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Ростовский Государственный Медицинский Университет
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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►
earlier,ifastapledanastomosisistobeperformed,theanvilshouldbe placedandsecuredbeforeclosureofthecolotomy.
FIGURE15-13Coloplasty:Alongitudinal
colotomyapproximately8–10cminlengthstarting4–6 cmfromthedistalcolonresectionmarginisclosed withasinglelayerofpolyglycolicacidsuturesinan interruptedmanner.
Ifthesideofthecolonreachesmoredistallyintothepelvis,aside-to­end(Baker)anastomosiscanbecreated(Fig.15-14).Thismaneuver preservesbloodsupplytotheanastomosis.Ifastapledanastomosisis used,theanvilcanbeplacedthroughthedistalresectionmargin,and spikeextrudedapproximately4–5cmproximaltothetransectionmargin ontheantimesentericborder.Theanvilissecuredwitha2-0polyglactin suture,andthedistaltransectionmarginisstapledoff.Ifahand-sewn anastomosisisused,markingsuturesmaybeplacedonthe antimesentericborderapproximately4–5cmproximaltothestapleline tohelpguidethissegmentintotheanalcanalandidentifythe appropriatesiteforcolotomy.
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FIGURE15-14Bakeranastomosis:Acolotomyis
createdapproximately3–5cmfromtheendofthe colonconduit.Ifastapledanastomosisistobe performed,theanvilwillbeplacedbeforeclosureof thedistalendofthecolon.Theanastomosisismade fromtheantimesentericsideofthecolontotheanus.
Anastomosis
Afterextracorporealabdominalpreparationoftheproximalcolonic segment,thecolonisreturnedtotheabdomen.Pneumoperitoneumis reestablishedbyclosingthespecimenextractionsiteoroccludingitby twistingthewoundprotectoronitselfandplacingalargeKellyclampto occludethehole.Amoistspongemaybewrappedaroundthewound protectortopreventleakageofgas.Thepatientisagainpositionedin Trendelenburgandtheoperativefieldischeckedforhemostasis.Proper mesentericalignmentisensuredbyidentifyingthemedialcutedgeofthe mesenteryneartheligamentofTreitzandfollowingitdistallyasa straightline.Thesmallbowelshouldbesweptmediallyandoutfrom behindthecolon.Thecolonisguidedintothepelvisandtheoperatorat thepelvismayassistbyplacingaringforcepsorBabcockthroughthe anusintothepelvistodeliverthecolonintotheanalcanal.Itisessential
toavoidtwistingduringthefinalpullthroughtheanalcanal.
ThecolotomyintheapexoftheJ-pouchisreopened(ifitwasclosed) ortheFoleyballoonispartiallydeflated.Thepreviouslyplacedtransanal anastomoticsuturesarebroughtthroughtheoutermuscularisofthe colonintothelumenandtiedintraluminally.Ifanend-to-endor coloplastyconfigurationwasused,theproximalsegmentwillstillhavea staplelineinplace.Caremustbetakentoensuretheorientationinan anterior-to-posteriordirectionatthetimeofspecimenremoval.Inthis case,thestaplelineispartiallyamputatedbeginninganteriorly,allowing theanteriorsuturestobesecuredbeforecompletelyremovingthestaple lineandfinishingtheanastomosis.
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Ifastapledanastomosisisused,theanvilshouldbeplacedbefore closureoftheproximalbowel.Therectumwillhavebeenstapled,just proximaltotheanalcanal.Becausethestaplelineissoclosetotheanus, extremecaremustbetakenwhenplacingthecircularstaplertoprevent distalstumpdisruptionandsphincterdamage.Digitalsphincter dilatationhelpspreventsphincterdamageduringstaplerintroduction andsphincterincorporationintotheanastomosis.Specifically,afterthe staplerisgentlypassedthroughthesphinctermusclesonemustensure thatthecircularringisfreeoftheanalcanal.Afteraclearindentationof theringofthestaplerislaparoscopicallyconfirmed,thestaplertrocaris extended.Dependingontheproximityofthevagina,andindentation, thistrocarspikemaybeplacedanterior,posterior,orthroughthelinear stapleline.Somesurgeonspreferposteriorextrusiontomovethe anastomosisawayfromthevagina,topreventthepossibilityof fistulizationwithanexposedvaginalcuff.
Theanvilisthenguidedintothepelvis.Asdiscussedbefore,the orientationshouldbecheckedtopreventtwistingaroundtheaxisofthe mesentery.Ifaside-to-endanastomosisisused,thesidestaplershould beguidedtothepatient’sright,awayfromtheanastomosis.Theanvilis laparoscopicallyreplacedoverthereceptacletrocarandthestapleris closedandfired.Thesurgeonshouldensurethatthereisadequatelength tocreateatension-freeanastomosis.Again,Indocyaninegreen fluorescenceimagingcanbeusedtoconfirmproximalanddistal perfusionassessment.
Ahydropneumaticleaktestisthenperformedtochecktheanastomosis afterthepelvisisfilledwithsaline.Theauthorsandeditorsprefera flexiblesigmoidoscopeorrigidproctoscopetovisualizethemucosaand thestaple/sutureline,andairleak;anyischemia,bleeding,orleakshould beaddressed.Alternatively,ahand-sewndistalpursestringsutureora
hand-sewnanastomosiscanbeperformedfromtheperinealfield.
DivertingLoopIleostomy
Foranastomosisbelow5cmfromtheanalverge,andforallpatientswho receivedpreoperativeradiation,theauthorstypicallyplaceadiverting ileostomytominimizecomplicationsofanastomoticleakthatmayoccur. Theileumislaparoscopicallyevaluatedproximallyfromtheileocecal valveandtoverifytension-freereachtotheanteriorabdominalwall. Ideally,theileostomyiscreatedatleast15and20cmproximaltothe ileocecalvalve.Proximalanddistalorientationischeckedtoensure maturationoftheileum.
Atrocarsiteontherightsideistypicallythepremarkedileostomysite. Theskinincisionisenlargedtoallowtwofingerstoreachintothe abdomen.Generally,thesubcutaneousandanteriorfasciaaresharply dissectedusingelectrocautery.Themusclewillbespreadusingtwolarge Kellyclampsatrightangles,andtheposteriorsheathisopened.Care mustbetakentoensuretheinferiorepigastricvesselsarenotinjured duringdissection.Theileostomyisliftedlaparoscopicallytotheanterior abdominalwallandpulledthroughtheabdominalwallusingaBabcock clamp.Asupportingrodisplacedundertheileumtopreventslippageof theposteriorilealwallintotheabdomenallowingforpassageoffecal streambeforematuration.TheostomyismaturedinaBrookemanner afterclosureofallportandspecimenextractionsites.Theauthorsusea Jackson-Pratt(CardinalHealth,Dublin,Ohio)drainselectivelyincases belowtheperitonealreflection.
POSTOPERATIVEMANAGEMENT
Patientsareplacedonstandardpostoperativeacceleratedrecovery programaftersurgery.Softfoodsandoralanalgesiaarestartedon postoperativeday1,andpatientsareencouragedtoambulateon postoperativeday0or1.TheFoleycatheteristypicallyremovedat48 hoursforalowpelvicanastomosis.Patientsshouldundergo postoperativeenterostomalteachingforcareofostomy,andostomybars areremovedafterapproximately2–3daysinmostpatients.

COMPLICATIONS

Complicationsaresimilartothoseofotherabdominalsurgeriesand includebleeding,infection,andpostoperativeileus.Inaddition,LAR withcoloanalanastomosisincreasesrisksofanastomoticleakandsexual andbladderdysfunctionwhencomparedtoothercolonsurgeries.
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Anastomoticleakratesforanastomosesbelow5cmfromtheanalverge areupto18%.Historyofradiation,lowanastomosis, immunosuppression,andtechnicaldifficultyhasbeenassociatedwith increasedanastomoticleakrates.Creationofadivertingileostomyhelps lessentheseverityofthecomplicationsofleak,butdoesnotdecreasethe anastomoticleakrate.Postoperativemorbidityratesarecomparable betweendivertedandnotdivertedpatients,butreoperativeratesare lowerwhenanileostomywascreated.Ingeneral,theauthorsemploythe useofadivertingileostomyforpatientswithlowrectalcancer.However, patientswithileostomieshavemorbidityassociatedwithasecond hospitalizationandoperativeintervention;asmallpercentageofpatients mayneverundergoileostomyclosure.
Sexualanderectiledysfunctionisincreasedinpatientsundergoing proctectomywithTME.Approximately30%ofmalesexperience difficultywitherectionorejaculationfollowingLARsecondaryto intraoperativeinjurytothesympatheticorparasympatheticnerves. Dysfunctionmayimprovewithtimeandstudiesdemonstratesome improvementwiththeuseofsidafenilpostoperatively.Therateof dysfunctionincreaseswithage,preoperativeradiation,andpoorer preoperativeejaculatoryfunction.Rateoffemalesexualdysfunctionis lesswelldescribed,butwomenmayhavedifficultywithpain,sensation, andorgasm.
Bladderdysfunctionisalesscommoncomplication.Upto15%of patientsexperiencesometemporarybladderdysfunctionpostoperatively, secondarytodissectioninthepelvisorinjurytoparasympatheticnerves. Lessthan5%sufferfrompermanentdysfunctionwhenemployingtotal mesorectaldissectiontechniques.Somepatientsmayrequire replacementoftheFoleycatheterpostoperatively.

RESULTS

Beyondthesurgicalcomplicationsmentioned,theprimaryoutcomesof interestforlaparoscopicLARwithcoloanalanastomosisareoncologic results(localrecurrencerate,disease-freesurvival,overallsurvival)and functionaloutcomes,includingqualityoflife.Sincetheinceptionof laparoscopiccolonandrectalsurgery,therehasbeenconcernaboutthe safetyoflaparoscopyforcancer.In2005,theCOlorectalcancer LaparoscopicorOpenResection(COLOR)trialreporteddecreasedblood loss,pain,andlengthofhospitalstayforpatientsrandomizedto laparoscopicversusopencolectomyforcancer;nodalharvestandmargin positivitywereequivalentbetweentheapproaches.The3-yeardisease­freesurvivalforallstageswas74.2%(95%CI70.4–78.0)forlaparoscopic and76.2%(95%CI72.6–79.8)foropensurgery.Althoughthese differencesweresmallandnotstatisticallysignificant,thestudywas unabletodemonstrate“non-inferiority”oflaparoscopiccolectomywith regardtotheprimaryendpointof3-yeardisease-freesurvivalbecausethe upperlimitofthe95%CIforthedifferenceexceededthepredetermined thresholdof7%.The3-yearoverallsurvivalrateswere81.8%(95%CI
78.4–85.1)forlaparoscopicand84.2%(95%CI81.1–87.3)foropen surgery.
Threelarge,prospectiverandomizedtrialscomparingoutcomesof laparoscopicversusopensurgeryforrectalcancerwerepublishedin
2015.TheCOLORIItrialhadasitsprimaryoutcomelocoregional recurrenceat3yearsaftersurgery,findinganoverallrateof5%inboth treatmentgroups.Interestingly,locoregionalrecurrenceaftersurgeryfor lowrectalcancerwassignificantlyhigherintheopengroup(4.4% laparoscopicvs.11.7%open;difference−7.3%;90%CI−13.9to−0.7). Disease-freeandoverallsurvivalrateswerenotsignificantlydifferent betweenthegroups.Laparoscopyresultedin1dayshorterlengthof hospitalstay,withnodifferencesinmorbidityormortality.
Twoothertrialsfoundlessfavorableresultsforlaparoscopicsurgery forrectalcancer.IntheAmericanCollegeofSurgeonsOncologyGroup (ACOSOG)Z6051trial,aneverbeforeusednon-validatedcomposite pathologicoutcomeofdistalmargin,circumferentialradialmargin,and TMEqualitywasusedastheprimaryoutcome.Fourhundredandsixty­twopatients(240laparoscopicand222open)wereanalyzed.Ofthese,
76.7%underwentLARand23.3%underwentAPR.Conversionrateof laparoscopicresectionswas11%.Patientsundergoinglaparoscopic resectionhadtheirfirstbowelmovement1dayearlierbutlengthof hospitalstaywasequivalentbetweenthegroups.Overallsurgicalsuccess, definedasanegativedistalandcircumferentialmarginandacomplete
TME,washigherintheopenarm(86.9%vs.81.7%).The95%CIofthe differencefailedtomeetthedefinedcriterionfornon-inferioritywith regardtonon-validatedcompositepathologicoutcomes,concludingthat laparoscopicresectionsforrectalcancerwerenot“not-inferior”toopen resectionswithregardtoqualityoftheresectionspecimen.
TheAustralianLaparoscopicCanceroftheRectum(ALaCaRT)trial, usingthesamenon-validatedcompositepathologicoutcomefor adequacyofresection,alsofailedtodemonstratenon-inferiorityof laparoscopicresectionforrectalcancer.Theresultwasaconsequenceof slightlylowerratesofcircumferentialresectionmarginnegativity(93% vs.97%)andcompletenessofTME(87%vs.92%)inthelaparoscopic arm,althoughneitherofthesedifferenceswasstatisticallysignificantin theirownright.Patientsundergoinglaparoscopicresectionhad decreasedbloodlossandpassedflatus1dayearlier,butlengthofhospital staywasequivalentbetweenthegroups.Whetherdifferencesin pathologicoutcomeswilltranslatetodifferencesinoncologicoutcomes remainstobeseen,anditistooearlytodeclareamoratoriumon laparoscopicsurgeryforrectalcancerbasedonthesestudies.However, giventhestrictinclusioncriteria(noT4tumors,nothreatenedmargins, onlyexpertsurgeonswithdocumentedproofofcompetence),thesetrials certainlyraiseconcernabouttheoncologicsafetyoflaparoscopicLAR. Furthermore,thedifferencesinshort-termclinicaloutcomeswere relativelysmallbetweenlaparoscopicandopenresection.Itispossible thatintheeraofstandardizedERPs,thebenefitsoflaparoscopymaybe lesspronouncedthanpreviouslythought.
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LARwithcoloanalanastomosismodifiesanorectalphysiology.The proximalcolonicportionoftheanastomosislacksthenormal distensibility,compliance,andsensationofthenormalrectum.The sphinctersmaybestretched,damaged,orevenpartiallyresectedduringa lowrectalresection.Complicationssuchaspelvicabscess,anastomotic leak,orstricturecanfurtherimpactfunction.Radiographicand physiologicstudiesafterLARwithcoloanalanastomosishave demonstratedlossofthenormalanorectalangle,decreasedmaximum toleratedvolume,decreasedrestinganalsphincterpressure,andlossof therectoanalinhibitoryreflex.Manyoftheseoutcomesimproveafterthe firstyearbutthecumulativeeffectofthesealterationsmayhavea negativeimpactonpatients’qualityoflife.
Insomeinstances,alterationsindefecatoryfunctionleadtosignificant dysfunctionandaconstellationofsymptomsknownas“anterior resectionsyndrome.”Patientswithanteriorresectionsyndromemay
experiencevaryingdegreesoffecalurgency,frequentstooling,soiling, incompleteevacuation,orfecalincontinence.Theincidenceofanterior resectionsyndromeishighestafterultralowcolorectalandcoloanal anastomoses,withratesapproaching20%.Creationofaneorectumwith acolonicJ-pouchhasbeenshowninnumerousrandomizedtrialsand meta-analysestoimprovefunctionaloutcomesduringthefirst6–18 monthsafterLARcomparedwithstraightcoloanalanastomosis.Patients experiencedecreasesinstoolfrequency,urgency,andsoiling.Some studieshavereportedimprovedqualityoflife,althoughmanyhavenot shownasignificantdifference.Comparativestudiesoftransverse coloplastyandside-to-endanastomoseswithcolonicJ-pouchhaveshown similarfunctionaloutcomes.

CONCLUSIONS

LARwithtransanalanastomosisprovidesrestorationofintestinal continuityinpatientswhomightotherwisebeleftwithapermanent colostomy.Preoperativestagingincludingproctoscopy,ultrasound,or MRItoevaluatedepthofinvasionandlymphnodeinvolvement,andfull colonoscopyisessentialforcreationofanappropriateoperativeplan.In addition,totalmesorectalresectionandattentiontomarginsareessential tomaintainingoncologicstandardsandlowrecurrencerates.
MostpatientsarecandidatesforlaparoscopicLARs.Patientswhohave hadpriorsurgery,obesepatients,andmaleswithnarrowpelvismaybe assessedforlaparoscopicapproachandmaybenefitfromminimally invasivetechniques.FunctionmaybeworsenedinpatientsfollowingLAR withtransanalanastomosis,withalargeseriesdemonstrating2–4bowel movementsperdayandupto25%ofpatientshavingsomedegreeof incontinencepostoperatively.Thedegreeofcontinenceimpairmentisin partcontingentupontheamountofintersphinctericresectionandthe anastomoticheight.Transabdominalortransanalcreationofa neorectumusingaJ-pouch,coloplasty,orBakeranastomosismay improvefunction,especiallyintheearlypostoperativeperiod.
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