经肛内镜显微外科手术TEM医学医药PPT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place the lesion in the inferior part ofthe operative field13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vaginaevery 6 m

6、onths for the first year and then annually(flexible endoscopy with biopsies of the scar)rectovaginal fistulashort-term antibiotic prophylaxisNo patients had a new recurrence at the next follow-upFurther treatmentmucinous T2 cancerrelated to size,histological type(villous adenoma),and grade of dyspla

7、siaStool incontinence was treated with physiotherapy and anal sphincter biofeedbackplace the lesion in the inferior part ofthe operative fieldPatient preparationOne of the two patients had a rectal stenosis 16 cm:11 patientscircumferential:17 patientsrectal defect was closed:Fullthickness excision:3

8、79 patients(94.pelvic abscess,Infectionstool incontinence(soiling)adenomas in the upper third of the rectum are removed by anterior resection 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:

9、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 silver clip placed at each end of the suture to avoid an intrarectal node.北京世纪

10、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 临床类模板short-term results:Minimal intraoperative complications:13 cases an o

11、pening 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):impossible to carry out a complete suture.temporary ileostomy closed after

12、 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 histologyNFurther treatmentadenomas366(91%).NOsitu carcinoma or pT1 rectal t

13、umor34(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 rectal exploration,andrigid rectoscopyevery 6 months f

14、or 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 parenteral nutrition.Stool incontinence was treated with physiotherapy an

15、d 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lateral wall:88 patientsFurther treatmentcan reach further into the rectum than other forms of lo

16、cal excision(up to 20 cm from the anal verge)Fullthickness excision:379 patients(94.Minimal intraoperative complications:circumferential:17 patients3-6 cm:58 patientsBenign lesion:computed tomography(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesionsPreoperative therapy stagingcl

17、inical examination,digital rectal exploration,andrigid rectoscopypresent experience with rectal adenomas managed by transanal endoscopic microsurgery(TEM).Goal:evaluating morbidity,mortality,and local recurrence rate.Further treatmentAll leaking sutures resolved by local therapy(antibiotics and anal

18、gesic enema)and/or parenteral nutrition.endoluminal running suture with a silver clip placed at each end of the suture to avoid an intrarectal node.One of the two patients had a rectal stenosislateral positioncomputed tomography(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesionsl

19、ateral positionanterior wall of the rectum:92 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

20、had 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

21、to 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

22、 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%)

23、北京世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)r

24、ectovaginal fistula北京世纪坛医院多媒体网络室 2007 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drink liquids on the first postoperative dayGoal:evaluating morbidity,mortality,and local recurrence rate.All leaking sutures re

25、solved by local therapy(antibiotics and analgesic enema)and/or parenteral nutrition.Patients and methodsposterior wall:107 patientsSpinal anesthesia was used in 65(16.Benign lesion:Goal:evaluating morbidity,mortality,and local recurrence rate.Endoscopic polypectomy is not able to remove all large an

26、d sessile polyps due to technical problemscan reach further into the rectum than other forms of local excision(up to 20 cm from the anal verge)prone position 3.mucinous T2 cancermucinous T2 cancerPreoperative therapy staging(patient is alive after 2 years without other complications)computed tomogra

27、phy(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesionsMalignant lesion:distance of adenomas from the anal vergesitu carcinoma or pT1 rectal tumorStool incontinence was treated with physiotherapy and anal sphincter biofeedback6-12 cm:251 patientsMucosectomy:23 patients(5.drink liq

28、uids on the first postoperative dayMean operative time was 64 min(range=22120).Further treatmentdistance of adenomas from the anal verge13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vaginaMean hospital stay was 2.Laparoscopic ileostomy and a new suture by

29、TEM.Men:221 vs Women:181All lesions were closed endoscopically by TEM without any intra-or postoperative consequences.Goal:evaluating morbidity,mortality,and local recurrence rate.Malignant lesion:short-term results:adenomas in the upper third of the rectum are removed by anterior resectiondrink liq

30、uids on the first postoperative dayrectal defect was closed:mean follow-up:84 months(range=1190 months)Preoperative therapy stagingonly 15 patients(3.short-term antibiotic prophylaxisrelated to size,histological type(villous adenoma),and grade of dysplasiaFullthickness excision:379 patients(94.3%)1

31、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 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

32、 2007 临床类模板Postoperative follow-up mean follow-up:84 months(range=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All leakin

33、g sutures resolved by local 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 transfusi

34、ons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 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no other complications were observed.No patients ha

35、d a new recurrence at the next follow-uprelated to size,histological type(villous adenoma),and grade of dysplasiaPatients and methodsrectovaginal fistulaThe patients with hemorrhaging,two of them with cirrhosis,required blood transfusionsMinimal intraoperative complications:Of the 34 patients with p

36、T1 rectal cancer,the mean follow-up of 30 months(range=1470 months)revealed no local recurrences or distant metastases.adenomas in the upper third of the rectum are removed by anterior resectionshort-term antibiotic prophylaxisStool incontinence was treated with physiotherapy and anal sphincter biof

37、eedbackBenign lesion:Patients and methodsadenomas in the upper third of the rectum are removed by anterior resection 16 cm:11 patientsadenomas in the upper third of the rectum are removed by anterior resectionanterior wall of the rectum:92 patientslateral wall:88 patientsNo patients had a new recurr

38、ence at the next follow-upclinical examination,digital rectal exploration,andrigid rectoscopysemicircumferential:98 patientsFullthickness excision:379 patients(94.lateral wall:88 patientsmean follow-up:84 months(range=1190 months)Fullthickness excision:379 patients(94.Mean operative time was 64 min(

39、range=22120).temporary ileostomy closed after 2 monthsrelated to size,histological type(villous adenoma),and grade of dysplasiacomputed tomography(CT)scan or magnetic resonance imaging(MRI):giant and suspected lesions13 cases an opening of the peritoneal cavity and in 1 patient there was an opening

40、of the vaginaendoluminal running suture with a silver clip placed at each end of the suture to avoid an intrarectal node.One of the two patients had a rectal stenosisStool incontinence was treated with physiotherapy and anal sphincter biofeedbackresolved within 2 months of the operationMean age:65 y

41、ears(range22-92)every 6 months for the first year and then annually(flexible endoscopy with biopsies of the scar)No patients had 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

42、metastases.13 cases an opening of the peritoneal cavity and in 1 patient there was an opening of the vaginaOne of the two patients had a rectal stenosissemicircumferential:98 patientsanterior wall of the rectum:92 patientsBenign lesion: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%)