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

目的：采用乙状结肠平滑肌套代替内括约肌重建新肛管和新括约肌，并行超低前切除术。这种手术的目的是切除肿瘤安全的边缘和改善生活质量（QOL），因为自愿肛门控制。方法：3例直肠腺癌患者和1例GIST患者行此手术。行局部大范围切除，重建新肛管及新括约肌，随访。结果：所有病例平均随访4年，无肿瘤复发。术后中期发生肛瘘2例，吻合口狭窄1例。3例盖性回肠造口闭合，1例因瘘管持续存在而无法完成造口。术后1个月左右，患儿均有排便感和禁气感。3例回肠造口闭合后，术后即刻每日排便次数由10 ~ 20次/天减少至6个月后的3 ~ 7次/天。3年后，每天排便3 - 4次。这三名患者对排便、自主控制排便和维持术前生活质量表示满意。结论：从心理学角度看，保留外括约肌皮下部分吻合乙状平滑肌套重建新肛管和新括约肌是治疗部分直肠癌或肛管恶性肿瘤的一种较好的治疗方法，可促进患者早期社会回报，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.