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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
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►Содержание►
FIGURE13-12Deloyer’sprocedure.Theright
colonandhepaticaremobilizedandallmesenteryis dividedexcepttheileocolicpedicle.Thecolonis rotatedcounterclockwise180degreesandaright colonanastomosisisperformedtotherectum/anus.
Ifthesemaneuversareunsuccessful,acecal–rectal/analanastomosis maybeperformedor,alternatively,atotalcolectomywithileorectal anastomosiscanbeused.Ifallelsefailsforananalanastomosis,anileal­pouchanalanastomosisoranendileostomymaybeemployed.
FecalDiversion
Diversionofthefecalstreamshouldbestronglyconsideredforall patientsundergoingTMEforrectalcancerinthemidandlowrectum. Thiscaveatisespeciallytrueforthosepatientswhoreceivedneoadjuvant radiotherapytothepelvisandthosewhosecolorectalanastomosisis<7 cmfromtheanalverge.Itisroutinepracticeatourinstitutiontostrongly considerconstructionofaloopileostomyinthesesituations.Afterusing
thisapproachforseveraldecades,wefeelthatfecaldiversionhas substantiallymitigatedthedeleteriousandpossiblelethaleffectsofpelvic sepsisduetoananastomoticdehiscenceandhasdecreasedreoperative rates.Althoughatemporaryloopileostomycanleadtosignificant problemssuchasdehydrationfromhighoutput,thesepticconsequences ofaleakcanbelethal,particularlyinfrail,elderlypatients.Therefore, evenifapatientrequiresantidiarrhealmedicationorevenintravenous fluidwhilethetemporarystomaisinplace,thesetemporaryunwanted issuesmaybepreferabletotheconsequencesofaleak.
POSTOPERATIVEMANAGEMENT
Patientsareplacedonanenhancedrecoveryprogramforbothopenand laparoscopiccases.Antibioticsarenotcontinuedfor24hoursafter surgeryandpatientsareallowedclearliquidsthefirstdayaftersurgery. Ambulationthenightofsurgeryisencouraged.Patient-controlled analgesiaisinstitutedfor1–2dayspostoperatively.Softdietandoral analgesiaareadvancedastoleratedandFoleycathetersareusually removedonpostoperativeday2(dependingontheamountofpelvic dissection).Patientsreceiveenterostomalteachingandcareearlyafter surgeryandostomyrodsareremovedafter2–3days.

COMPLICATIONS

Complicationsaresimilartothoseobservedinotherabdominopelvic operationsandincludebleeding,infectious(superficialanddeeporgan space),bladder/sexualdysfunctionfromnervedamage,prolongedileus, andearlyandlatecomplicationsofanastomoticleak.
AnastomoticleakratesarehigherwiththeadoptionofTMEinlow colorectalandespeciallycoloanalanastomoses;leakratesinthese patientscanreach20%insomeseries.Theseratesareinfluencedbythe heightoftheanastomosis,technicalfactors(tension,bloodsupply),and patientfactors(radiationexposure,obesity,malesex, immunosuppression,andothercomorbiddiseases).Aspreviously mentioned,therationaluseoffecaldiversionhasbeenshowntodecrease theneedforreoperationandhelpsmitigatethedeleteriouseffectsofthe leak.
Sexualanderectiledysfunctionisawell-recognizedriskinpatients undergoingLARwithTME.Intraoperativeinjurytothesympathetic and/orparasympatheticnervesmaycauseawidearrayofsymptoms. SympatheticdenervationaroundtheIMA/aortaandpelvicbrimmay causeretrogradeejaculation;and,additionally,injurytothe parasympatheticplexianteriolaterallyneartheseminalvesiclesand anteriortoDenonvilliers’fasciamayresultintemporaryorpermanent impotenceinsomepatients.Bladderdysfunctionvariesandisreportedin up15%ofpatientsundergoingLARwithTME.Mostdysfunctionisthe formoftemporaryurinaryretentionduetotheparasympatheticnerve injury.Permanentdysfunctionmandatingself-catheterizationmayoccur inupto5%ofpatients.

RESULTS

TheuseofTME(andneoadjuvantchemoradiotherapyregimenin selectedpatients)hasbeenshowntobothsubstantiallydecreaselocal recurrenceratesandincreasedisease-freesurvivalandoverallsurvival whencomparedtoconventionalsurgery.Moststudiesreportanaverage of10%localrecurrencerateat5yearsandoverall5-yearsurvivalrates (stagedependent)ofabout70–85%forlocallyadvancedrectalcancer.
Withincreasedlocalcontrolandsurvival,comesapricetopayinthe wayofLARsyndrome.LARsyndromeconsistingoffecalurgency, frequency,clustering,andfecalincontinencemayoccurafterTME,in part,duetoalossofrectalreservoir.LARsyndromeoccursinatleast10– 15%ofpatientsafterTMEwithsphincterpreservation.Analsphincter damageandphysiologicalchangesfromradiotherapymayalsoinfluence thesedebilitatingsymptoms.Outcomesofvariousneorectumreservoir constructiontechniquesarediscussedinsubsequentchapters.
LARwithTMEintheopenapproachisthegoldstandardsphincter­preservingtechniqueformidandlowrectalcancerpatients.Avarietyof surgicalapproachesexistforperformingaLAR,includinglaparoscopic, robotic,andhybridprocedures.Recentstudieshavedocumentednoclear advantage(andinferiority)oflaparoscopicTMEversusopenTME.Long­termoncologicdataisstillpending,but,nonetheless,everycolorectal surgeonandtraineemustbecomfortableandfacileattheopen technique,becausethisisthefoundationforrectalcancersurgery.

CONCLUSIONS

Acombinationoffactors,includingbetterunderstandingofthedisease process,moreaccurateradiologicstaging,multimodalitytherapeutic intervention,refinedsurgicaltechniquewithTME,andmoredetailed histopathologicreporting,haveallcontributedtoimprovementsinthe managementandsurvivalofpatientswithrectalcancer.LARwith sphincter-sparingproctectomycanbeaccomplishedforthemajorityof mid-to-lowrectalcancerwithavarietyofanastomotictechniques.Proper dissectionalongtheanatomicalplanesensurescompleteremovalof lymph-bearingtissueinthemesorectumandpreservationofvitalnerves forsexualandbladderfunction.
RECOMMENDEDREFERENCESAND READINGS
BrownCJ,FenechDS,McLeodRS.Reconstructivetechniquesafterrectalresectionforrectal
cancer.CochraneDatabaseSystRev2008;(2):CD006040. deCampos-LobatoLF,GeislerDP,daLuzMoreiraA,StocchiL,DietzD,KaladyMF.Neoadjuvant
therapyforrectalcancer:theimpactoflongerintervalbetweenchemoradiationandsurgery.J
GastrointestSurg2011;15(3):444–50. DelaneyCP,ZutshiM,SenagoreAJ,RemziFH,HammelJ,FazioVW.Prospective,randomized,
controlledtrialbetweenapathwayofcontrolledrehabilitationwithearlyambulationanddiet
andtraditionalpostoperativecareafterlaparotomyandintestinalresection.DisColonRectum
2003;46(7):851–9.
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FazioVW,ZutshiM,RemziFH,etal.Arandomizedmulticentertrialtocomparelong-term
functionaloutcome,qualityoflife,andcomplicationsofsurgicalproceduresforlowrectal
cancers.AnnSurg2007;246:481–8. MonsonJR,WeiserMR,BuieWD,etal;StandardsPracticeTaskForceoftheAmericanSocietyof
ColonandRectalSurgeons.Practiceparametersforthemanagementofrectalcancer(revised).
DisColonRectum2013;56(5):535–50. NesbakkenA,NygaardK,Bull-NjaaT,CarlsenE,EriLM.Bladderandsexualdysfunctionafter
mesorectalexcisionforrectalcancer.BrJSurg2000;87(2):206–10. PokalaN,DelaneyCP,KiranRP,BastJ,AngermeierK,FazioVW.Arandomizedcontrolledtrial
comparingsimultaneousintra-operativevssequentialprophylacticuretericcatheterinsertion
inre-operativeandcomplicatedcolorectalsurgery.IntJColorectalDis2007;22(6):683–7. TanWS,TangCL,ShiL,EuKW.Meta-analysisofdefunctioningstomasinlowanteriorresection
forrectalcancer.BrJSurg2009;96:462–72. vandeVeldeCJ,BoelensPG,BorrasJM,etal.EURECCAcolorectal:multidisciplinary
management:Europeanconsensusconferencecolon&rectum.EurJCancer2014;50(1):1.e1–
1.e34.
WexnerSD,BerhoME.Therationaleforandrealityofthenewnationalaccreditationprogramfor
rectalcancer.DisColonRectum2017;60(6):595–602. WibeA,SyseA,AndersenE,etal.Oncologicaloutcomesaftertotalmesorectalexcisionforcure
forcancerofthelowerrectum:anteriorvs.abdominoperinealresection.DisColonRectum
2004;47(1):48–58.
Chapter14
LaparoscopicLowAnterior Resection
JohnMigalyandHarveyG.Moore

INDICATIONS/CONTRAINDICATIONS

Theindicationsforalaparoscopiclowanteriorresection(LAR)are primarilyformiddletolowtumorsoftherectum.Middlerectaltumors aredefinedastumorsbetween5and10cmfromtheanalvergeanddistal tumorsarethosetumors5cmorlessfromtheanalverge.
AbsolutecontraindicationsforalaparoscopicLARincludesystemic sepsis,unstablehemodynamics,andfeculentperitonitis.
ThedecisiontoproceedwithalaparoscopicapproachtoLARis dependentonmanyfactorsthataresurgeonspecificandshouldguidethe choiceofoperativeapproach.First,thesurgeonshouldbeanexpertin theconceptandperformanceofatotalmesorectalexcision(TME), becausetheconductandqualityoftheTMEisoneofthemoreimportant determinantsofoncologicoutcome.Second,thesurgeonshouldbean expertinadvancedlaparoscopyforcolonresection,becausethe laparoscopicLARisoneofthemorechallengingresectionsincolonand rectalsurgery.
Contingentonexperience,amultidisciplinaryapproachshouldbe stronglyconsideredforpatientsinwhomthetumorisfelttoinvolve contiguousorganssuchasthevagina,uterus,bladder,andprostate,and inbulkytumorsorintumorsthatthreatenthelateralresectionmargin.
Alsocontingentonexpertise,potentialrelativecontraindicationstoa laparoscopicLARincludemorbidobesity,cirrhosis,coagulopathy,severe cardiacorpulmonarydisease,intra-abdominalabscess,orphlegmon. PriorsurgeryisnotacontraindicationforlaparoscopicLAR,and,when possible,adiagnosticlaparoscopyshouldbeperformedtoevaluatethe extentofintra-abdominaladhesionsandfeasibilityofalaparoscopic approach,includingtheanticipatedtimecommitmentrequiredforthe
adhesiolysis.
PREOPERATIVEPLANNING
Theessentialprinciplesinvolvedinthepreoperativeplanningofa laparoscopicLARbeginatthefirstvisit.Completehistoryandphysical examinationarethemainstaysofanyevaluation,but,moreimportantly, theprecisecharacterizationofthetumorduringdigitalrectal examinationanddirectvisualizationduringproctoscopyandmagnetic resonanceimaging(MRI)arenecessities.Digitalrectalexamination identifiestumorlocationandallowsthesurgeontoevaluatesphincter toneandfunction.Therearenodatatosupporttheroutineuseofanal manometrytopreoperativelyevaluatethesphincter;thus,functionand analmanometryisnotanymoreusefulthanisphysicalexamination. Proctoscopyisusefulincharacterizingthelocationofthetumorin relationtotheupperportionoftheanorectalringandallowsthesurgeon tojudgewhetherreconstructionispossible.Inaddition,theevaluationof theTandNstageallowfortheadditionofpreoperativemultimodality neoadjuvanttherapywhereappropriate.Currentrecommendations advocatetheuseofneoadjuvantchemoradiotherapyforT3tumorswith threatenedmarginsorT4tumors.
Acompletebloodcount,chemistryassessment,liverfunctiontests,and carcinoembryonicantigenareroutinelycollected.Computedtomography (CT)withcontrastofthechest,abdomen,andpelviscompletethe metastaticevaluation,possiblywithaprotonemissiontomography(PET) scan.Patientsshouldmeetwiththeostomynurseinadvanceofsurgery, tobetterprepareforandacclimatetotheideaofatemporarydiverting loopileostomy(DLI)orpossiblyapermanentcolostomy.Patientsare markedforastomainadvanceofsurgery.Internalmedicineevaluationis scheduledbeforesurgery,withpulmonary,cardiac,renal,oranesthesia assessmentincluded,asnecessary.
p.103
p.104
Weroutinelyuseacathartic/purgativepreoperativebowelpreparation forsurgeryinadditiontooralneomycinanderythromycin.Current population-basedliteraturedemonstratesthattheadditionof preoperativeoralantibioticsreducestherateofsurgicalsiteinfection (SSI)andreadmission.
Patientsaregivenacarbohydratedrinkimmediatelybeforesurgery andasingledoseofintravenous(IV)ertapenembeforetheincisionis made.Heparin5,000Uissubcutaneouslyadministeredimmediately beforeintubation.
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