经肛内镜显微外科手术TEM医学医药课件.pptx

1、北京世纪坛医院多媒体网络室 2007 临床类模板Backgroundpresent experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).Goal:evaluating morbidity,mortality,and local recurrence rate.北京世纪坛医院多媒体网络室 2007 临床类模板Patients and methodsEnrolled:402 patients,preoperative diagnosis of adenomas.(1993.1-2008.

2、10)Mean age:65 years(range22-92)Men:221 vs Women:181北京世纪坛医院多媒体网络室 2007 临床类模板distance of adenomas from the anal verge0-3 cm:28 patients3-6 cm:58 patients6-12 cm:251 patients12-16 cm:54 patients 16 cm:11 patients北京世纪坛医院多媒体网络室 2007 临床类模板1 cm minimum of normal mucosa around the lesion0-3 cm:28 patients1

3、%)high-risk patients(ASA 4).present experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).The patients with hemorrhaging,two of them with cirrhosis,required blood transfusionslaparoscopic anterior rectal resection with temporary ileostomySometimes,large adenomas in the lo

4、wer third of the rectum are treated by abdominoperineal excision or coloanal anastomosisLesion positionPreoperative therapy stagingThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusions6-12 cm:251 patientsstool incontinence(soiling)Malignant lesion:complicationsshort-t

5、erm results:Lesion positionanterior wall of the rectum:92 patientsposterior wall:107 patientslateral wall:88 patientssemicircumferential:98 patientscircumferential:17 patients北京世纪坛医院多媒体网络室 2007 临床类模板Preoperative therapy stagingdigital examination to evaluate tumor fixationtotal colonoscopyrigid rect

6、oscopy:macrobiopsies;measure the distance from the anal verge;determine the location and consequently select the position北京世纪坛医院多媒体网络室 2007 临床类模板transanal endosonography(EUS)by a rotative probecomputed tomography(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesions北京世纪坛医院多媒体网络室 200

7、7 临床类模板Patient preparationwashout of the colonshort-term antibiotic prophylaxisgeneral anesthesia in the majority of patientsSpinal anesthesia was used in 65(16.1%)high-risk patients(ASA 4).北京世纪坛医院多媒体网络室 2007 临床类模板 1.supine position2.prone position 3.lateral positionplace the lesion in the inferior

8、part ofthe operative field北京世纪坛医院多媒体网络室 2007 临床类模板Fullthickness excision:379 patients(94.3%)1 cm minimum of normal mucosa around the lesionMucosectomy:23 patients(5.7%)北京世纪坛医院多媒体网络室 2007 临床类模板Mean operative time was 64 min(range=22120).rectal defect was closed:endoluminal running suture with a silve

9、r clip placed at each end of the suture to avoid an intrarectal node.北京世纪坛医院多媒体网络室 2007 临床类模板only 15 patients(3.7%)required the repeated administration of ketorolac 30 mg in the first 48 h.drink liquids on the first postoperative dayMean hospital stay was 2.5 days(range=18 days).北京世纪坛医院多媒体网络室 2007 临

10、床类模板short-term results:Minimal intraoperative complications:13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vagina All lesions were closed endoscopically by TEM without any intra-or postoperative consequences.北京世纪坛医院多媒体网络室 2007 临床类模板giant adenomas(2 cases):i

11、mpossible to carry out a complete suture.temporary ileostomy closed after 2 months One of the two patients had a rectal stenosisrequired endoscopic dilatation.At follow-up of 24 and 30 months(the patient with rectal stenosis)no other complications were observed.北京世纪坛医院多媒体网络室 2007 临床类模板Definitive his

12、tologyNFurther treatmentadenomas366(91%).NOsitu carcinoma or pT1 rectal tumor34(8.4%)NOmucinous T2 cancer2(0.5%)laparoscopic anterior rectal resection with temporary ileostomy北京世纪坛医院多媒体网络室 2007 临床类模板Postoperative follow-up mean follow-up:84 months(range=1190 months)1 month after discharge:clinical e

13、xamination,digital rectal exploration,andrigid rectoscopyevery 6 months for the first year and then annually(flexible endoscopy with biopsies of the scar)北京世纪坛医院多媒体网络室 2007 临床类模板complications北京世纪坛医院多媒体网络室 2007 临床类模板All leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or

14、parenteral nutrition.Stool incontinence was treated with physiotherapy and anal sphincter biofeedback resolved within 2 months of the operationThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusions北京世纪坛医院多媒体网络室 2007 临床类模板北京世纪坛医院多媒体网络室 2007 临床类模板Long-term results(patien

15、t is alive after 2 years without other complications)laparoscopic anterior rectal resection with temporary ileostomyAll leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.Enrolled:402 patients,preoperative diagnosis of adenomas.short-term results:7%

16、)required the repeated administration of ketorolac 30 mg in the first 48 h.Preoperative therapy stagingT1N0 rectal tumor6-12 cm:251 patients1 cm minimum of normal mucosa around the lesion13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vaginashort-term antibi

17、otic prophylaxissupine position2.0-3 cm:28 patientsSurgical drainage and colostomy(patient is alive after 1 year)Laparoscopic ileostomy and a new suture by TEM.(patient is alive after 2 years without other complications)北京世纪坛医院多媒体网络室 2007 临床类模板Long-term results北京世纪坛医院多媒体网络室 2007 临床类模板No patients had

18、 a new recurrence at the next follow-upOf the 34 patients with pT1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.北京世纪坛医院多媒体网络室 2007 临床类模板Discussionadenomas of the colon and rectum have the potential to become malignant;related to

19、size,histological type(villous adenoma),and grade of dysplasia北京世纪坛医院多媒体网络室 2007 临床类模板Endoscopic polypectomy is not able to remove all large and sessile polyps due to technical problemsin the middle or upper rectum,it may be difficult to excise it completely北京世纪坛医院多媒体网络室 2007 临床类模板Sometimes,large ad

20、enomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosisadenomas in the upper third of the rectum are removed by anterior resection Resection of the rectum is a major surgical procedure associated with significant morbidity(768%)and mortality(06.5%)北京世

21、纪坛医院多媒体网络室 2007 临床类模板TEM:minimally invasive and safecan reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge)北京世纪坛医院多媒体网络室 2007 临床类模板Risk:pelvic abscess,Infectionbleedingperforation into the peritoneal cavitysuture dehiscencestool incontinence(soiling)rect

22、ovaginal fistula北京世纪坛医院多媒体网络室 2007 临床类模板rectovaginal fistulaTEM:minimally invasive and safeshort-term results:7%)required the repeated administration of ketorolac 30 mg in the first 48 h.Sometimes,large adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal an

23、astomosisThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusionsshort-term results:3-6 cm:58 patients13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vaginasupine position2.lateral wall:88 patientsshort-term results:TEM:minimally

24、 invasive and safe1%)high-risk patients(ASA 4).All leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.indicationBenign lesion:polypsadenomasMalignant lesion:T1N0 rectal tumor北京世纪坛医院多媒体网络室 2007 临床类模板Thank you北京世纪坛医院多媒体网络室 2007 临床类模板supine position2.s

25、emicircumferential:98 patientswashout of the colonshort-term results:Fullthickness excision:379 patients(94.short-term results:adenomas of the colon and rectum have the potential to become malignant;Of the 34 patients with pT1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed

26、no local recurrences or distant metastases.required endoscopic dilatation.washout of the colonPreoperative therapy staging1%)high-risk patients(ASA 4).Sometimes,large adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosiscomputed tomography(CT)scan

27、 or magnetic resonance imaging(MRI):giant and suspected lesionsplace the lesion in the inferior part ofthe operative fieldFullthickness excision:379 patients(94.3%)1 cm minimum of normal mucosa around the lesionMucosectomy:23 patients(5.7%)北京世纪坛医院多媒体网络室 2007 临床类模板Definitive histologyNFurther treatme

28、ntadenomas366(91%).NOsitu carcinoma or pT1 rectal tumor34(8.4%)NOmucinous T2 cancer2(0.5%)laparoscopic anterior rectal resection with temporary ileostomy北京世纪坛医院多媒体网络室 2007 临床类模板Postoperative follow-up mean follow-up:84 months(range=1190 months)1 month after discharge:clinical examination,digital rec

29、tal exploration,andrigid rectoscopyevery 6 months for the first year and then annually(flexible endoscopy with biopsies of the scar)北京世纪坛医院多媒体网络室 2007 临床类模板All leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.Stool incontinence was treated with ph

30、ysiotherapy and anal sphincter biofeedback resolved within 2 months of the operationThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusions北京世纪坛医院多媒体网络室 2007 临床类模板No patients had a new recurrence at the next follow-upOf the 34 patients with pT1 rectal cancer,the mean fo

31、llow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.北京世纪坛医院多媒体网络室 2007 临床类模板Sometimes,large adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosisadenomas in the upper third of the rectum are removed by anterior resection Resection of the rectum is a major surgical procedure associated with significant morbidity(768%)and mortality(06.5%)