Anovel neoanal canal and neosphincter reconstruction technique for the treatment of rectal malignancies using a pull-through sigmoidal smooth muscle cuff

目的：采用乙状结肠肌袖代替内括约肌行超低位前切除术，重建新肛管和新括约肌。该手术的目的是切除肿瘤的肿瘤安全边缘和改善生活质量(QOL)，因为自愿的肛门控制。方法：对3例直肠腺癌和1例胃肠道间质瘤患者进行手术治疗。局部广泛切除，重建新肛管和新括约肌，并进行随访。结果：所有病例平均随访4年，无肿瘤复发。术后中期并发症为肛瘘2例，吻合口狭窄1例。3例盖式回肠造口术关闭，1例因吻合口瘘持续不能给药。术后1个月左右出现排便、排气等症状。3例回肠吻合术后，术后即刻每日排便由10~20次/d降至6个月后3~7次/d。术后3年，每天排便3~4次。这三名患者报告说，他们对手术前的排便、自愿控制排便和维持生活质量感到满意。结论：保留外括约肌皮下部分重建新肛管和新括约肌，并与乙状结肠肌袖吻合是治疗直肠癌或肛管恶性肿瘤的一种较好的治疗方法，主要从心理角度出发，可促进患者的早期社会回报，提高患者的生活质量。

PURPOSE: Ultralow anterior resection was performed with following reconstruction of neoanal canal and neosphincter using sigmoidal smooth muscle cuff, which substitutes the internal sphincter. This surgery aims at resection of the tumor with oncologically safe margins and improvement the quality of life (QOL) because of the voluntary anal control. METHODS: Three patients with rectal adenocarcinoma and 1 with GIST underwent this surgery. Wide local resection was done and reconstruction of neoanal canal and neosphincter was performed Follow-up was done. Assessment of function and QOL were recorded RESULTS: No tumoral recurrence was noted in the long-term follow-up of 4 years, in average, in all cases. The morbidity in the intermediate postoperative period was anal fistula in 2 patients and stricture of the anastomosis in one patient. Three cases had the covering ileostomy closed, and one case could not have it dosed due to persistent fistula. About one month after the surgical resection, sensation of defecation and continence to gas were achieved. After the closure of ileostomy in three cases, the daily bowel movements immediately after the resective surgery that were from 10 to 20 times a day, decreased to 3 to 7 times a day after 6 months. After 3 years, the bowel movements varied from 3 to 4 times a day. These three patients reported satisfaction with the bowel movements, voluntary control of evacuation, and maintenance of the QOL they had before surgery. CONCLUSION: These results show that reconstruction of neoanal canal and neosphincter using the preserved subcutaneous part of external sphincter muscle and anastomosis to sigmoidal smooth muscle cuff may be a good therapeutical approach in the management of selected cases of rectal carcinoma or malignancies of the anal canal mainly from the psychological point-of-view because the technique may promote the early social return and improve the QOL of these patients.