TaTME-直肠癌手术的新突破

直肠肿瘤的手术方式Currentstatusoftrans-analtotalmesorectalexcision(TaTME)followingtheSecondInternationalConsensusConferencepublishedinColorectalDiseasethink:Thechallengeofoperatinginthedeeppelvisisconfirmedbyresultsofarecentrandomizedcontrolledtrialshowinga10%positivecircumferentialradialmarginrateinlaparoscopicandopenTMEandinparticularaconcerning22%positivecircumferentialradialmarginrateinthelowerrectumintheopenarmofthetrial[1].Furthermore,theneedformultiplefiringsoflinearstaplingdevicesinlowrectaldivisionhasbeenassociatedwithanincreaseinthesurgicalmorbidityoftheprocedure[2].1vanderPasMHGM,HaglindE,CuestaMA,FurstA,LacyAM,HopWCJ.BonjerHJLaparoscopicversusopensurgeryforrectalcancer(COLORII):short-termoutcomesofarandomised,phase3trial.LancetOncol2013;14:210–8.2ItoM,SugitoM,KobayashiA,NishizawaY,TsunodaY,SaitoN.Relationshipbetweenmultiplenumbersofstaplerfiringsduringrectaldivisionandanastomoticleakageafterlaparoscopicrectalresection.IntJColorectalDis2008;23:703–7.经自然腔道手术NOTES腹腔镜技术平台全直肠系膜切除原则经肛全直肠系膜切除术（TaTME）经肛门直肠内拖出术TATA腹腔镜辅助TaTME完全TaTMETrans-analtotalmesorectalexcision(TaTME)followingtheSecondInternationalConsensusConference：Rectalcancerinclude:(i)malegender(ii)rectalcancerlessthan12cmfromtheanalverge,includingverylowcancers,(iii)narrowand/ordeeppelvis,(iv)visceralobesityand/orobesitywithbodymassindex(BMI)30kg/m2,(v)prostatichypertrophy,(vi)tumourdiameter4cm,(vii)distortedtissueplanesduetoneoadjuvantradiotherapy,and(viii)impalpable,lowprimarytumourrequiringaccurateplacementofthedistalresectionmargin.直肠癌经肛门全直肠系膜切除术专家意见1．ｔaＴMＥ对于中低位直肠癌尤其是男性、肥胖、骨盆狭小患者的直肠系膜间隙术野显露有一定优势，可能提高手术质量和降低副损伤，具有一定的应用前景2.ｔaＴMＥ实施初期建议选择适当病例，如术前分期小于或等于Ｔ3期、肿瘤体积不宜过大的中低位直肠癌患者。3．临床开展ｔaＴMＥ手术前须经专业培训，建议在有腹腔镜直肠癌手术和经肛门手术经验的中心开展；有条件的中心可先进行动物实验或尸体实验。4．实施ｔaＴMＥ手术需进行必要的术前评估，如：MＲI、ＣＴ、超声等，并经MＤＴ讨论。5．根据各个中心的操作经验，ｔaＴMＥ手术可以采用ＴＡMＩＳ或ＴＥM平台进行。6．完全ｔaＴMＥ可行，但是技术难度相对较大，学习曲线较长；腹腔镜辅助的ｔaＴMＥ可发挥经腹和经肛各自优势，学习曲线相对短，可能更易推广。7．ｔaＴMＥ开展过程中尤其需注意骶前出血、尿道损伤和盆神经损伤等相关并发症。8．ｔaＴMＥ手术是否行保护性造口，可依据患者术中情况和术者经验选择。9．ｔaＴMＥ手术目前尚处起步阶段，仍有待于多中心、大样本和长期随访的临床数据为其安全性、有效性和适应证选择等提供循证医学证据。注：（a）ＳＩＬＳ；（ｂ）ＳＳＬ；（ｃ）ＧｅｌＰＯＩＮＴ；（ｄ）ＴＥM平台的直肠镜经肛门全直肠系膜切除手术（ｔaＴMＥ）时，经肛门微创手术（ＴＡMＩＳ）平台与经肛门内镜显微手术（ＴＥM）平台相比，操作角度大23．7°肛门脱出避免腹部切口，杜绝切口感染、切口疝及肿瘤切口种植转移等并发症，减少因多次钉合而出现吻合口并发症，直视下可加固缝合吻合口taTME术中直肠前壁游离（黑色箭头示前壁Denovilliers筋膜游离层面）taTME术中直肠中下段系膜侧后壁游离（黑色箭头示通向直肠和肛门内扩约肌的下腹下神经丛后支）Table1PatientdemographicsConclusions：Wedemonstratednodifferencesinperioperative/postoperativeoutcomesorpathologicTMEoutcomesoftransanalorbottoms-upTMEcomparedtostandardlaparoscopicTME.TaTMEisapromisingprogressiveapproachtoNOTESanddeservesadditionalevaluation.Conclusions：Transanaltotalmesorectalexcisionhasemergedasasafeandeffectivetechniqueinthetreatmentofrectalcancer.Short-termresultsappearpromisingbutlongtermfollow-upisstillneededtoconfirmtheseearlyoncologicoutcomes.