Various reliable reconstructive options are available for treatment of perineal and perianal skin and soft tissue defects resulting from tumor ablation. Indications for TAR include the following: very low rectal cancers, in which low anterior resection or resection with coloanal anastomosis is not possible: persistent or recurrent anal cancer that has failed to respond to chemoradiation therapy; and previous rectal excision with either recurring colostomy complications or an unacceptable quality of life with a stoma. Of course, adequate surgical oncologic principles must not be compromised to enhance sphincter reconstruction. Either primary reconstruction at the time of cancer excision or secondary reconstruction at a later date is an acceptable alternative. Most investigators believe that primary reconstruction is technically easier and associated with fewer complications. Secondary reconstruction provides the advantage of oncologic certainty. Double dynamic graciloplasty after APR has proved to be anoncologically sound procedure with a good chance of continence and a life without a stoma in most patients. Finally, the preliminary experience with new techniques of electrode implants encourages further application. In most patients who have rectal cancer, a sphincter-saving resection can avoid the need for a permanent stoma. Very low rectal tumors, however, still require an APR as the treatment of choice when a safe coloanal anastomosisis not possible. In recent years, several authors have reported their experience on sphincteric reconstruction after APR. Most of these authors used gracilis muscles transposed from the thigh to the perineum (graciloplasty) to surround a coloperineal anastomosis after pull-through of the distal colon. The best way to achieve fecal continence is to obtain a mechanically sufficient contraction of the sphincter. Electrostimulation of the transposed gracilis muscles creates an essential framework for their postoperative muscular growth and contractility. In particular, adoption of continuous low-frequency stimulation has proved to be effective in increasing fatigue resistance of the transposed muscles, allowing their continuous "pseudotonic" contraction. Despite the general acceptance of the efficacy of this scheme, there are significant variations in various authors' experiences pertaining to graciloplasty configuration, surgical timing of resection and transposition, and electrostimulation device use and implantation.

译文

各种可靠的重建选择可用于治疗会阴和肛周皮肤和肿瘤消融引起的软组织缺损。TAR的适应症包括: 非常低的直肠癌,其中无法进行低位前切除或结肠吻合术切除: 对化学放射治疗无效的持续性或复发性肛门癌; 以及先前的直肠切除术,其中有反复的结肠造口并发症或造口的生活质量令人无法接受。当然,不能损害适当的外科肿瘤学原理以增强括约肌重建。癌症切除时的初次重建或以后的二次重建是可接受的选择。大多数研究人员认为,初次重建在技术上更容易,并且并发症更少。二次重建提供了肿瘤确定性的优势。事实证明,在大多数患者中,APR后的双动态股薄肌成形术是一种合理的手术方法,有很好的节制和无造口的生活。最后,电极植入新技术的初步经验鼓励了进一步的应用。在大多数患有直肠癌的患者中,保留括约肌的切除术可以避免永久性造口的需要。但是,如果无法实现安全的结肠吻合术,则非常低的直肠肿瘤仍然需要APR作为首选治疗方法。近年来,一些作者报道了他们在APR后括约肌重建的经验。这些作者中的大多数人使用从大腿转移到会阴的gra肌 (gracillasty) 在远端结肠拉通后包围了一起会阴吻合术。实现大便失禁的最佳方法是获得括约肌的机械充分收缩。转位的gracilis肌肉的电刺激为其术后肌肉生长和收缩力创造了必要的框架。特别是,事实证明,采用连续的低频刺激可有效提高转位肌肉的乏力性,从而使其连续的 “假性” 收缩。尽管该方案的功效已得到普遍接受,但在gra成形术的配置,切除和转位的手术时机以及电刺激装置的使用和植入方面,各种作者的经验仍存在显着差异。

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