. 20 实现保肛, 仍然是结直肠外科极具挑战性的难 [9], 题年 Schiessel 等在英国外科杂志首 (intersphincteric resection, ISR), 次报道采用经括约肌间切除术 (intersphincteric resection, ISR) 成功实

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: http://www.baishideng.com/wcjd/ch/index.aspx : http://www.wjgnet.com/esps/helpdesk.aspx DOI: 10.11569/wcjd.v24.i26.

1 : : DOI: /wcjd.v24.i ; 24(26): ISSN (print) ISSN (online) 2016 Baishideng Publishing Group Inc. All rights reserved. EDITORIAL 低位直肠癌经括约肌间保肛手术应用现状背景资料 <5 cm,,,. (intersphincteric resection, ISR),, 2 cm. anal verge, abdominoperineal resection (APR) with permanent sigmoid colostomy is usually used to ensure the R0 resection. Sphincter saving surgery has emerged in the last 20 years, and the introduction of intersphincteric resection (ISR) can successfully preserve the anal function and guarantee a radical tumor resection for patients with ultra-low lying Intersphincteric resection for low rectal cancer Abstract For low rectal cancer located < 5 cm from the tumors. Therefore, the use of APR has been consistently declining worldwide. Recently, a growing body of research on ISR has been reported. However, more evidence based results are needed to clarify some issues about ISR. In the current review, we discuss the indications for ISR and the oncological and functional outcomes following the procedure. Some technique issues of ISR are also discussed. 同行评议者,,, ;,,, Jian-Hua Ding, Bin Zhang Jian-Hua Ding, Bin Zhang, Department of Colorectal Surgery, the General Hospital of the PLA Rocket Force, Beijing , China Supported by: the Clinical Research Fund of Beijing Municipal Science and Technology Commission, No. Z Correspondence to: Jian-Hua Ding, Department of Colorectal Surgery, the General Hospital of the PLA Rocket Force, 16 Xinjiekouwai Road, Xicheng District, Beijing , China. jianhuading75@163.com Received: Revised: Accepted: Published online: The Author(s) Published by Baishideng Publishing Group Inc. All rights reserved. Key Words: Intersphincteric resection; Low rectal cancer; Abdominoperineal resection Ding JH, Zhang B. Intersphincteric resection for low rectal cancer. Shijie Huaren Xiaohua Zazhi 2016; 24(26): URL: com/ /full/v24/i26/3764.htm DOI: dx.doi.org/ /wcjd.v24.i <5 cm, WCJD

2 . 20 实现保肛, 仍然是结直肠外科极具挑战性的难 [9], 题年 Schiessel 等在英国外科杂志首 (intersphincteric resection, ISR), 次报道采用经括约肌间切除术 (intersphincteric resection, ISR) 成功实现了低位直肠癌的保肛. 实., 施该手术的解剖基础是 : 直肠末端肠壁环形肌. 层增厚, 并向肛管内延伸形成肛门内括约肌包, 绕肛管, 肛门内括约肌又被周围的外括约肌., 耻骨直肠肌等包绕, 共同形成肛门直肠环实现. ISR 肛门控便功能. 在肛门内括约肌与其他括约肌之间存在先天的解剖间隙, ISR 手术即在腹部游. 离直肠至盆底最低位后, 经肛门距离肿瘤下极 1-2 cm 处环形切开末端直肠壁及内括约肌, 进入 The Author(s) Published by Baishideng Publishing Group Inc. All rights reserved. 上述内外括约肌间隙, 再沿间隙向近端游离与腹部会合, 然后经肛门拖出游离的直肠乙状结肠, 直视下离断肠管移除标本, 行近端肠管与肛管手工吻合, 从而既保证了充分的肿瘤切缘 (intersphincteric 又实现了保肛. 该手术一经报道引起了广泛的 resection, ISR) 关注, 日本学者 Teramoto 称之为极限保肛手术 [10]., 由于该手术可保证绝大多数低位超低位直肠 [11], ISR. 癌实现 1-2 cm 切缘, 因此法国学者 Rullier 等认为该手术方式是肿瘤远切缘 2 cm 法则的终结, 所有直肠癌采用该手术均可实现技术上保肛. URL: 然而 ISR 在国际上的推广并不迅速, 许多 DOI: 学者对该手术切除肿瘤的彻底性术后肛门功能存在担忧, 而手术的适应证具体操作过程等也有不同的观点. 近十年来, 随着国际上 0 引言多个中心研究结果的发表, 一些问题得到了明尽管腹会阴联合切除术 (abdominoperineal 确的答案, 而围绕该手术的更深入研究的开展, resection, APR) 仍然是低位直肠癌 ( 距离肛缘使我们对 ISR 术有了更系统全面的认识. [1-4] <5 cm) 的标准术式, 越来越多的研究发现 ARP 不仅具有较高的环周切缘 (circumferential resection margin, CRM) 阳性率和肿瘤穿孔率, 并且患者术后远期生活质量欠佳. 随着双吻合器技术全直肠系膜切除术新辅助治疗等技术的相继开展, 低位直肠癌保肛率显著上升. [5-7] 然而, 文献报道低位直肠癌永久性肠造口的比率高达 30%-50%. 其原因在于手术时远切端距离肿瘤下极至少需要 1-2 cm, 以保证足够切缘, 防止术后复发, 而直肠末端至肛缘间还有长约 2-4 cm 的肛管, 其周围为肛门括约肌包绕. 因此, 传统的低位前切除术 (low anterior resection, LAR) 常难于保证低位直肠癌足够的远切缘, 不得不牺牲肛门以保证根治手术的彻底性 [8]. 对于距离齿状线 <1 cm 的超低位直肠癌 [7], 如何在保证低位直肠癌手术彻底性的前提下 1 适应证选择低位直肠癌行 ISR 手术适应证考虑以下几个方面 : (1) 位置 : 上限为肿瘤下极距离肛直环上缘 <2 cm 的直肠癌, 高于该水平的直肠癌可采用传统 LAR 双吻合器技术完成. 下限为肿瘤下极距离内外括约肌间沟 1 cm, 位置更低的直肠肛管癌采用 ISR 也无法获得 1 cm 以上的安全切缘 ; (2) 浸润深度 : ISR 治疗 T1 T2 期直肠癌已达成共识. 对于 T3 期肿瘤, 有学者担忧术后 [4,12,13] 局部复发率高, 但既往多项研究结果表明, 只要术前评估预期可获得阴性环周切缘, 采用 ISR 切除 T3 期肿瘤安全可行. 而对于 T4 期肿瘤, 应作为 ISR 禁忌证 [9,14,15]. 有学者对 T4 期肿瘤侵犯外括约肌者采用 ISR 术同时切除受侵犯部分外括约肌, 但切缘阳性率达 36.7%, 且研研发前沿 ISR ( R 0,, ) (???). WCJD

相关报道 2012, 14 1289 ISR, R 0 97%, 56 mo, 6.7%, 5 86.3%, DFS 78.6%,, 90.8%. A B C [16,17] 究显示 T4 期为 ISR 术后局部复发的危险因素 ; (3) 分化程度 : 高中分化直肠癌适宜, 而低分化直肠黏液癌为术后复发危险因素, 不适宜本手术 [18].

国际上多个研究也推荐采用三维直肠腔内超声进行术前分期 [21,22]. 我们的经验, 三维直肠腔内超声不仅能够准确进行肿瘤 T 分期, 并且可清晰显示耻骨直肠肌内外括约肌的解剖结构, 并量化分析肿瘤下极与耻骨直肠肌的距离肿瘤浸润内外括约肌的深度, 对环周切缘的预估有重要作用 ( 图 1).

1 常规采用开腹或腹腔镜 4 孔法 ( 脐上缘右下腹分别置入 12 mm Trocar 作为观察孔和主操作孔, 右上腹与左下腹直肌外缘分别置入 5 mm Trocar 作为辅助操作孔 ), 全程超声刀中间入路法完成保留自主神经的标准全直肠系膜切除, 清扫肠系膜下血管根部及以下淋巴结, 自肠系膜下动脉根部或左结肠动脉分支下方切断肠系膜下动脉. 充分游离左半结肠.

3 相关报道 2012, ISR, R 0 97%, 56 mo, 6.7%, %, DFS 78.6%,, 90.8%. A B C [16,17] 究显示 T4 期为 ISR 术后局部复发的危险因素 ; (3) 分化程度 : 高中分化直肠癌适宜, 而低分化直肠黏液癌为术后复发危险因素, 不适宜本手术 [18]. 为获得良好适应证, 术前准确评估肿瘤浸润深度是否能达到环周切缘阴性 (>1 mm) 至关重要. 核磁共振成像 (magnetic resonance imaging, MRI) 为直肠癌术前分期最常用的方法, 其判断环周切缘受累的敏感性和特异性为 85.4% 和 80% [19] ; 然而, 新辅助放化疗后由于肿瘤灶周围组织炎症反应和纤维化, MRI 再次评估时准确性下降 [20]. 国际上多个研究也推荐采用三维直肠腔内超声进行术前分期 [21,22]. 我们的经验, 三维直肠腔内超声不仅能够准确进行肿瘤 T 分期, 并且可清晰显示耻骨直肠肌内外括约肌的解剖结构, 并量化分析肿瘤下极与耻骨直肠肌的距离肿瘤浸润内外括约肌的深度, 对环周切缘的预估有重要作用 ( 图 1). 此 [23] [4] 外, 正如 Rullier 等和 Kim 等教授指出, 直肠指诊虽然简单, 但对有经验的医师, 指诊即可大体了解肿瘤浸润深度及肛门括约肌情况, 对部分病例即可明确是否适合 ISR 手术. 2 手术方法 2.1 常规采用开腹或腹腔镜 4 孔法 ( 脐上缘右下腹分别置入 12 mm Trocar 作为观察孔和主操作孔, 右上腹与左下腹直肌外缘分别置入 5 mm Trocar 作为辅助操作孔 ), 全程超声刀中间入路法完成保留自主神经的标准全直肠系膜切除, 清扫肠系膜下血管根部及以下淋巴结, 自肠系膜下动脉根部或左结肠动脉分支下方切断肠系膜下动脉. 充分游离左半结肠. 保护上腹下神经骶前神经及盆腔自主神经丛, 按直肠后方两侧前方顺序完全游离直肠系膜直至盆底, 直肠前壁分离注意保护两侧血管神经束. 如镜下视野清晰, 操作空间充分, 可于正后方切断裂孔韧带进入肛提肌裂孔, 自直肠后外侧进入内括约肌间隙. 常规行末端回肠预防性袢式造口. 盆腔经左下腹 Trocar 孔置入 26F 双套管引流. 2.2 碘伏消毒直肠肛管, 放置 Lone Star 自动拉钩 (Lone Star Medical Products Inc., Houston, Texas, United States) 固定, 避免过度图 1 三维肛肠直肠腔内超声行直肠癌术前评估. 牵拉损伤肛门括约肌. 手术方式的选择依照低位直肠癌 Rullier 分型 [24], 即根据肿瘤下缘与肛直环的距离确定 ISR 手术方式, 确保远切缘距肿瘤下极至少 1-2 cm. 如肿瘤下缘距离肛直环 1 cm, 采用部分 ISR 或次全 ISR 手术, 即自齿状线附近或齿状线与肛门括约肌间沟之间环形切除内括约肌全层 ; 如肿瘤下缘位于肛直环平面以下, 或侵犯内括约肌而未累及外括约肌, 则选择完全 ISR 手术, 即经肛门括约肌间沟环形切除全部内括约肌. 远端缝闭避免术中肿瘤播散. 沿内外括约肌间隙自后方侧方前方向盆腔分离, 与腹部会师后, 经肛门拖出标本直视下切除肿瘤近端肠管, 切除组织标本送检病理 ( 图 2). 2-0 可吸收缝线间断行结肠 - 肛管手工吻合 (colo-anal anastomosis, CAA). 3 肿瘤学结果 ISR 手术理论上实现了低位直肠癌足够的切缘, 从而实现了保肛, 但实际肿瘤学结果尚需要临 WCJD

丁健华等低位直肠癌经括约肌间保肛手术应用现状 A B C D E F 创新盘点本文系统性阐述了低位直肠癌 ISR保肛手术的解剖学基础手术适应证的选择相关肿瘤学结果术后肛门功能和生活质量手术相关技术问题, 明确了 ISR手术应用现

ＡＬｏｎｅｓｔａｒ拉钩暴露肛门即见肿瘤位于齿线处于内外括约肌间沟作环形切口Ｂ沿括约肌间沟向上完全游离直肠外括约肌耻骨直肠肌盆底肌清晰可见Ｃ自肛门部拉出包含肿瘤之肠管并予离断Ｄ行手工结肠肛管吻合Ｅ完成吻合保肛成功Ｆ

因此除了术前准确评估肿瘤浸润 0%-15%, 而传统APR术后局部复发率为6.7%, 深度环周切缘, 选择合适适应证外, 手术操作两者比较无明显差异 [15,25-31]. M a r t i n等 [32] 于是关键.

0切除率97%, 中位随离, 尤其对男性直肠前壁肿瘤者, 准确的手术操访56 mo, 局部复发率为6.7%, 5年生存率86.3%, 作是保证阴性环周切缘远切缘的关键. 术中 [17] DFS为78.6%, 显示了良好的手术根治性.

4 功能性结果由于研究设计及伦理等方面原因, 目前尚由于I S R手术切除了全部或部分肛门内括约无低位直肠癌行ISR与APR直接比较的前瞻性肌, 而且吻合口位置接近肛门口, 术后肛门功显示两组术后DFS 能生活质量也是备受关注的问题.

1%), 5年生存率(76.4% vs 51.2%), 失禁评分及肛门功能显著优于术后3 mo[37].

4 丁健华等低位直肠癌经括约肌间保肛手术应用现状 A B C D E F 创新盘点本文系统性阐述了低位直肠癌 ISR保肛手术的解剖学基础手术适应证的选择相关肿瘤学结果术后肛门功能和生活质量手术相关技术问题, 明确了 ISR手术应用现状及注意要点. 图 2 经直肠癌经括约肌间切除术会阴部操作过程. ＡＬｏｎｅｓｔａｒ拉钩暴露肛门即见肿瘤位于齿线处于内外括约肌间沟作环形切口Ｂ沿括约肌间沟向上完全游离直肠外括约肌耻骨直肠肌盆底肌清晰可见Ｃ自肛门部拉出包含肿瘤之肠管并予离断Ｄ行手工结肠肛管吻合Ｅ完成吻合保肛成功Ｆ切除标本见肿瘤位于齿线处远切缘足够充分床循证数据验证. 近年来, 国际上研究结果陆续切缘应>2 mm 远切缘>1.5 cm, 否则局部复发发表, R0切除率为87%-100% 术后局部复发率率明显上升. 因此除了术前准确评估肿瘤浸润 0%-15%, 而传统APR术后局部复发率为6.7%, 深度环周切缘, 选择合适适应证外, 手术操作两者比较无明显差异 [15,25-31]. M a r t i n等 [32] 于是关键. 需要熟练的盆腔深部操作技巧, 同时熟 2012年对所有已发表研究筛选后进行系统分悉肛门部括约肌解剖[35], 经肛门切开直肠壁时析后发表于英国外科杂志, 共入选14项必须深达括约肌间隙, 并准确沿括约肌间隙分研究1289例I S R患者, R 0切除率97%, 中位随离, 尤其对男性直肠前壁肿瘤者, 准确的手术操访56 mo, 局部复发率为6.7%, 5年生存率86.3%, 作是保证阴性环周切缘远切缘的关键. 术中 [17] DFS为78.6%, 显示了良好的手术根治性. Saito等切缘冰冻切片有助于评估手术是否彻底. 更远期的研究显示, 199例ISR平均随访78 mo, 7年 OS: 78% DFS: 67% LFS: 80%. 4 功能性结果由于研究设计及伦理等方面原因, 目前尚由于I S R手术切除了全部或部分肛门内括约无低位直肠癌行ISR与APR直接比较的前瞻性肌, 而且吻合口位置接近肛门口, 术后肛门功显示两组术后DFS 能生活质量也是备受关注的问题. 研究[36]显相当, APR复发率甚至高于ISR. Koyama等[33]比示, 术后短期内肛门功能下降, 但排便评分及肛较了77例ISR和33例APR, 结果显示局部复发率肠测压结果均显示随时间逐渐改善, 术后24 mo (7.8% vs 12.1%), 5年生存率(76.4% vs 51.2%), 失禁评分及肛门功能显著优于术后3 mo[37]. 在两组病例TNM分期虽无差异, 但APR组分化 Martin等[32]的荟萃分析中, 中位随访56 mo, 术程度更差, 高中分化腺癌的比例ISR组为94%, 后排便次数平均2.7次/d, 29.1%控制稀便功能研究, 一些回顾性研究 [1-4,17] APR组为76%. 最近, Kim等通过倾向得分匹下降, 23.8%控制气体功能下降, 18.6%有排便配减少选择性偏倚, 多因素分析结果同样证实急迫感, 但与切除肛门相比, 90.8%的患者对术 APR比ISR具有更高的5年局部复发率. 后肛门功能表示满意, 愿意接受该手术, 其他 [4] 如何尽可能避免术后局部复发是ISR手术研究也有类似结果[15,25-31]. Koyama等[33]比较了的重要问题, 研究显示T3 环周切缘阳性为高 77例ISR和68例前切除患者, 术后5年, ISR组肛危因素[34]. Komori等[22]研究报道, ISR手术环周门失禁评分差于前切除组(8.1 vs 4.9), 但排便 WCJD

5 应用要点 ISR. T1-3,, ISR,,,. 相关生活质量评分两组无差异. 为尽可能的保护术后肛门功能, 除了肿瘤位置吻合口高度外 [38], 其他一些可能影响术后功能的因素值得注意. 由于吻合口极低, 术后吻合口狭窄并不少见, 研究提示其为术后肛门功能下降的危险因素 [39], 我们也发现一些患者有明显的便次增多排便不净感, 查体发现为吻合狭窄, 因此术后随访如发现有狭窄应尽早扩肛, 多数狭窄经简单手指扩肛即可解除. 术前新辅助放化疗在低位直肠癌治疗中应用越来越广泛. 然而, 术前放化疗是 ISR 术后远期肛门功能不佳的危险因素 [27,37,40]. [41] Nishizawa 等对 199 例 ISR 平均随访 78 mo, 术前放化疗组肛门失禁评分生活质量评分均差于直接手术组 [17]. 而且新辅助治疗反应越好, ISR 术后肛门功能越差. 术前放化疗可导致明显的神经变性, 从而影响肛门功能 [42]. 但该效 [43] 应具有普遍性, 并非 ISR 特有, 最近 Beppu 等报道了 105 例术前接受了新辅助放化疗的低位直肠癌患者, 其中 46 例行 ISR, 41 例行双吻合器前切除, 术后平均随访 6.5 年, 组间比较低位前切除综合征评分无统计学差异, 其中仅肛门失禁亚类 ( 肛门控气液状便 ) 评分 ISR 低于前切除, 两组术后排便功能随时间逐渐改善. 因此, 如患者拟行 ISR 术保肛, 术前新辅助治疗对肛门功能的潜在影响应予考虑. 同时术前应评估肛门功能, 并行肛肠测压, 如术前即存在明显肛门功能不佳, 是否行 ISR 及新辅助治疗应慎重考虑. 5 手术相关问题 5.1 ISR 术后常规行预防性回肠造口是普遍被采用的方式, 90% 以上的文献均予采用. 然而也有少数学者未行预防性造口. Koyama 等 [33] 135 例 ISR 未行预防性造口, 吻合口漏发生率 17%, 单因素分析显示男性术前化疗部分 ISR 侧方淋巴结清扫肿瘤距离和直接吻合是危险因素, 该研究中排除了术前放疗患者. ISR 吻合时在直视下手工吻合, 吻合较确切, 然而由于吻合口位于括约肌环内, 吻合口可能因受挤压而缺血 [44], 导致吻合口漏. 文献报道 ISR 术后吻合口漏的发生率为 5%-16% [11,25-27], 盆腔脓肿发生率为 5%, 大多也来源于吻合口漏 [27]. 预防性回肠造口虽然并不能减少吻合口漏的发生, 但可明显减低后续危害, 因此, 预防性回肠造口仍是目前主流方法. 5.2 低位直肠癌前切除术后, 一些学者采用结肠储袋与直肠残端吻 [45] 合, 以改善术后肛门功能. 研究显示, 结肠储袋可改善术后肛门功能, 尤其在术后 1 年内. 但术后 2 年, 结肠储袋与直肠端端吻合者无差异. 在 ISR 手术中, 也有学者主张采用结肠储袋与 [46] 肛管吻合. 但 Akasu 等报道, 结肠储袋肛管吻合是发生严重吻合口漏的文献因素. 即一旦发生吻合口漏, 行结肠储袋者后果严重. 我们 1 例 ISR 患者行结肠储袋肛管吻合后发生吻合口漏, 继发储袋严重感染缺血坏死, 后再次手术切除储袋行永久性造口. 因此, ISR 是否行结肠储袋, 应综合考虑患者术前肛门功能术中是否具有条件, 以及如果发生严重吻合口漏患者身体的耐受性等. 5.3 国际上 ISR 手术前期报道绝大多数为开腹手术, 近年来关于腹腔镜 ISR [47] 术的结果相继增多. Laurent 等回顾性研究报道, 开腹 ISR 与腹腔镜 ISR 术后并发症率分别为 28% 23%, 术后 5 年局部复发率分别为 2% 5% 无病生存率分别为 71% 70%, 总存生率分别为 85% 82%, 两组比较均无统计学意义, 提示微创手术可以安全用于 ISR 操作. 国内学者池畔教授回顾性分析 48 例开腹 ISR 与 89 例完全腹腔镜部分 ISR 术后的中期结果 ( 平均随访时间 32.3 mo), 结果证实两组间肿瘤学结果及肛门功能无显著统计学差异 [48]. 其他研 [7,45,49-54] 究也证明腹腔镜 ISR 术无论在彻底性安全性还是功能性方面都是可行的. 我们回顾了全军肛肠专病中心已完成的 76 例腹腔镜 ISR 手术, 结果显示本组患者均顺利完成标准腹腔镜 TME 及经肛门 ISR 手术, 无中转开腹及死亡病例, 手术时间 195 min( min) 出血量 100 ml( ml) 淋巴结清扫数目 14 枚 (3-33 枚 ) 肿瘤远切缘距离 2 cm(1-3.5 cm) R 0 切除率 98.6% 中位随访 2 年局部复发率 4.6%. 最近, 国外学者在手术步骤方面提出经肛 ISR 先行腹腔镜 TME 后行的策略, 认为可能减少手术时间降低操作难度, 提高 CRM 阴性率, 术后短期长期结果和经腹手术无差异 [51,54] [55]. 另有长期随访结果 ( 平均随访时间 69 mo) 表明 ISR 手术并不增加永久性肠造口的比率. 此外, 机器人 ISR 手术也开始尝试, 其 WCJD

6 3 年生存率无复发生存率肛门功能等与腹腔镜 ISR 手术相比无差异 [56,57]. 6 结论总之, ISR 术使部分既往不能保肛的低位直肠癌患者实现了保肛, 对于术前肛门功能好保肛意愿强烈术前评估预期可实现环周切缘阴性的患者, 通过严格的手术适应证筛选, ISR 是一种安全可行的保肛术式. 7 参考文献 1 Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ. Patients with low rectal cancer treated by abdominoperineal excision have worse tumors and higher involved margin rates compared with patients treated by anterior resection. Dis Colon Rectum 2010; 53: [PMID: DOI: /DCR.0b013e3181c70465] 2 Reshef A, Lavery I, Kiran RP. Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only? Dis Colon Rectum 2012; 55: [PMID: DOI: / DCR.0b013e c1f] 3 Konanz J, Herrle F, Weiss C, Post S, Kienle P. Quality of life of patients after low anterior, intersphincteric, and abdominoperineal resection for rectal cancer--a matched-pair analysis. Int J Colorectal Dis 2013; 28: [PMID: DOI: /s z] 4 Kim CH, Lee SY, Kim HR, Kim YJ. Factors Associated With Oncologic Outcomes Following A b d o m i n o p e r i n e a l o r I n t e r s p h i n c t e r i c Resection in Patients Treated With Preoperative Chemoradiotherapy: A Propensity Score Analysis. Medicine (Baltimore) 2015; 94: e2060 [PMID: DOI: /MD ] 5 van Gijn W, Marijnen CA, Nagtegaal ID, Kranenbarg EM, Putter H, Wiggers T, Rutten HJ, Påhlman L, Glimelius B, van de Velde CJ. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol 2011; 12: [PMID: DOI: / S (11) ] 6 Richardson DP, Porter GA, Johnson PM. Population-based use of sphincter-preserving surgery in patients with rectal cancer: is there room for improvement? Dis Colon Rectum 2013; 56: [PMID: DOI: / DCR.0b013e c2b] 7 Chau A, Maggiori L, Debove C, Kanso F, Hennequin C, Panis Y. Toward the end of abdominoperineal resection for rectal cancer? An 8-year experience in 189 consecutive patients with low rectal cancer. Ann Surg 2014; 260: ; discussion [PMID: DOI: /SLA ] 8 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: [PMID: DOI: / ] 9 Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M. Intersphincteric resection for low rectal tumours. Br J Surg 1994; 81: [PMID: DOI: /bjs ] 10 Teramoto T, Watanabe M, Kitajima M. Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum 1997; 40: S43-S47 [PMID: DOI: /BF ] 11 Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 2005; 241: [PMID: DOI: /01.sla e1] 12 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; 2011: [PMID: DOI: /2011/901574] 13 Kim HS, Ko S, Oh NG. Long-term results of extended intersphincteric resection for very low rectal cancer: a retrospective study. BMC Surg 2016; 16: 21 [PMID: DOI: / s ] 14 Tilney HS, Tekkis PP. Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Dis 2008; 10: 3-15; discussion [PMID: ] 15 Kuo LJ, Hung CS, Wu CH, Wang W, Tam KW, Liang HH, Chang YJ, Wei PL. Oncological and functional outcomes of intersphincteric resection for low rectal cancer. J Surg Res 2011; 170: e93-e98 [PMID: DOI: / j.jss ] 16 Akagi Y, Kinugasa T, Oka Y, Mizobe T, Yoshida T, Yuge K, Shirouzu K. External sphincter resection for lower rectal and anal canal adenocarcinoma: achieving anal preservation with oncological and functional satisfaction. Surg Today 2014; 44: [PMID: DOI: / s ] 17 Saito N, Ito M, Kobayashi A, Nishizawa Y, Kojima M, Nishizawa Y, Sugito M. Long-term outcomes after intersphincteric resection for low-lying rectal cancer. Ann Surg Oncol 2014; 21: [PMID: DOI: /s y] 18 Spanos CP. Intersphincteric resection for low rectal cancer: an overview. Int J Surg Oncol 2012; 2012: [PMID: DOI: /2012/241512] 19 Oberholzer K, Junginger T, Heintz A, Kreft A, Hansen T, Lollert A, Ebert M, Düber C. Rectal Cancer: MR imaging of the mesorectal fascia and effect of chemoradiation on assessment of tumor involvement. J Magn Reson Imaging 2012; 36: [PMID: DOI: / jmri.23687] 20 Zhao RS, Wang H, Zhou ZY, Zhou Q, Mulholland 名词解释 :, ( 5 cm 1 cm). <1 cm,. Rullier. WCJD

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Yanagi H, Yamanaka N. Long-Term Functional Outcomes of Total Mesorectal Excision Following Chemoradiotherapy for Lower Rectal Cancer: Stapled Anastomosis versus Intersphincteric Resection.

8 Yanagi H, Yamanaka N. Long-Term Functional Outcomes of Total Mesorectal Excision Following Chemoradiotherapy for Lower Rectal Cancer: Stapled Anastomosis versus Intersphincteric Resection. Dig Surg 2016; 33: [PMID: DOI: / ] 44 Scala D, Niglio A, Pace U, Ruffolo F, Rega D, Delrio P. Laparoscopic intersphincteric resection: indications and results. Updates Surg 2016; 68: [PMID: DOI: /s ] 45 Heriot AG, Tekkis PP, Constantinides V, Paraskevas P, Nicholls RJ, Darzi A, Fazio VW. Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. Br J Surg 2006; 93: [PMID: ] 46 Akasu T, Takawa M, Yamamoto S, Yamaguchi T, Fujita S, Moriya Y. Risk factors for anastomotic leakage following intersphincteric resection for very low rectal adenocarcinoma. J Gastrointest Surg 2010; 14: [PMID: DOI: /s ] 47 Laurent C, Paumet T, Leblanc F, Denost Q, Rullier E. Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach. Colorectal Dis 2012; 14: 35-41; discussion [PMID: DOI: /j x] 48 Chi P, Huang SH, Lin HM, Lu XR, Huang Y, Jiang WZ, Xu ZB, Chen ZF, Sun YW, Ye DX. Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome. Ann Surg Oncol 2015; 22: [PMID: DOI: /s ] 49 Park JS, Choi GS, Jun SH, Hasegawa S, Sakai Y. Laparoscopic versus open intersphincteric resection and coloanal anastomosis for low rectal cancer: intermediate-term oncologic outcomes. Ann Surg 2011; 254: [PMID: DOI: /SLA.0b013e318236c448] 50 Cong JC, Chen CS, Ma MX, Xia ZX, Liu DS, Zhang FY. Laparoscopic intersphincteric resection for low rectal cancer: comparison of stapled and manual coloanal anastomosis. Colorectal Dis 2014; 16: [PMID: DOI: /codi.12573] 51 Maglio R, Meucci M, Muzi MG, Maglio M, Masoni L. Laparoscopic total mesorectal excision for ultralow rectal cancer with transanal intersphincteric dissection as a first step: a singlesurgeon experience. Am Surg 2014; 80: [PMID: ] 52 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: [PMID: DOI: /SLA ] 53 Pai VD, Desouza A, De Menezes JL, Saklani AP. Laparoscopic intersphincteric resection and handsewn coloanal anastomosis: a natural orifice specimen extraction technique. J Laparoendosc Adv Surg Tech A 2015; 25: [PMID: DOI: /lap ] 54 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: [PMID: DOI: /DCR ] 55 Celerier B, Denost Q, Van Geluwe B, Pontallier A, Rullier E. The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer. Colorectal Dis 2016; 18: [PMID: DOI: /codi.13124] 56 Park JS, Kim NK, Kim SH, Lee KY, Lee KY, Shin JY, Kim CN, Choi GS. Multicentre study of robotic intersphincteric resection for low rectal cancer. Br J Surg 2015; 102: [PMID: DOI: /bjs.9914] 57 Luca F, Valvo M, Guerra-Cogorno M, Simo D, Blesa-Sierra E, Biffi R, Garberoglio C. Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis. Eur J Surg Oncol 2016 Mar 18. [Epub ahead of print] [PMID: DOI: /j.ejso ] 编辑 : 电编 : ISSN (print) ISSN (online) DOI: Baishideng Publishing Group Inc. All rights reserved. 世界华人消化杂志 2011 年开始不再收取审稿费消息本刊讯为了方便作者来稿, 保证稿件尽快公平公正的处理, 世界华人消化杂志编辑部研究决定, 从 2011 年开始对所有来稿不再收取审稿费. 审稿周期及发表周期不变. ( 世界华人消化杂志编辑部 ) WCJD

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instillation therapy combined with Western medicine can reduce the levels of ALT, TBA, ALP, TBIL, DBIL and GGT, and improve the anti-cmv-igm negative

instillation therapy combined with Western medicine can reduce the levels of ALT, TBA, ALP, TBIL, DBIL and GGT, and improve the anti-cmv-igm negative 在线投稿 : http://www.baishideng.com/wcjd/ch/index.aspx 帮助平台 : http://www.wjgnet.com/esps/helpdesk.aspx DOI: 10.11569/wcjd.v23.i28.4568 世界华人消化杂志 2015 年 10 月 8 日 ; 23(28): 4568-4573 ISSN 1009-3079

. 20 实现保肛, 仍然是结直肠外科极具挑战性的难 [9], 题 年 Schiessel 等在 英国外科杂志 首 (intersphincteric resection, ISR), 次报道采用经括约肌间切除术 (intersphincteric resection, ISR) 成功实

. 20 实现保肛, 仍然是结直肠外科极具挑战性的难 [9], 题年 Schiessel 等在英国外科杂志首 (intersphincteric resection, ISR), 次报道采用经括约肌间切除术 (intersphincteric resection, ISR) 成功实