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Value of CT Virtual Endoscopy in Preoperative Staging of Rectal Cancer

目的　探讨CT仿真内镜（CT virtual endoscopy，CTVE）在低位直肠癌术前分期中的价值。方法　收集我院2008年8月1日至2011年3月1日期间的直肠癌患者57例，术前行直肠CTVE检查，详细记录患者直肠癌周围组织浸润和淋巴结转移的情况；患者术后常规进行病理检查，比较两者结果的差异。结果　术前直肠CTVE检查与术后石蜡病理检查对直肠癌周围淋巴结转移的判断经四格表χ2检验，差异无统计学意义（χ2=2.5，P＞0.05），其对直肠癌周围淋巴结转移预测的敏感性为66.67%，特异性为93.94%。术前直肠CTVE预测直肠癌周围组织浸润和术后病理检查结果经四格表χ2检验，差异有统计学意义（χ2=4.4，P＜0.05），其对直肠癌周围组织浸润判断的敏感性为27.78%，特异性为42.86%。结论　CTVE在术前评估直肠癌周围淋巴结转移有较高的可信性，但对直肠癌周围组织浸润的评价较差。

Neoadjuvant Chemoradiotherapy Combined with SphincterPreserving Surgery in Treatment of 34 Patients with Rectal Cancer

Objective To explore the safety of neoadjuvant chemoradiotherapy combined with sphincter-preserving operation in treatment of locally advanced low rectal cancer. Methods The clinical data of thirty-four patients admitted into our hospital between June 2007 and June 2009 with T3 and T4 low rectal cancer treated by neoadjuvant chemoradiotherapy and sphincter-preserving operation were collected and analyzed retrospectively. Routine fraction of radiation was given with total dose of 40 Gy, five times a week, 2 Gy per fraction. Patients received oxaliplatin （150 mg/d1）, plus folinic (100 mg/d1-3) and 5FU (750 mg/d1-3) for total 1 cycles started from the 4th week of irradiation. Operation was performed 4 weeks after neoadjuvant therapy. Results After neoadjuvant therapy, all patients underwent surgical resection with average tumor size decreased by 41.2%, tumor T stage decreased in 67.6% （23/34) patients, and lymph nodenegative change rate was 58.8% (10/17). One patient had liver metastasis and one had local recurrence, but without stomal leak. And 88.2% (30/34) patients showed good function of sphincter. Conclusions Neoadjuvant chemoradiotherapy in advanced lower rectal cancer patients has shown its efficacy in down-staging, which is safe without increasing operation complications when combined with sphincterpreserving surgery.

Laparoscopic Assisted Sphincter-Ｐreserving Surgery for Ultra-Low Rectal Cancer　(Report of ５８Cases)

目的　探讨腹腔镜超低位直肠癌保肛手术的可行性。方法　回顾性总结2004年9月至2007年10月期间行腹腔镜超低位直肠癌保肛手术58例患者的临床资料。结果　54例在腹腔镜下顺利完成手术，中转开腹4例，无手术死亡病例。平均手术时间187 min，术中平均失血110 ml，术后肛门排气时间平均为2.3 d。手术切除淋巴结平均为18.5个； 随访6~42个月(平均17.6个月)未见切口种植及吻合口复发。结论　腹腔镜超低位直肠癌保肛手术具有创伤小、术后恢复快等优点，可以取得比开腹手术更好的根治效果。

Present Status and Progress of Extralevator Abdominoperineal Excision for Low Rectal Cancer

Comparison and Analysis of Abdominal-Perineal Resection and Sphincter Preservation Operation on Middle to Low Third Rectal Cancer

【Abstract】ObjectiveTo explore selective criteria of sphincter preservation operation (SPO) for middle to low third rectal cancer, and analyze clinicopathologic parameters resulting in the selective criteria. MethodsTwo hundred and seventynine cases of middle to low third rectal cancer who accepted operative treatment from 1996 to 2004 were analyzed retrospectively. One hundred and eightyseven rectal tumours were located in 5-10 cm from anus, 92 rectal tumours in below 5 cm from anus. Among them 127 cases were treated by abdominalperineal resection (APR), and 152 cases were treated by SPO in which there were 130 Dixon operations, 12 Bacon operations, and 10 Parks operations. Clinicopathologic parameters and survival rate in APR and SPO groups were compared statistically. ResultsGender, age, size, tumor types, site of tumor, degree of differentiation, infiltrated circumference of intestine, and lymph node metastasis, depth of invasion and Dukes stages were not significantly different between APR and SPO groups. SPO performed rate was 54.48% in all. SPO was performed in 48 lower third rectal cancer cases (52.17%, 48/92). Regional recurrence rate was 6.81% （19/279）.Middle survival time was （65.00±6.87）months and 5year survival rate was 63.51% in SPO group. Middle survival time was （52.23±5.63） months and 5year survival rate was 52.50% in APR group. ChiSuqare was 18.14 by Logrank test (P=0.054 1). ConclusionThere is no statistically difference in survival rate between APR and SPO groups.

Anal Sphincteric Function Assessment of Intersphincteric Resection for Low Rectal Cancer by Vectorial Manometry

Objective　To assess the anal sphincteric function after intersphincteric resection for low rectal cancer by vectorial manometry. Methods　Maximal anal pressure, vector volume, vector symmetric index and rectal anal inhibitory reflex were assessed in 16 patients underwent intersphincteric resection for low rectal cancer from 1999 to 2006. Thirty patients with low anterior resection for rectal cancer and another 30 healthy individuals were selected as control. Results　The patients in intersphincteric resection group were subdivided into soiling group and defecation function good group. Maximal pressure, vector volume and vector symmetric index of the patients in soiling group and defecation function good group were significantly lower than those of the healthy and low anterior resection controls (P＜0.001). The maximal systole pressure, systole vector volume and vector symmetric index in soiling group were significantly lower than those in function good group (P＜0.001). The 25.0% patients in intersphincteric resection group had rectal anal inhibitory reflex， was significantly lower than that of the low anterior resection control group (93.3%, P＜0.001). Conclusion　The maximal pressure and vector volume are compromised in patients underwent intersphincteric resection . The vectorial manometry can be an objective comprehensive tool for the evaluation of anal sphincter function in patients with intersphincteric resection.

低位直肠癌保肛术后早期排便功能训练对肛门功能影响的临床研究

目的:探讨低位直肠癌保肛术后早期排便功能训练和控制大便的效果。方法:随机将60名低位直肠癌保肛术后患者分为观察组和对照组。对照组患者按直肠癌术后护理常规,观察组在此基础上进行早期排便功能训练和控制大便。结果:术后1月两组排便功能比较,差异有统计学意义,提示观察组优于对照组。结论:早期排便功能训练和控制大便可促进患者排便功能早日恢复,有效地提高其术后早期生活质量。

Risk factors of liver metastasis after preoperative total neoadjuvant chemoradiotherapy for middle and low rectal cancer of Ⅱ–Ⅲ stage

Objective To investigate the risk factors of liver metastasis in patients with middle and low rectal cancer of Ⅱ–Ⅲ stage after preoperative short course radiotherapy combined with chemotherapy. MethodsThe clinical data of 89 patients with middle and low rectal cancer of Ⅱ–Ⅲ stage admitted to the Dongnan Hospital of Xiamen University from January 2019 to June 2020 were retrospectively analyzed. All patients were treated with short-course radiotherapy combined with chemotherapy before operation. The risk factors of postoperative liver metastasis were analyzed by multivariate logistic regression. ResultsThe 89 patients were followed up for 7–53 months, with a median follow-up time of 33 months. During the follow-up period, 25 patients developed liver metastasis, the onset time was 7–35 months, and the median time of liver metastasis was 17 months. Among them, 5 patients (5.6%) developed liver metastasis in the first year after surgery, 15 patients (16.8%) developed liver metastasis at the second year after surgery, 5 patients (5.6%) developed liver metastasis at the 3rd year after surgery. Multivariate logistic regression results showed that lymph node metastasis [OR=3.550, 95%CI (1.425, 8.953), P=0.041], vascular invasion [OR=3.335, 95%CI (1.011, 11.001), P=0.048], maximum tumor diameter ≥5 cm [OR=4.477, 95%CI (1.273, 15.743), P=0.019], and peri-tumor diameter ≥1/2 [OR=4.633, 95%CI (1.387, 15.475), P=0.013] were risk factors for liver metastasis. ConclusionsLymph node metastasis, vascular invasion, maximum tumor diameter ≥5 cm, and circumferential tumor diameter ≥1/2 are risk factors for liver metastasis in patients with middle and low rectal cancer of Ⅱ–Ⅲ stage after preoperative short course radiotherapy combined with chemotherapy.

Experience of cylindrical abdominoperineal resection for rectal cancer

目的总结低位直肠癌采用柱状经腹会阴切除术（APR）的应用体会。 方法徐州医学院附属医院普通外科于2010年1月至2013年7月期间采用柱状APR治疗22例低位直肠癌患者（柱状APR组），并与同期行传统APR治疗的35例患者（传统APR组）进行对比，分析术中、术后和随访的各项指标。 结果与传统APR组比较，柱状APR组的环周切缘阳性率及术中穿孔率明显降低〔4.55%（1/22）比34.29%（12/35）和4.55%（1/22）比31.43%（11/35）〕，差异有统计学意义（P＜0.05）；2组手术时间、术中出血量、并发症发生率比较，差异无统计学意义（P＞0.05）。术后随访3～30个月（平均21个月），柱状APR组无肿瘤复发及远处转移患者，未见死亡病例；传统APR组出现盆底局部复发4例，远处转移3例，死亡2例。2组局部复发、远处转移及死亡率比较差异均无统计学意义（P＞0.05）。 结论柱状APR可以切除更多的肿瘤周围组织，降低环周切缘阳性率，减少术中肠穿孔的发生，降低局部复发。

Treatment for Male Patients with Low Rectal Cancer by Means of Laparoscopic Total Mesorectal Excision and Per Anum Rectal Pull-Type of Anastomosis

Objective To study the effect of laparoscopic total mesorectal excision and per anum rectal pull-type of anastomosis on male patients with low rectal cancer. Methods The successful experiences of anus saving operation on 23 male patients with low rectal cancer were summarized. Results A laparoscopic total mesorectal excision technique was used, with the full separation of the rectum at the bottom. After pulling out the distal rectum together with the cancer from the anus, the transection of the proximal tumor was performed. The end-to-end anastomosis of rectum and descending colon was performed by tubular stapler. Anus was reserved successfully in the 23 cases. There was no left-tumor stump after surgery detected by postoperative pathological examinations, no anastomotic leakage, and no operative death. Conclusions To the relatively narrow male pelvis, laparoscopic total mesorectal excision and per anum rectal pull-through resection and anastomosis is safe and reliable for anus saving in low rectal cancer. It can simplify the operation, and raise the success rate of sphincter preserving in surgery of low rectal cancer.