低位直肠癌根治性手术治疗中肛门保留的研究进展
Research Progress on Anal Preservation in Radical Surgery for Low Rectal Cancer
DOI: 10.12677/hjbm.2026.164063, PDF,   
作者: 吴 浪*：大理大学临床医学院，云南 大理；杨继武#：大理大学临床医学院，云南 大理；大理大学第一附属医院胃肠外科，云南 大理
关键词: 低位直肠癌；保肛手术；吻合口漏；低位前切除综合征；保肛策略；Low Rectal Cancer； Anus-Preserving Surgery； Anastomotic Leakage； Low Anterior Resection Syndrome； Anus-Preserving Strategy
摘要: 低位直肠癌(Low Rectal Cancer, LRC)因肿瘤位置较低，长期处于肿瘤学根治与肛门保留的两难境地。而随着全直肠系膜切除(Total Mesorectal Excision, TME)原则的提出、腹腔镜与机器人技术的成熟以及其他极限保肛术式的发展，低位直肠癌患者的保肛率得到了显著的提升。然而，低位甚至超低位吻合带来的吻合口漏(Anastomotic Leakage, AL)、低位前切除综合征(Low Anterior Resection Syndrome, LARS)以及预防性造口相关并发症，极大影响着患者保肛后的真实获益。本文综合了国内的外相关研究，系统综述低位直肠癌根治术中肛门保留的最新研究进展，探讨低位直肠癌患者的保肛策略，并展望未来发展方向。
Abstract: Low rectal cancer (LRC) is a type of cancer where the tumor is located at a relatively low position, thus remaining in a dilemma of achieving radical tumor treatment while preserving the anus. With the introduction of the Total Mesorectal Excision (TME) principle, the maturity of laparoscopic and robotic technologies, and the development of other extreme anus-preserving surgical methods, the rate of anus preservation for patients with low rectal cancer has significantly increased. However, the anastomotic leakage (AL) caused by low or even ultra-low anastomosis, the Low Anterior Resection Syndrome (LARS), and the complications related to preventive ostomy have greatly affected the actual benefits of patients after anus preservation. This article integrates domestic related studies, systematically reviews the latest research progress on anus preservation in radical rectal cancer surgery, discusses the anus-preservation strategies for patients with low rectal cancer, and looks forward to future development directions.
文章引用：吴浪, 杨继武. 低位直肠癌根治性手术治疗中肛门保留的研究进展[J]. 生物医学, 2026, 16(4): 616-625. https://doi.org/10.12677/hjbm.2026.164063

参考文献

[1] Han, B., Zheng, R., Zeng, H., Wang, S., Sun, K., Chen, R., et al. (2024) Cancer Incidence and Mortality in China, 2022. Journal of the National Cancer Center, 4, 47-53. [Google Scholar] [CrossRef] [PubMed]
[2] 王宁, 孙婷婷, 郑荣寿, 等. 中国2009年结直肠癌发病和死亡资料分析[J]. 中国肿瘤, 2013, 22(7): 515-520.
[3] 苗儒林, 李子禹, 武爱文. 中国胃肠肿瘤外科联盟数据报告(2014-2016) [J]. 中国实用外科杂志, 2018, 38(1): 90-93.
[4] Lee, B.C., Lim, S., Lee, J.L., Kim, C.W., Yoon, Y.S., Park, I.J., et al. (2020) Defunctioning Protective Stoma Can Reduce the Rate of Anastomotic Leakage after Low Anterior Resection in Rectal Cancer Patients. Annals of Coloproctology, 36, 192-197. [Google Scholar] [CrossRef] [PubMed]
[5] 汪欣宇, 陶燃, 屈展, 等. 经腹直肠癌前切除术临时性造口永久化的危险因素分析[J]. 中华胃肠外科杂志, 2020, 23(8): 780-785.
[6] Heald, R.J., Husband, E.M. and Ryall, R.D.H. (1982) The Mesorectum in Rectal Cancer Surgery—The Clue to Pelvic Recurrence? Journal of British Surgery, 69, 613-616. [Google Scholar] [CrossRef] [PubMed]
[7] 汪建平. 低位直肠癌保肛手术的回顾和思考[J]. 大肠肛门病外科杂志, 2003(2): 69.
[8] 李辰生, 李乐平, 潘志忠, 等. 中下段直肠癌远端壁内浸润和系膜转移的研究[J]. 中华普通外科杂志, 2008, 23(9): 669-671.
[9] Pollett, W.G., Nicholls, R.J. and Chir, M. (1983) The Relationship between the Extent of Distal Clearance and Survival and Local Recurrence Rates after Curative Anterior Resection for Carcinoma of the Rectum. Annals of Surgery, 198, 159-163. [Google Scholar] [CrossRef] [PubMed]
[10] Bujko, K., Rutkowski, A., Chang, G.J., Michalski, W., Chmielik, E. and Kusnierz, J. (2012) Is the 1-cm Rule of Distal Bowel Resection Margin in Rectal Cancer Based on Clinical Evidence? A Systematic Review. Indian Journal of Surgical Oncology, 3, 139-146. [Google Scholar] [CrossRef] [PubMed]
[11] 赖浩, 卢榜裕. 超低位直肠癌保肛手术方式的研究进展[J]. 微创医学, 2012, 7(1): 55-58.
[12] 周海涛, 徐正. 完全腹腔镜手术在结肠癌外科治疗中的应用前景[J]. 中国现代医学杂志, 2022, 32(23): 1-5.
[13] Schietroma, M., Romano, L., Apostol, A.I., Vada, S., Necozione, S., Carlei, F., et al. (2021) Mid-and Low-Rectal Cancer: Laparoscopic vs Open Treatment—Short-and Long-Term Results. Meta-Analysis of Randomized Controlled Trials. International Journal of Colorectal Disease, 37, 71-99. [Google Scholar] [CrossRef] [PubMed]
[14] Arezzo, A., Passera, R., Scozzari, G., Verra, M. and Morino, M. (2012) Laparoscopy for Rectal Cancer Reduces Short-Term Mortality and Morbidity: Results of a Systematic Review and Meta-Analysis. Surgical Endoscopy, 27, 1485-1502. [Google Scholar] [CrossRef] [PubMed]
[15] Katsuno, H., Shiomi, A., Ito, M., Koide, Y., Maeda, K., Yatsuoka, T., et al. (2015) Comparison of Symptomatic Anastomotic Leakage Following Laparoscopic and Open Low Anterior Resection for Rectal Cancer: A Propensity Score Matching Analysis of 1014 Consecutive Patients. Surgical Endoscopy, 30, 2848-2856. [Google Scholar] [CrossRef] [PubMed]
[16] Schiessel, R., Karner-Hanusch, J., Herbst, F., Teleky, B. and Wunderlich, M. (1994) Intersphincteric Resection for Low Rectal Tumours. Journal of British Surgery, 81, 1376-1378. [Google Scholar] [CrossRef] [PubMed]
[17] Kitaguchi, D., Nishizawa, Y., Sasaki, T., Tsukada, Y., Ikeda, K. and Ito, M. (2019) Recurrence of Rectal Anastomotic Leakage Following Stoma Closure: Assessment of Risk Factors. Colorectal Disease, 21, 1304-1311. [Google Scholar] [CrossRef] [PubMed]
[18] Du, Q., Yang, W., Zhang, J., Qiu, S., Liu, X., Wang, Y., et al. (2024) Oncologic Outcomes of Intersphincteric Resection versus Abdominoperineal Resection for Lower Rectal Cancer: A Systematic Review and Meta-Analysis. International Journal of Surgery, 110, 2338-2348. [Google Scholar] [CrossRef] [PubMed]
[19] Sylla, P., Rattner, D.W., Delgado, S. and Lacy, A.M. (2010) NOTES Transanal Rectal Cancer Resection Using Transanal Endoscopic Microsurgery and Laparoscopic Assistance. Surgical Endoscopy, 24, 1205-1210. [Google Scholar] [CrossRef] [PubMed]
[20] Larsen, S.G., Pfeffer, F. and Kørner, H. (2019) Norwegian Moratorium on Transanal Total Mesorectal Excision. British Journal of Surgery, 106, 1120-1121. [Google Scholar] [CrossRef] [PubMed]
[21] Sylla, P., Sands, D., Ricardo, A., Bonaccorso, A., Polydorides, A., Berho, M., et al. (2023) Multicenter Phase II Trial of Transanal Total Mesorectal Excision for Rectal Cancer: Preliminary Results. Surgical Endoscopy, 37, 9483-9508. [Google Scholar] [CrossRef] [PubMed]
[22] 姚增鹏, 罗斌, 周自立, 等. 机器人与普通腹腔镜辅助结直肠癌D3根治术短期临床疗效比较[J]. 实用医院临床杂志, 2023, 20(5): 45-51.
[23] 王佳琦, 李兴源, 熊寰, 等. 机器人手术系统辅助下的结直肠癌经自然腔道取标本手术与常规辅助切口取标本手术的近期疗效对比研究[J]. 中华结直肠疾病电子杂志, 2024, 13(2): 121-128.
[24] 崔皖晋, 褚亮, 周少波. 人工扶镜与机器人辅助扶镜下腹腔镜结直肠癌手术患者的临床疗效比较[J]. 机器人外科学杂志(中英文), 2024, 5(3): 447-453.
[25] 张之远, 冯青阳, 许剑民. 直肠癌的手术治疗: 达芬奇机器人手术的应用及其与腹腔镜手术的优劣[J]. 结直肠肛门外科, 2024, 30(3): 259-263.
[26] Boccola, M.A., Buettner, P.G., Rozen, W.M., Siu, S.K., Stevenson, A.R.L., Stitz, R., et al. (2011) Risk Factors and Outcomes for Anastomotic Leakage in Colorectal Surgery: A Single‐institution Analysis of 1576 Patients. World Journal of Surgery, 35, 186-195. [Google Scholar] [CrossRef] [PubMed]
[27] van Workum, F., Talboom, K., Hannink, G., Wolthuis, A., de Lacy, B.F., Lefevre, J.H., et al. (2020) Treatment of Anastomotic Leakage after Rectal Cancer Resection: The Tentacle-Rectum Study. Colorectal Disease, 23, 982-988. [Google Scholar] [CrossRef] [PubMed]
[28] Parthasarathy, M., Greensmith, M., Bowers, D. and Groot‐Wassink, T. (2017) Risk Factors for Anastomotic Leakage after Colorectal Resection: A Retrospective Analysis of 17 518 Patients. Colorectal Disease, 19, 288-298. [Google Scholar] [CrossRef] [PubMed]
[29] Frasson, M., Flor-Lorente, B., Ramos Rodríguez, J.L., Granero-Castro, P., Hervás, D., Alvarez Rico, M.A., et al. (2015) Risk Factors for Anastomotic Leak after Colon Resection for Cancer: Multivariate Analysis and Nomogram from a Multicentric, Prospective, National Study with 3193 Patients. Annals of Surgery, 262, 321-330. [Google Scholar] [CrossRef] [PubMed]
[30] Huisman, D.E., Reudink, M., van Rooijen, S.J., Bootsma, B.T., van de Brug, T., Stens, J., et al. (2020) LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Annals of Surgery, 275, e189-e197. [Google Scholar] [CrossRef] [PubMed]
[31] Eveno, C., Latrasse, V., Gayat, É., Lo Dico, R., Dohan, A. and Pocard, M. (2016) Colorectal Anastomotic Leakage Can Be Predicted by Abdominal Aortic Calcification on Preoperative CT Scans: A Pilot Study. Journal of Visceral Surgery, 153, 253-257. [Google Scholar] [CrossRef] [PubMed]
[32] 欧阳一鸣, 叶一如, 吴尚, 等. 腹腔镜直肠低位前切除术后早期吻合口瘘发生情况及影响因素分析[J]. 中外医学研究, 2024, 22(35): 162-168.
[33] Dekker, J.W.T., Liefers, G.J., de Mol van Otterloo, J.C.A., Putter, H. and Tollenaar, R.A.E.M. (2011) Predicting the Risk of Anastomotic Leakage in Left-Sided Colorectal Surgery Using a Colon Leakage Score. Journal of Surgical Research, 166, e27-e34. [Google Scholar] [CrossRef] [PubMed]
[34] Rahbari, N.N., Weitz, J., Hohenberger, W., Heald, R.J., Moran, B., Ulrich, A., et al. (2010) Definition and Grading of Anastomotic Leakage Following Anterior Resection of the Rectum: A Proposal by the International Study Group of Rectal Cancer. Surgery, 147, 339-351. [Google Scholar] [CrossRef] [PubMed]
[35] 《保留左结肠动脉的直肠癌根治术中国专家共识》编审委员会, 中国医师协会肛肠医师分会大肠癌综合治疗组, 中西医结合学会普通外科专业委员会直肠癌防治专家委员会. 保留左结肠动脉的直肠癌根治术中国专家共识(2021版) [J]. 中华胃肠外科杂志, 2021, 24(11): 950-955.
[36] Fan, Y., Ning, F., Zhang, C. and Dai, D. (2018) Preservation versus Non-Preservation of Left Colic Artery in Sigmoid and Rectal Cancer Surgery: A Meta-Analysis. International Journal of Surgery, 52, 269-277. [Google Scholar] [CrossRef] [PubMed]
[37] Tanaka, J., Nishikawa, T., Tanaka, T., Kiyomatsu, T., Hata, K., Kawai, K., et al. (2015) Analysis of Anastomotic Leakage after Rectal Surgery: A Case-Control Study. Annals of Medicine & Surgery, 4, 183-186. [Google Scholar] [CrossRef] [PubMed]
[38] De Nardi, P., Elmore, U., Maggi, G., Maggiore, R., Boni, L., Cassinotti, E., et al. (2019) Intraoperative Angiography with Indocyanine Green to Assess Anastomosis Perfusion in Patients Undergoing Laparoscopic Colorectal Resection: Results of a Multicenter Randomized Controlled Trial. Surgical Endoscopy, 34, 53-60. [Google Scholar] [CrossRef] [PubMed]
[39] Nishigori, H., Ito, M., Nishizawa, Y., Nishizawa, Y., Kobayashi, A., Sugito, M., et al. (2014) Effectiveness of a Transanal Tube for the Prevention of Anastomotic Leakage after Rectal Cancer Surgery. World Journal of Surgery, 38, 1843-1851. [Google Scholar] [CrossRef] [PubMed]
[40] Xiao, L., Zhang, W., Jiang, P., Bu, X., Yan, Q., Li, H., et al. (2011) Can Transanal Tube Placement after Anterior Resection for Rectal Carcinoma Reduce Anastomotic Leakage Rate? A Single‐Institution Prospective Randomized Study. World Journal of Surgery, 35, 1367-1377. [Google Scholar] [CrossRef] [PubMed]
[41] Yang, S., Tang, G., Zhang, Y., Wei, Z. and Du, D. (2024) Meta-Analysis: Loop Ileostomy versus Colostomy to Prevent Complications of Anterior Resection for Rectal Cancer. International Journal of Colorectal Disease, 39, Article No. 68. [Google Scholar] [CrossRef] [PubMed]
[42] 吕亮, 王爱丽, 潘志辉, 等. 腹腔镜直肠癌根治术中回肠双腔、单腔造口效果对比观察[J]. 山东医药, 2019, 59(20): 50-52.
[43] 陶俊, 束宽山, 郑明, 等. 回肠双腔造口对中低位直肠癌前切除术后转流性结肠炎的发生及疾病转归的影响[J]. 中国老年学杂志, 2023, 43(19): 4655-4658.
[44] Mrak, K., Uranitsch, S., Pedross, F., Heuberger, A., Klingler, A., Jagoditsch, M., et al. (2016) Diverting Ileostomy versus No Diversion after Low Anterior Resection for Rectal Cancer: A Prospective, Randomized, Multicenter Trial. Surgery, 159, 1129-1139. [Google Scholar] [CrossRef] [PubMed]
[45] Zhou, L., Qin, Z. and Wang, L. (2023) Risk Factors and Incidence of Non-Closure Stoma in Patients with Anterior Resection of Rectal Cancer with Temporary Stoma: A Systematic Review and Meta-Analysis. European Journal of Surgical Oncology, 49, Article ID: 107120. [Google Scholar] [CrossRef] [PubMed]
[46] Keane, C., Wells, C., O’Grady, G. and Bissett, I.P. (2017) Defining Low Anterior Resection Syndrome: A Systematic Review of the Literature. Colorectal Disease, 19, 713-722. [Google Scholar] [CrossRef] [PubMed]
[47] Christensen, P., IM Baeten, C., Espín‐Basany, E., Martellucci, J., Nugent, K.P., Zerbib, F., et al. (2021) Management Guidelines for Low Anterior Resection Syndrome—The MANUEL Project. Colorectal Disease, 23, 461-475. [Google Scholar] [CrossRef] [PubMed]
[48] Brock, H., Lambrineas, L., Ong, H.I., Chen, W.Y., Das, A., Edsell, A., et al. (2023) Preventative Strategies for Low Anterior Resection Syndrome. Techniques in Coloproctology, 28, Article No. 10. [Google Scholar] [CrossRef] [PubMed]
[49] Kakodkar, R., Gupta, S. and Nundy, S. (2006) Low Anterior Resection with Total Mesorectal Excision for Rectal Cancer: Functional Assessment and Factors Affecting Outcome. Colorectal Disease, 8, 650-656. [Google Scholar] [CrossRef] [PubMed]
[50] Miyo, M., Akizuki, E., Okuya, K., Noda, A., Ishii, M., Miura, R., et al. (2025) Diagnosis and Treatment of Low Anterior Resection Syndrome. Journal of the Anus, Rectum and Colon, 9, 1-9. [Google Scholar] [CrossRef] [PubMed]
[51] Kim, K., An, S., Kim, M.H., Jung, J.H. and Kim, Y. (2022) High versus Low Ligation of the Inferior Mesenteric Artery in Colorectal Cancer Surgery: A Systematic Review and Meta-analysis. Medicina, 58, Article 1143. [Google Scholar] [CrossRef] [PubMed]
[52] Mollà, M. and Panés, J. (2007) Radiation-Induced Intestinal Inflammation. World Journal of Gastroenterology, 13, 3043-3046. [Google Scholar] [CrossRef] [PubMed]
[53] Sun, R., Dai, Z., Zhang, Y., Lu, J., Zhang, Y. and Xiao, Y. (2021) The Incidence and Risk Factors of Low Anterior Resection Syndrome (LARS) after Sphincter-Preserving Surgery of Rectal Cancer: A Systematic Review and Meta-Analysis. Supportive Care in Cancer, 29, 7249-7258. [Google Scholar] [CrossRef] [PubMed]
[54] Bohlok, A., Mercier, C., Bouazza, F., Galdon, M.G., Moretti, L., Donckier, V., et al. (2019) The Burden of Low Anterior Resection Syndrome on Quality of Life in Patients with Mid or Low Rectal Cancer. Supportive Care in Cancer, 28, 1199-1206. [Google Scholar] [CrossRef] [PubMed]
[55] Harji, D., Fernandez, B., Boissieras, L., Berger, A., Capdepont, M., Zerbib, F., et al. (2021) A Novel Bowel Rehabilitation Programme after Total Mesorectal Excision for Rectal Cancer: The BOREAL Pilot Study. Colorectal Disease, 23, 2619-2626. [Google Scholar] [CrossRef] [PubMed]
[56] 中国医师协会肛肠医师分会. 低位前切除综合征诊治中国专家共识(2025版) [J]. 中国普通外科杂志, 2025, 34(8): 1603-1617.
[57] 宋建宁, 王佾, 李铁军, 等. 保肛术与腹会阴联合直肠癌根治造瘘术治疗老年低位直肠癌的效果及对生活质量的影响比较[J]. 中国老年学杂志, 2018, 38(24): 5984-5986.
[58] Conroy, T., Castan, F., Etienne, P., Rio, E., Mesgouez-Nebout, N., Evesque, L., et al. (2024) Total Neoadjuvant Therapy with Mfolfirinox versus Preoperative Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer: Long-Term Results of the UNICANCER-PRODIGE 23 Trial. Annals of Oncology, 35, 873-881. [Google Scholar] [CrossRef] [PubMed]
[59] Zwart, W.H., Temmink, S.J.D., Hospers, G.A.P., Marijnen, C.A.M., Putter, H., Nagtegaal, I.D., et al. (2024) Oncological Outcomes after a Pathological Complete Response Following Total Neoadjuvant Therapy or Chemoradiotherapy for High-Risk Locally Advanced Rectal Cancer in the RAPIDO Trial. European Journal of Cancer, 204, Article ID: 114044. [Google Scholar] [CrossRef] [PubMed]
[60] Garcia-Aguilar, J., Patil, S., Gollub, M.J., Kim, J.K., Yuval, J.B., Thompson, H.M., et al. (2022) Organ Preservation in Patients with Rectal Adenocarcinoma Treated with Total Neoadjuvant Therapy. Journal of Clinical Oncology, 40, 2546-2556. [Google Scholar] [CrossRef] [PubMed]
[61] Diefenhardt, M., Kosmala, R., Fleischmann, M., Martin, D., Hofheinz, R.-., Ghadimi, M., et al. (2025) Chemotherapy before or after Preoperative Chemoradiotherapy and Surgery for Locally Advanced Rectal Cancer: 5-Year Results of the CAO/ARO/AIO-12 Trial—A General Pairwise Comparison. ESMO Open, 10, Article ID: 104483. [Google Scholar] [CrossRef] [PubMed]
[62] Wang, L., Zhang, X., Zhao, Y., Li, S., Li, Z., Sun, Y., et al. (2023) Intentional Watch and Wait or Organ Preservation Surgery Following Neoadjuvant Chemoradiotherapy Plus Consolidation CAPEOX for MRI-Defined Low-Risk Rectal Cancer: Findings from a Prospective Phase 2 Trial (PKUCH-R01 Trial, NCT02860234). Annals of Surgery, 277, 647-654. [Google Scholar] [CrossRef] [PubMed]
[63] 中国直肠癌新辅助治疗后等待观察数据库研究协作组, 中华医学会外科学分会结直肠外科学组, 中国医师协会结直肠肿瘤医师专业委员会, 等. 直肠癌新辅助治疗后等待观察策略中国专家共识(2024版) [J]. 中华胃肠外科杂志, 2024, 27(4): 301-315.

为你推荐