TaTME直肠癌手术的新突破.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,TaTME直肠癌手术的新突破,腹腔镜,TME,手术的肿瘤根治效果（腹腔镜手术,3,年局部复发率、无病存活率、总存活率）与开放手术相似。,Bonjer HJ,Deijen CL,Abis GA.A randomized trial of laparoscopic laparoscopicvesus open surgery for rectal cancer,J,.N Engl J Med,2015,372(14):1324-1332.,直肠肿瘤的手术方式,Current status of transanal total mesorectal excision(TaTME)following the Second International Consensus Conference published in Colorectal Disease think,:,The challenge of operating in the deep pelvis is confirmed by results of a recent randomized controlled trial showing a 10%positive circumferential radial margin rate in laparoscopic and open TME and in particular a concerning 22%positive circumferential radial margin rate in the lower rectum in the open arm of the trial 1.Furthermore,the need for multiple firings of linear stapling devices in low rectal division has been associated with an increase in the surgical morbidity of the procedure 2.,1 van der Pas MHGM,Haglind E,Cuesta MA,Furst A,Lacy,AM,Hop WCJ.Bonjer HJ Laparoscopic versus open surgery,for rectal cancer(COLOR II):short-term outcomes of a randomised,phase 3 trial.Lancet Oncol 2013;14:2108.,2 Ito M,Sugito M,Kobayashi A,Nishizawa Y,Tsunoda Y,Saito N.Relationship between multiple numbers of stapler,firings during rectal division and anastomotic leakage after,laparoscopic rectal resection.Int J Colorectal Dis 2008;23:,7037.,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,TaTME,Tatme,适应证,Trans-anal total mesorectal excision(TaTME)following the Second International Consensus Conference,：,Rectal cancer include:(i)male gender(ii)rectal cancer less,than 12 cm from the anal verge,including very low,cancers,(iii)narrow and/or deep pelvis,(iv)visceral obesity and/or obesity with body mass index,(BMI)30 kg/m2,(v)prostatic hypertrophy,(vi)tumour diameter 4 cm,(vii)distorted tissue planes,due to neoadjuvant radiotherapy,and(viii)impalpable,low primary tumour requiring accurate placement,of the distal resection margin.,直肠癌经肛门全直肠系膜切除术专家意见,1,a,M,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,2a,M,实施初期建议选择适当病例，如术前分期小于或等于,3,期、肿瘤体积不宜过大的中低位直肠癌患者。,3,临床开展,a,M,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,a,M,手术需进行必要的术前评估，如：,M,I,、超声等，并经,M,讨论。,5,根据各个中心的操作经验，,a,M,手术可以采用,M,或,M,平台进行。,6,完全,a,M,可行，但是技术难度相对较大，学习曲线较长；腹腔镜辅助的,a,M,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,a,M,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,a,M,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,a,M,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。,TaTME,操作平台,经肛门微创手术（,M,）平台商品化的经肛门单孔通道和经肛门内镜显微手术（,M,）平台的直肠镜,注：（,a,）；（）；（）；（）,M,平台的直肠镜,TEM,与,TAMIS,平台的比较,经肛门全直肠系膜切除手术（,a,M,）时，经肛门微创手术（,M,）平台与经肛门内镜显微手术（,M,）平台相比，操作角度大,23,7,TaTME,手术步骤,TATME,与腹腔镜辅助,TME,比较,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,Heald,认为,tatme,的最大优势之一是解决了既往,TME,术中对中下段直肠系膜周围间隙暴露不佳而造成的盆腔神经副损伤。,Heald RJ.A new solution to some old problems:transanal TME,J,.Tech Coloproctol,，,2013,，,17(3):257-258.,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）,Transanal TATA/TME:a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer,Table1 Patient demographics,Transanal TATA/TME:a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer,Transanal TATA/TME:a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer,Conclusions,：,We demonstrated no differences in perioperative/postoperative outcomes or pathologic TME outcomes of transanal or bottoms-up TME compared to standard laparoscopic TME.TaTME is a promising progressive approach to NOTES and deserves additional evaluation.,Transanal total mesorectal excision:surgical technique description andoutcomes,Conclusions,：,Transanal total mesorectal excision has emerged as a safe and effective technique in the treatment of rectal cancer.Short-term results appear promising but longterm follow-up is still needed to confirm these early oncologic outcomes.,