2022年 · 第37卷第10期

With the progress of surgical concept, technology and equipment improvement, the anus preservation rate of low rectal cancer surgery continues to increase^［1］, but anastomotic leakage remains a great challenge for colorectal surgeons. Prophylactic stoma is a common method to deal with the above problems in clinical practice. In June 2022, the Chinese Expert Consensus on Preventive Enterostomy for Middle and Low Rectal Cancer Surgery (2022 Edition) was officially released (hereinafter referred to as the Consensus), written by more than 70 experts including Anorectal Physician Branch of Chinese Medical Physicians Association, Colorectal Surgery Group of Chinese Medical Association Surgery Branch and Colorectal Oncology Professional Committee of Chinese Medical Physicians Association. This consensus expounds the clinical value of preventive stoma, indications for use, standardization of prevention and treatment of stoma and complications, stoma repayment and stoma nursing^［2］。 Through the experience of our center, combined with consensus and literature review, the author briefly describes the related problems and clinical countermeasures of postoperative preventive ileostomy for middle and low rectal cancer.

The patient was a 41-year-old female. Blood in the stool appeared in June 2021, which was bright red. In August of the same year, colonoscopy revealed that there was a raised and depressed lesion below 6 cm from the anal opening to the anus, with mucosal necrosis and exudation, and easy bleeding at touch, accounting for about 4/5 of the intestinal lumen circumference. A raised mass can be seen in the anus, which is hard in texture. At the same time, the patient complained that there was exhaust and defecation in the vagina, which was yellow in color. Digital rectal examination: The tumor protrudes from the anus in the left lateral recumbent position, and a hard mass can be palpable from the lower end of the rectum 5 cm to 3~6 o'clock in the anus. It cannot be pushed, and the finger cuff is stained with blood when it withdraws. Enhanced MRI examination of lower abdomen: rectum and anal canal occupy space, considering malignant neoplastic lesions, invading the adventitia and adjacent pelvic floor muscles, and multiple lymph nodes in the perirectal space, pelvic cavity and bilateral inguinal areas are partially enlarged (Figure 1A). Transanal iodine hydrography: partial stenosis of the rectal intestinal lumen, considering the presence of rectovaginal fistula. Routine blood test: red blood cells 3.18×10¹²/L, hemoglobin 54 g/L. The diagnosis was recto-anal mass occupation, recto-vaginal fistula, and severe anemia. After symptomatic treatment such as blood transfusion and parenteral nutrition, elective laparoscopic female posterior pelvic dissection (laparoscopic abdominoperineal rectal resection + transabdominal hysterectomy + bilateral salpingo-oophorectomy + partial vaginal resection + vaginal epineoplasty) was performed. Pathological examination showed that anal canal squamous cell carcinoma was moderately differentiated. The cancer invaded the whole thickness of the intestinal wall to the fibrous connective tissue outside the intestinal wall, focally involved the vaginal wall, and partly to the mucosal surface with ulcer formation. Tumor size: 7.0 cm ×4.0 cm ×3.5 cm, and no clear nerve and vascular invasion was observed (Figures 1B and 1C). There was no cancer metastasis in peri-intestinal lymph nodes (0/17). There was no cancer metastasis (0/8) in 253 lymph nodes groups. Immunohistochemistry: Tumor cells ck-p (+), ck7 (+), ck20 (-), villin (+), p63 (+), p40 (+), ck5/6 (+), p16 (+), p53 (+ +), cea (+), cd34 (vascular +), pd-1 (-), pd-11 (tps: 3%; cps: 5), ki-67 (70% +). After six months of follow-up, the patient's perineal wound had healed, the skin of the stoma was rosy and unobstructed, and no complications were found. Sequential chemotherapy after operation showed no signs of tumor recurrence.

A 70-year-old male patient accidentally discovered a painless mass in the left lower abdomen 3 years ago, about 2.0 cm ×2.5 cm in size, and recently reported that the mass was gradually increasing. Physical examination: A mass can be reached in the left lower abdomen, about 5.0 cm ×5.5 cm in size, hard in texture, not red in skin color, no tenderness, poor mobility, and clear boundary. CT enhancement showed: an irregular soft tissue mass was seen in the left inguinal area, about 5.1 cm ×5.2 cm ×4.6 cm in size, with uniform plain scan density (Figure 1), and the CT value was about 36 HU. The mass was unevenly enhanced in the enhanced arterial phase, with multiple tortuous small vessel-like enhancement shadows (Figure 2). The mass was progressively enhanced in the venous phase and the delayed phase, mainly marginal enhancement (Figure 3), and the delayed phase tended to be uniform. The CT values of the mass in the arterial phase, the venous phase and the delayed phase were about 47, 68, and 75 HU respectively, and the mass boundary was clear. MRI enhancement showed that the mass in the left inguinal area showed low signal in T1WI and non-uniform high signal in T2WI, with multiple strip-like and separated low signal in it (Figure 4). The mass in the arterial phase of the enhanced scan showed non-uniform mild enhancement, and the mass in the venous phase and the delayed phase was further enhanced, mainly with marginal and separated enhancement (Figure 5). Surgical resection was performed. During the operation, the mass was irregular in shape, tough in texture, and there was capsule. Postoperative pathological examination showed that the tumor cells were round, oval and fusiform under light microscope, the cytoplasm was eosinophilic or translucent, the nucleoli were obvious, nested, flaky and grid-like, the interstitium was rich in mucus and blood vessels, the tumor was separated into nodules by fibrous tissue, and the local tumor cells showed atypia, showing mitotic images (Figure 6). Combined with the results of immunohistochemical examination, the final diagnosis was soft tissue myoepithelial carcinoma (MC).