目的 总结经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)治疗直肠肿瘤的手术经验及技巧.方法 2006年5月～2009年12月,对106例直肠肿瘤行TEM手术,选择适当体位使直肠肿瘤位于TEM器械视野下方,据肿瘤边缘至少0.5～1 cm行全层或黏膜下切除,切除创面缝合关闭,标本取出送病理检查. 结果 101例获得完整切除,1例因上段直肠切穿中转开腹行根治性直肠癌切除术,4例不完整切除.平均手术时间90 min(47～133 min).平均住院时间4.8 d (3～7 d).主要并发症为尿潴留3例,3～5天后恢复自主排尿;术后短期内肛门括约肌功能异常2例,分别于2天、5天恢复;术后便血1例,3天后症状消失.106例平均随访16个月(3～40个月).直肠腺瘤(T0期)77例中3例复发,复发率3.9%,直肠类癌22例中复发1例,复发率4.5%;原位癌3例无复发. 结论 TEM是针对于直肠中上段肿瘤的手术方式,应根据肿瘤位置调整患者正确的体位,切除过程遵循一定的手术步骤,良性肿瘤可行黏膜下切除,怀疑恶性肿瘤建议行全层切除,安全切缘距离应≥1 cm,切除创面缝合关闭.TEM手术慎用于距齿状线10 cm以上的女性直肠前壁肿瘤.%Objective To summarize our experience in transanal endoscopic microsurgery (TEM) for rectal tumors.Methods Between May 2005 and December 2009, TEM was performed on 106 patients with rectal tumor in our hospital. The patients were positioned properly so that the tumor was directly under the surgical field through transanal endoscope. The tumor was removed with 0. 5 to 1.0 cm adjacent tissues by endoscopic mucosal resection or full-thickness excision. Afterwards, the surgical wound was closed with suturing and the removed tumor issues were sent for pathological examination. Results In the patients, the tumor was removed completely in 101 cases. In the other 5 cases, 4 patients received incomplete resection, the other was converted to open surgery because of rectal perforation. The mean operation time was 90 minutes in our cases (47 - 133 minutes). The mean hospital stay was 4.8 d(3 -7 d). The main postoperative complications included urine retention (3 cases, cured spontaneously in 3 to 5 days) , transient dysfunction of the sphincter ani (2 cases, cured spontaneously in 2 and 5 days respectively) , and postoperative hematuresis ( 1 case, cured spontaneously in 3 days). The 106 cases were followed up for 16 months (3 to 40 months), during which we detected recurrence in 3 of the 77 patients (3.9％) with rectal adenoma ( stage T0 ), and 1 of the 22 cases (4.5％) who had rectal carcinoid. The three patients who had in situ carcinoma showed no recurrence during follow-up. Conclusions TEM is a choice for patients with tumors in the middle or lower rectum. Surgical position shall be determined by the site of the tumor. A certain surgical procedure is requested during the operation: submucosal resection is suggested for benign tumors, while full-thickness resection is for suspicious malignant tumors. A ≥ 1 cm margin for resection is a must for safety, and the surgical wound shall be closed by suturing.For female patients with rectal tumors located at the anterior wall 10 cm above the dentate line, TEM is not the first choice.
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