Anatomical, surgical and clinical considerations related with operative procedures performed in combined abdominal and perineal approaches for the treatment of lower rectal cancer / Considerações anatômicas, cirúrgicas e clínicas relacionadas a procedimentos operatórios realizados em abordagens abdominais e perineais combinadas para o tratamento de câncer retal baixo

ABSTRACT Background and aim: Combined abdominal and perineal (anterior or posterior) approaches used in lower rectal cancer surgery have been based on similar anatomical and surgical features. The main aim of this manuscript is to evaluate the results of combined approaches performed for lower rectal cancer and to comment on surgical and anatomical features of the operations. Methods: Anatomical, surgical and clinical details of the combined abdominal and perineal approaches performed for lower rectal cancer were evaluated by reviewing published articles about this subject in English in PubMed, EMBASE, Cochrane library and other sources. Results: Ten articles including case reports were found on combined abdominal and perineal approaches published between 2003 and 2015. There were 83 patients who had been operated by using combined approaches for lower rectal cancer surgical treatment in these series. While the circular resection margine positivity had not been reported in the cases; the mean Wexner continence score had been reported between 5 and 5.5. The most important dissatisfaction of these surgical methods has been reported as persistent perineal fistulas encountered 9.6% of the patients in average in the postoperative period. Conclusion: The APPEAR (Anterior Perineal Plane for Ultra Low Anterior Resection) procedure is the most known surgical procedure in which the combined abdominal and anterior perineal approach is used. Combined abdominal and perineal (anterior or posterior) approaches can be described as surgical procedures in which the sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques are performed.

RESUMO Experiência e objetivo: As abordagens abdominais e perineais (anterior ou posterior) combinadas, utilizadas na cirurgia para o câncer retal baixo, têm se baseado em características anatômicas e cirúrgicas similares. O objetivo principal desse estudo é avaliar os resultados de abordagens combinadas realizadas em pacientes com câncer retal baixo e também comentar as características cirúrgicas e anatômicas das operações. Métodos: Avaliamos os detalhes anatômicos, cirúrgicos e clínicos das abordagens abdominais e perineais combinadas para o câncer retal baixo por meio de uma revisão dos artigos publicados no idioma inglês sobre esse tópico em PubMed, EMBASE, Cochrane Library e outras fontes. Resultados: Encontramos 10 artigos, inclusive relatos de casos, sobre abordagens abdominais e perineais combinadas publicados entre 2003 e 2015. Nessas séries, 83 pacientes no total tinham sido operados com o uso de abordagens combinadas para o tratamento de câncer retal baixo. Embora a positividade para ressecção circular da margem não tenha sido informada nos casos, foi relatado um escore de Wexner para continência que variou de 5-5,5. A insatisfação mais importante relatada com esses métodos cirúrgicos foi a persistência de fístulas perineais, em uma média de 9,6% dos pacientes no período pós-operatório. Conclusão: APPEAR é o procedimento cirúrgico mais conhecido; com seu uso, emprega-se a abordagem abdominal/perineal anterior combinada. As abordagens abdominais e perineais (anterior ou posterior) combinadas podem ser descritas como procedimentos cirúrgicos nos quais são realizadas técnicas de dissecção extra-esfinctérica (com preservação do esfíncter) e de excisão esfinctérica segmentar proximal.

A long-term effect of in situ artificial anal reconstruction using five combined operations / 中华整形外科杂志

Objective@#To explorea long-term effect of in situ artificial anal reconstruction using five-combined-operation technique after lower rectal cancer resection.@*Methods@#After miles operation, 60 patients suffered with lower rectal cancers underwent in situ artificial anal reconstruction using five-combined-operation technique, which included internal and external anal sphincter, rectal flap, rectal angle, and anoperineal reconstruction.@*Results@#All cases in this study were performed successfully, with primary healing in the wounds. Awareness of defecation had reoccurred in all cases since 1 week postoperatively and self-control of defecation had been regained since 3 weeks postoperatively with formed stool excreted once or twice a day. Long-term follow-ups: ①In 95% cases, rectal controlled discharge time was longer than 2 minutes, which was significantly higher than that of sphincter reconstruction group as a control(P<0.05). ② Five-year survival rate reached to 88%, which was significantly higher than that of the control group(P<0.05).@*Conclusions@#Anal reconstruction using five-combined operation method after Miles operation could be a safe and effective surgical procedure, which could completely cure tumor, and improve patients′ life quality and long-term survival rate.

Sphincter-saving extrasphincteric rectal dissection and proximal segmental sphincteric excision techniques by using combined abdominal and transvaginal anterior perineal access in female patients who have lower rectal cancer (Transvaginal low anterior rectal resection) / Técnicas de dissecção retal extra-esfincteriana e de excisão esfincteriana segmentar proximal com preservação de esfíncter com o uso de acesso abdominal e perineal anterior transvaginal combinado em mulheres portadoras de câncer retal baixo (Ressecção anterior do reto baixa por via transvaginal)

ABSTRACT Background: Combined abdominal and transvaginal anterior perineal approaches have been used as an alternative surgical method for the surgical treatment of the lower rectal cancer. The main aim of this paper is to describe the surgical stages of the combined abdominal and transvaginal approaches performed for lower rectal cancer, especially in transvaginal anterior perineal stage. Method: We have performed sphincter-saving surgical operations by using transvaginal anterior perineal access by combining with the abdominal access in four female patients who had lower rectal cancer. Results: Sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques were performed in four female patients operated with combined abdominal and transvaginal anterior perineal approach. All patients were found to have continence. Postoperatively, one patient was converted to abdominoperineal rectal amputation due to the detected distal resection margin positivity. Conclusion: Transvaginal anterior perineal access provides the extrasphincteric rectal dissection possibility in the ischioanal fossa. Therefore, the combined abdominal and transvaginal anterior perineal approaches have been based on the different anatomical and surgical features when compared to intersphincteric dissection technique which is the most common used surgical procedure in lower rectal cancer surgery.

RESUMO Introdução: Uma combinação de abordagens abdominal e perineal anterior transvaginal tem sido empregada como método cirúrgico alternativo para o tratamento cirúrgico do câncer de reto baixo. O principal objetivo do presente artigo é a descrição dos estágios cirúrgicos das abordagens abdominal e transvaginal combinadas realizadas para câncer de reto baixo, especialmente no estágio perineal anterior transvaginal. Método: Realizamos operações cirúrgicas com preservação de esfíncter com o uso do acesso perineal anterior transvaginal, em combinação com o acesso abdominal, em quatro pacientes mulheres portadoras de câncer de reto baixo. Resultados: Realizamos técnicas de dissecção extra-esfincteriana e de excisão esfincteriana segmental proximal com preservação de esfíncter em quatro pacientes operadas com uma combinação de abordagens abdominal e perineal anterior transvaginal. Todas as pacientes estavam continentes. Em uma paciente, houve necessidade de conversão para amputação retal abdominoperineal, por ter sido detectada, no pós-operatório, positividade na margem de ressecção distal. Conclusão: O acesso perineal anterior transvaginal torna possível a dissecção retal extra-esfincteriana na fossa isquioanal. Portanto, as abordagens combinadas abdominal e perineal anterior transvaginal se baseiam em diferentes características anatômicas e cirúrgicas, em comparação com a técnica de dissecção interesfincteriana, que é o procedimento cirúrgico de uso mais comum na cirurgia para câncer de reto baixo.

Effect of behavior-changes-in-stages theory on defecation function of lower rectal cancer after sphincter-preserving operation / 现代临床护理

Objective To study the effect of behavior-changes-in-stages theory on defecation function of lower rectal cancer after sphincter-preserving operation. Methods 84 patients with lower rectal cancer undergoing sphincter-preserving operation from June 2013 to June 2016 were divided into control group (n=42)and intervention group (n=42)according to their willingness to care.The control group implemented routine nursing,mainly for diet intervention,wound care,bowel function training and in the intervention group the behavior-changes-in-stages theory was used.Comparisons were done between the groups in terms of the anus incontinence defecation function and quality of life for 6 months after operation. Result The degrees of anus incontinence and defecation function in the intervention group were both significantly better than those in the control group 6 months after the operation (P<0.05). Conclusions The behavior-change-in-stages plays a significant role in the postoperative rehabilitation.It can significantly reduce the anus incontinence, better the bowel function,improve the quality of life and promote rehabilitation.

Male sexual function after laparosco-pic and laparotomye section in patients with lower rectal cancer / 实用医学杂志

Objective To investigate the effects of laparoscopic and open resection with pelvic autonomic nerve preservation (PANP) on sexual function of male patients with lower rectal cancer. Methods Total 177 male patients with lower rectal cancer received surgery from September 2008 to December 2013 were enrolled into two groups: the laparoscopic PANP group (n = 105) and the open PANP group (n = 72). The classifications of erectile and ejaculatory functions were used to evaluate the sexual functions of patients at 6 months and 12 months post-operation, respectively. The effect of different operation on the sexual function of the male patients was compared between the two groups. Results The incidence rates of erectile dysfunction at 6 months and 12 months post-operation in the laparoscopic group were lower than those in the laparotomy group (P < 0.05). The incidence rates of ejaculatory dysfunction at 6 months and 12 months post-operation in the laparoscopic group were also lower than those in the laparotomy group (P < 0.05). Conclusion The laparoscopic resection with PANP in patients with lower rectal cancer can not only clearly reveal pelvic autonomic nerve and effectively protect them, but also reduce the incidence of postoperative sexual dysfunction.

Long-term results of intersphincteric resection for ultra-low rectal cancer / 国际外科学杂志

Objective To evaluate the long-term therapeutic results of intersphincteric resection (ISR) in the treatment of ultra-low rectal cancer.Methods Sixty cases of ultra-low rectal cancer with the inferior border of the tumor within 5 cm to the edge of anus underwent intersphincteric resection (ISR),and the clinical data were analyzed retrospectively.There were 39 males,21 females and their average age was 55 years old (range from 30 to 77 years old).The inferior border of the tumor were from 28 to 50 mm to the edge of anus,averaging 42 mm.Results Sixty patients underwent intersphincteric resection successfully with 3 cases developing anastomotic leakage and 2 cases anastomotic stenosis postoperatively.After a median follow-up period of 49 months (range from 18 to 90 months),local and distant recurrence were observed in 6 and 4 patients respectively.Five-year overall survival rate and disease-free survival rate were 88.3％ and 83.3％ respectively.The mean stool frequency were (3.8 ± 1.3) times in each day based on data from 53 patients,and the stool control function of 73.6％ of all patients was preserved satisfactorily according to Kirwan classification.Conclusions This study indicated that intersphincteric resection might be a candidate technique in the treatment of early stage ultra-low rectal cancer restricted within rectal wall and could achieve satisfactory long-term results in both oncologic and functional respects.

Clinical comparison of laparoscope versus laparoscopic total mesorectal excision with anal sphincter preservation for =middle-lower rectal cancer / 国际外科学杂志

ObjectiveTo evaluate the feasibility,safety and therapeutic efficiency of laparoscopic total mesorectal excision (TME) with anal sphincter preservation in the treatment of the middle-lower rectal cancer.MethodsFrom February 2008 to June 2010,37 patients with middle-lower rectal cancer received laparoscopic TME with anal sphincter preservation,while 45 patients underwent conventional open TME with anal sphincter preservation according to their wills.The operative procedures,postoperative recovery,postoperative complication and short-term outcome were collected and compared between the two groups.ResultsBlood loss was (60.6 ± 20.9) mL in laparoscope group which was significantly less than that in laparotomy group (P＜0.01),time for bowel movement retrieval and hospital stay were (3.3 ±0.6) and (9.2 ±2.8) days respectively,which were significantly shorter than those in laparotomy group (P ＜ 0.01 ).The incidence of postoperative complications was 8.1％ in laparoscope group,which was significantly lower than those in laparotomy group (P ＜ 0.05 ).The mean distance between resected margin and the tumor,the mean number of disected lymph nodes were not different between the two groups.The rate of sphincter preservation was 91.9％ in laparoscope group,which was higher than those in laparotomy group (73.3％) ( P ＜ 0.05 ).All patients were followed-up from 6 to 36 months,the recurrent rate and overall survival rate were 10.8％ and 94.6％ in laparoscope group,with no significant difference compared to those in laparotomy group (11.1％ and 91.1％,P ＞ 0.05).ConclusionsLaparoscopic TME with anal sphincter preservation which achieved the same effect of oncological clearance is a safe and feasible procedure for middle-lower rectal cancer,with less postoperative complications and better recovery after treatment,and enhances the rate of sphincter preservation,which is worthy of clinical application.

USE OF PEDUNCULATED ILEOCECUM TRANSPOSITION IN ANAL RECONSTRUCTION IN SITU / 中国癌症杂志

PURPOSE To investigate the value of pedunculated ileocecum transporition in allowing patients with cancer of lower rectal and anal canal to defecate normally.METHODS Pedunculated ileocecum transposition in anal reconstruction in situ was done experimentally first on dogs;and later 22 cases of patients with cancer of lower rectal and anal canal under went the technique following the successful animal experiments.RESULTS All patients had satisfactory results.CONCLUSION The method no only had the advantage of radical resection of lower rectel and anal canal,but also retained normal defecation.It was better than the other methods of anal reconstruction in situ.