法。 需要进一步的研究来检查 TARD 和 TaTME 之间的差异。

日本机构一项对123名连续患者的短期和长期结果的研究

经肛门直肠切除术 (TARD) 手术。 在直视下用荷包缝合关闭肿瘤下缘的远端，然后用 5% 聚维酮碘冲洗肛管。 然后在距离远端边缘≥2cm的后侧开始直肠的划分。 首先，通过用间断缝合 (a) 关闭直肠的切口端来执行直肠的圆形切口。 其次，在使用自持牵开器（孤星牵开器）和刀开发手术野的同时，将远端直肠向近端移动。 在直肠后侧，在切开直肠和尾骨之间的韧带后，可以使用电子手术刀和推进器轻松移动远端直肠 (b)。 在直肠的前侧，在使用刀形成手术野的同时切开直肠尿道肌，然后解剖直肠的两个前外侧。 然而，在神经血管束所在的位置，直肠的前外侧将经腹部解剖（c 和 d）。 尽可能进行直肠（包括直肠系膜）的分离和动员，直到识别出前侧的腹膜反射和后侧的直肠骶韧带（e）。 最后，在腹腔镜检查期间，将微创腔镜适应肛管以保持压力 (f)

日本机构一项对123名连续患者的短期和长期结果的研究

经肛门全直肠系膜切除术 (TaTME) 手术。 通常至少在肛门直肠环上方移动远端直肠，以便在肛管处设置 EZ ACCESS 平台。 尝试解剖直到识别直肠前侧的腹膜反折，因为经常难以通过 EZ ACCESS 平台解剖直肠前侧

1. van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14:210–218. doi: 10.1016/S1470-2045(13)70016-0.   
2. Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314:1356–1363. doi: 10.1001/jama.2015.12009.   
3. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of laparoscopic-assisted resection vs open resection of Stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314:1346–1355. doi: 10.1001/jama.2015.10529.   
4. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324–1332. 10.1056/NEJMoa1414882
5. Stevenson ARL, Solomon MJ, Brown CSB, Lumley JW, Hewett P, Clouston AD, et al. Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the Australasian laparoscopic cancer of the rectum randomized. Clin Trial Ann Surg. 2019;269:596–602. doi: 10.1097/SLA.0000000000003021.   
6. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24:1205–1210. doi: 10.1007/s00464-010-0965-6.   
7. Funahashi K, Koike J, Teramoto T, Saito N, Shiokawa H, Kurihara A, et al. Transanal rectal dissection: a procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis. Am J Surg. 2009;197:e46–e50. doi: 10.1016/j.amjsurg.2008.07.060.   
8. Funahashi K, Shiokawa H, Teramoto T, Koike J, Kaneko H. Clinical outcome of laparoscopic intersphincteric resection combined with transanal rectal dissection for t3 low rectal cancer in patients with a narrow pelvis. Int. J Surg Oncol. 2011:901574. 10.1155/2011/901574.  
9. Shiokawa H, Funahashi K, Kaneko H, Teramoto T. Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus. J Anus Rectum Colon. 2017;1:29–34. doi: 10.23922/jarc.2016-002.   
10. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996–999. doi: 10.1016/s0140-6736(86)92612-7.   
11. Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg. 1983;198(2):159–163. doi: 10.1097/00000658-198308000-00008.   
12. Shirouzu K, Ogata Y. Histopathologic tumor spread in very low rectal cancer treated with abdominoperineal resection. Dis Colon Rectum. 2009;52(11):1887–1894. doi: 10.1007/DCR.0b013e3181b1585a.   
13. Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant. 2013;48:452–458. doi: 10.1038/bmt.2012.244.   
14. Marks GJ, Marks JH, Mohiuddin M, Brady L. Radical Sphincter preservation surgery with coloanal anastomosis following high-dose external irradiation for the very low lying rectal cancer. Recent Results Cancer Res. 1998;146:161–174. doi: 10.1007/978-3-642-71967-7_15.   
15. Marks JH, Montenegro GA, Salem JF, Shields MV, Marks GJ. Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer. Tech Coloproctol. 2016;20:467–473. doi: 10.1007/s10151-016-1482-y.   
16. Marks JH, Myers EA, Zeger EL, Denittis AS, Gummadi M, Marks GJ. Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer. Surg Endosc. 2017;31(12):5248–5257. doi: 10.1007/s00464-017-5597-7.   
17. Kanso F, Maggiori L, Debove C, Chau A, Ferron M, Panis Y. Perineal or abdominal approach first during intersphincteric resection for low rectal cancer: which is the best strategy? Dis Colon Rectum. 2015;58:637–644. doi: 10.1097/DCR.0000000000000396.   
18. Denost Q, Adam JP, Rullier A, Buscail E, Laurent C, Rullier E. Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg. 2014;260:993–999. doi: 10.1097/SLA.0000000000000766.   
19. Roodbeen SX, Penna M, Mackenzie H, Kusters M, Slater A, Jones OM, et al. Transanal total mesorectal excision (TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes. Surg Endosc. 2019;33:2459–2467. doi: 10.1007/s00464-018-6530-4.   
20. Munini M, Popeskou SG, Galetti K, Roesel R, Mongelli F, Christoforidis D. Transanal (TaTME) vs. laparoscopic total mesorectal excision for mid and low rectal cancer: a propensity score-matched analysis of early and long-term outcomes. Int J Color Dis. 2021;36:2271–2279. doi: 10.1007/s00384-021-04019-0.   
21. Hallam S, Ahmed F, Gouvas N, Pandey S, Nicol D. Oncological outcomes and stoma-free survival following TaTME, a prospective cohort study. Tech Coloproctol. 2021;25:439–447. doi: 10.1007/s10151-020-02390-8.   
22. An Y, Roodbeen SX, Talboom K, Tanis PJ, Bemelman WA, Hompes R. A systematic review and meta-analysis on complications of transanal total mesorectal excision. Color Dis. 2021;23:2527–2538. doi: 10.1111/codi.15792.   
23. Klein MF, Seiersen M, Bulut O, Bech-Knudsen F, Jansen JE, G&#246;genur I. Short-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark - a prospective multicentre study. Color Dis. 2021;23:834–842. doi: 10.1111/codi.15454.   
24. Sylla P, Knol JJ, D’Andrea AP, Perez RO, Atallah SB, Penna M, et al. Urethral injury and other urologic injuries during transanal total mesorectal excision: an international collaborative study. Ann Surg. 2021;274:e115–e125. doi: 10.1097/SLA.0000000000003597.   
25. 2017 European Society of Coloproctology (ESCP) collaborating group. An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME). Color Dis. 2018;6:33–46. 10.1111/codi.14376.
26. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, et al. Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry. Ann Surg. 2019;269:700–711. doi: 10.1097/SLA.0000000000002653.   
27. Kitaguchi D, Nishizawa Y, Sasaki T, Tsukada Y, Ikeda K, Ito M. Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors. Color Dis. 2019;21:1304–1311. doi: 10.1111/codi.14728.   
28. Jiang HP, Li YS, Wang B, Wang C, Liu F, Shen ZL, et al. Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a systematic review with meta-analysis. Surg Endosc. 2018;32:2632–2642. doi: 10.1007/s00464-018-6103-6.   
29. Funahashi K, Goto M, Kaneko T, Ushigome M, Kagami S, Koda T, et al. What is the advantage of rectal amputation with an initial perineal approach for primary anorectal carcinoma? BMC Surg. 2020;20:22. doi: 10.1186/s12893-020-0683-5.   
30. Wasmuth HH, Faerden AE, Myklebust T&#197;, Pfeffer F, Norderval S, Riis R, et al. Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg. 2020;107:121–130. doi: 10.1002/bjs.11459.   
31. van Oostendorp SE, Belgers HJ, Bootsma BT, Hol JC, Belt EJTH, Bleeker W, et al. Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg. 2020;107:1211–1220. doi: 10.1002/bjs.11525.   
32. Caycedo-Marulanda A, Lee L, Chadi SA, Verschoor CP, Crosina J, Ashamalla S, et al. Association of transanal total mesorectal excision with local recurrence of rectal cancer. JAMA Netw Open. 2021;4:e2036330. doi: 10.1001/jamanetworkopen.2020.36330.   
33. Denost Q, Loughlin P, Chevalier R, Celerier B, Didailler R, Rullier E. Transanal versus abdominal low rectal dissection for rectal cancer: long-term results of the Bordeaux’ randomized trial. Surg Endosc. 2018;32:1486–1494. doi: 10.1007/s00464-017-5836-y.   
34. Hol JC, van Oostendorp SE, Tuynman JB, Sietses C. Long-term oncological results after transanal total mesorectal excision for rectal carcinoma. Tech Coloproctol. 2019;23:903–911. doi: 10.1007/s10151-019-02094-8.   
35. Our&#244; S, Ferreira M, Roquete P, Maio R. Transanal versus laparoscopic total mesorectal excision: a comparative study of long-term oncological outcomes. Tech Coloproctol. 2022;26:279–290. doi: 10.1007/s10151-022-02570-8.   
36. Milone M, Adamina M, Arezzo A, Bejinariu N, Boni L, Bouvy N, et al. UEG and EAES rapid guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed European recommendations on TaTME for rectal cancer. Surg Endosc. 2022;36:2221–2232. doi: 10.1007/s00464-022-09090-4.   
37. Alimova I, Chernyshov S, Nagudov M, Rybakov E. Comparison of oncological and functional outcomes and quality of life after transanal or laparoscopic total mesorectal excision for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol. 2021;25:901–913. doi: 10.1007/s10151-021-02420-z.   
38. Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach-a meta-analysis. Surg Endosc. 2020;34:3908–3919. doi: 10.1007/s00464-019-07160-8.   
39. Hajibandeh S, Hajibandeh S, Eltair M, George AT, Thumbe V, Torrance AW, et al. Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer. Int J Color Dis. 2020;35:575–593. doi: 10.1007/s00384-020-03545-7.   
40. Zhang X, Gao Y, Dai X, Zhang H, Shang Z, Cai X, et al. Short- and long-term outcomes of transanal versus laparoscopic total mesorectal excision for mid-to-low rectal cancer: a meta-analysis. Surg Endosc. 2019;33:972–985. doi: 10.1007/s00464-018-6527-z.   
41. Xu W, Xu Z, Cheng H, Ying J, Cheng F, Xu W, et al. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis. Eur J Surg Oncol. 2016;42:1841–1850. doi: 10.1016/j.ejso.2016.09.002.   
42. Deijen CL, Velthuis S, Tsai A, Mavroveli S, Elly S M de Lange-de Klerk, Sietses C, et al. COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc 2016;30:3210–3215. 10.1007/s00464-015-4615-x  
43. Lelong B, de Chaisemartin C, Meillat H, Cournier S, Boher JM, Genre D, et al. A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design. BMC Cancer. 2017;17:253. doi: 10.1186/s12885-017-3200-1.