摘要
经肛门内镜显微手术（TEM）是目前已知的唯一一套利用人体的自然开口通过腔内途径直达目标器官进行操作的单孔内镜外科系统，其在结直肠外科的应用已超过30年。相对根治性手术而言，TEM具有手术恢复快、住院时间短以及更少并发症的优势。完善的TEM手术系统是规范开展TEM的基础，其主要由特殊的手术用直肠镜、专用手术器械和显像系统三部分组成。准确的术前评估和分期是TEM技术治疗能获得良好疗效的关键，除了直肠指检，应常规行硬性乙状结肠镜（或直肠镜）检查，明确并以钟点形式记录直肠病变的位置，性质待定者取活检明确诊断；对于直肠肿瘤患者，在常规行直肠腔内超声检查（ERUS）基础上，可选择结合盆腔MRI检查。腔内缝合是规范开展TEM的难点所在，尤其是缝合较大肠壁缺损的时候，需要专业的培训才能熟练掌握缝合技术。2016年中国抗癌协会大肠癌专业委员会TEM学组探讨制定了TEM技术专家共识，推荐的TEM手术适应证包括：（1）直肠腺瘤；（2）良好组织病理学特征的早期直肠癌；（3）经结肠镜切除局部恶变息肉的扩大切除；（4）适合局部切除的其他直肠肿瘤；（5）直肠的良性狭窄或吻合口狭窄；（6）直肠低位前切除术后吻合口瘘的修补术；（7）直肠出血的诊断；（8）直肠及周围病变的活组织检查；（9）直肠阴道瘘或肛瘘内口的黏膜瓣易位修补；（10）直肠异物的处理。随着TEM技术的成熟，TEM适应证范围不断拓展，可应用于直肠神经内分泌肿瘤和胃肠间质瘤的切除、直肠阴道瘘的修补，甚至可作为经肛全直肠系膜切除术（taTME）＂自下而上＂的操作平台。本文重点介绍了如何规范开展TEM、其目前的适应证以及新的含义和未来的展望，以期TEM在我国得以进一步普及和更加健康地发展。
Transanal endoscopic microsurgery （TEM） is currently the only one-port system in endoscopic surgery, which a direct endoluminal approach can lead to the target organ through a natural opening of human body. TEM has been applied in colorectal surgery for over 3 decades. Compared with radical surgery, TEM has the advantages, such as quicker recovery, shorter hospital stay and fewer complications. One perfect TEM surgical system, which mainly consists of three parts, namely peculiar rectoscope for surgery, special surgical instruments and imaging system, is the foundation of standardized development of TEM. Accurate preoperative evaluation and staging is the key for good outcomes in TEM technology. In addition to digital examination of rectum, rigid sigmoidoscopy （or rectoscopy） should be routinely performed to confirm the location of the lesion and record it in a＂time-in-clock＂form. For lesions with undetermined nature, biopsy should be performed. For patients with rectal tumor, pelvic MRI examination can be used on the basis of routine endorectal ultrasonography （ERUS） . Endoluminal suture is the challenge for standardized development of TEM, especially for those with large intestinal wall defects. Professional training is required to master suture technique. In 2016, the consensus of experts on TEM technology was formulated by TEM Study Group of Colorectal Cancer Specialty Committee of Chinese Anticancer Association. The recommended surgical indications for TEM include （1） rectal adenoma; （2） early rectal cancer with good histopathological features; （3） extended resection of locally malignant polyps by colonoscopy; （4） other rectal tumors suitable for local resection; （5） benign stricture or anastomotic stricture of the rectum; （6） repair of anastomotic leakage after low anterior resection of rectum; （7） diagnosis of rectal hemorrhage; （8） biopsy of rectum and surrounding lesions; （9） repair of rectovaginal fistula or mucosal flap transposition of the internal m
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2017年第8期852-856,共5页
Chinese Journal of Gastrointestinal Surgery
基金
北京市科技重大专项基金（D171100002617003）
关键词
直肠肿瘤
经肛门内镜显微手术
规范化
适应证
Rectal neoplasms
Transanal endoscopic microsurgery
Standardization
Indication
