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Lesion positionanterior wall of the rectum:92 patientsposterior wa
3、ll: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 rectoscopy:macrobiopsies;measure the distance from the anal verge;determine the lo
4、cation 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 2007 临床类模板Patient preparationwashout of the colonshort-term antibiotic prophylaxi
5、sgeneral 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 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 p
6、atients(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 silver clip placed at each end of the suture to avoid an intrarectal node.北京世纪坛医院多媒
7、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 临床类模板Stool incontinence was treated with physiotherapy and anal sphincter biofe
8、edbackLesion positionStool incontinence was treated with physiotherapy and anal sphincter biofeedbackEndoscopic polypectomy is not able to remove all large and sessile polyps due to technical problemsmean follow-up:84 months(range=1190 months)Lesion positionshort-term antibiotic prophylaxisSpinal an
9、esthesia was used in 65(16.digital examination to evaluate tumor fixationPatients and methodsAll lesions were closed endoscopically by TEM without any intra-or postoperative consequences.laparoscopic anterior rectal resection with temporary ileostomyAt follow-up of 24 and 30 months(the patient with
10、rectal stenosis)Of the 34 patients with pT1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.Fullthickness excision:379 patients(94.suture dehiscencePatients and methodstemporary ileostomy closed after 2 monthsplace the lesion in the
11、 inferior part ofthe operative fieldFurther treatmentshort-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.
12、北京世纪坛医院多媒体网络室 2007 临床类模板giant adenomas(2 cases):impossible 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 wer
13、e observed.北京世纪坛医院多媒体网络室 2007 临床类模板Definitive histologyNFurther 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(ran
14、ge=1190 months)1 month after discharge:clinical examination,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 loca
15、l therapy(antibiotics and analgesic enema)and/or 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
16、板北京世纪坛医院多媒体网络室 2007 临床类模板Surgical 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 a new recurrence at the n
17、ext 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 size,histological type(vil
18、lous adenoma),and grade of dysplasia北京世纪坛医院多媒体网络室 2007 临床类模板Patients and methodsStool incontinence was treated with physiotherapy and anal sphincter biofeedbackPatient preparationin the middle or upper rectum,it may be difficult to excise it completelysemicircumferential:98 patientsperforation into
19、the peritoneal cavity 16 cm:11 patientsrelated to size,histological type(villous adenoma),and grade of dysplasia1 month after discharge:total colonoscopypresent experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).adenomas in the upper third of the rectum are removed by
20、anterior resectionDefinitive histologyLaparoscopic ileostomy and a new suture by TEM.Further treatmentSpinal anesthesia was used in 65(16.adenomas in the upper third of the rectum are removed by anterior resectionFullthickness excision:379 patients(94.general anesthesia in the majority of patientsNo
21、 patients had a new recurrence at the next follow-upEndoscopic 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 adenomas in the lower third of the r
22、ectum 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%)北京世纪坛医院多媒体网络室 2007 临床类模板TEM:minimally
23、 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)rectovaginal fistula北京世纪坛医院多媒体网络室 2007
24、 临床类模板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Definitive histologyNFu
25、rther 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 examinatio
26、n,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All leaking sutures resolved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.Stool incontinence was tr
27、eated 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No patients had a new recurrence at the next follow-upOf the 34 patients with pT1 rectal cance
28、r,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Enrolled:402 patients,preoperative diagnosis of adenomas.All lesions were closed endoscopically by TEM without any intra-or postoperative consequences.Mucosectomy:23 patien
29、ts(5.rectovaginal fistulatemporary ileostomy closed after 2 monthsplace the lesion in the inferior part ofthe operative fieldlaparoscopic anterior rectal resection with temporary ileostomyPatients and methodstransanal endosonography(EUS)by a rotative probeLaparoscopic ileostomy and a new suture by T
30、EM.Sometimes,large adenomas in the lower third of the rectum are treated by abdominoperineal excision or coloanal anastomosissuture dehiscencemean follow-up:84 months(range=1190 months)T1N0 rectal tumor1%)high-risk patients(ASA 4).Fullthickness excision:379 patients(94.stool incontinence(soiling)ade
31、nomas in the upper third of the rectum are removed by anterior resectionGoal:evaluating morbidity,mortality,and local recurrence rate.situ carcinoma or pT1 rectal tumorcan reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge)Further treatmenttotal colonosc
32、opyPatients and methodsLesion positionPatient preparationlateral wall:88 patientsStool incontinence was treated with physiotherapy and anal sphincter biofeedbackcircumferential:17 patientsLesion positionSpinal anesthesia was used in 65(16.Definitive histologyFurther treatmentFullthickness excision:3
33、79 patients(94.related to size,histological type(villous adenoma),and grade of dysplasiaSpinal anesthesia was used in 65(16.suture dehiscenceT1N0 rectal tumormucinous T2 canceradenomas in the upper third of the rectum are removed by anterior resectionT1N0 rectal tumorPatient preparation1 cm minimum
34、of normal mucosa around the lesionOf the 34 patients with pT1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.Further treatmentsuture dehiscenceresolved within 2 months of the operation0-3 cm:28 patientsPatients and methodsadenomas
35、in the upper third of the rectum are removed by anterior resectionAt follow-up of 24 and 30 months(the patient with rectal stenosis)adenomas in the upper third of the rectum are removed by anterior resectionPatients and methodsAt follow-up of 24 and 30 months(the patient with rectal stenosis)Maligna
36、nt lesion:rectal defect was closed:No patients had a new recurrence at the next follow-upNo patients had a new recurrence at the next follow-upadenomas in the upper third of the rectum are removed by anterior resectionperforation into the peritoneal cavity5 days(range=18 days).suture dehiscencePatie
37、nts and methodsSpinal anesthesia was used in 65(16.Patients and methodsLesion positionperforation into the peritoneal cavityLesion positionlaparoscopic anterior rectal resection with temporary ileostomymean follow-up:84 months(range=1190 months)prone position 3.lateral wall:88 patientsFullthickness
38、excision:379 patients(94.suture dehiscencewashout of the colontotal colonoscopyStool incontinence was treated with physiotherapy and anal sphincter biofeedbackFurther treatmentNo patients had a new recurrence at the next follow-upAt follow-up of 24 and 30 months(the patient with rectal stenosis)shor
39、t-term antibiotic prophylaxisplace the lesion in the inferior part ofthe operative fieldAt follow-up of 24 and 30 months(the patient with rectal stenosis)adenomas in the upper third of the rectum are removed by anterior resection1 cm minimum of normal mucosa around the lesionSpinal anesthesia was us
40、ed in 65(16.Endoscopic polypectomy is not able to remove all large and sessile polyps due to technical problemsLaparoscopic ileostomy and a new suture by TEM.perforation into the peritoneal cavityStool incontinence was treated with physiotherapy and anal sphincter biofeedbackrelated to size,histolog
41、ical type(villous adenoma),and grade of dysplasiaLaparoscopic ileostomy and a new suture by TEM.Patients and methodsAt follow-up of 24 and 30 months(the patient with rectal stenosis)Lesion positionPatient preparationSpinal anesthesia was used in 65(16.1 cm minimum of normal mucosa around the lesionF
42、urther treatmentdigital examination to evaluate tumor fixationDefinitive histologytotal colonoscopyLesion positionSometimes,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%)
