VIETNAM MEDICAL JOURNAL N°1 - FEBRUARY - 2018
khde d ngu'di mae benh ve xu'dng khdp tai 03 huyen chiem ty le 61,5%; eac hp gia dinh ly^
ehpn phu'dng phap Y hoc eo truyen de cham sdc sire khde khi dieu tri benh man tinh chiem ty le cao nhat la d gia dinh ed mu'c thu nhap tren trung binh 27,5%; thu nhap trung binh la 24,8%; du'di trung binh lan lu'dt la 16,2%.
TAI LIEU THAM KHAO
1. Le Vu Anh va cac cpng siT (2010), Xay diTng mo hinh nang cao siTc khde ngu'di cao tuoi thong qua su' tham gia tich cu'c trong mpt chirong trinh can thiep Y te cong cpng d Tien Hai, Thai Binh, Bao cao toan van Hgi nghi khoa hoc toan quoc Hoi Y tecong cong Viet Nam lan thu" VI, chii bien, Nha Trana, Khanh Hoa. tr. 128-141.
2. &au Xuan Canh {20171. Truven hinh tru'e tuven:
Nhuhq sai lim khi dieu tri benh ctJ xu'tJna khdp httD://vutm.edu.vn/vi/tin-tuc-18.nd/truven-hinh- truc-tuven-nhunq-sai-lam-khi-dieu-tri-benh—co- xuong-khop.html
, Dau Xuan Canh f 2 0 l 7 ) . Truven hinh tru'e tuven:
Ket hOD DSnq - Tav v hieu qua tronq dieu tri benh' httn://vutm.edu .vn/vi/tin-tuc-18. nd/truven-hinh- truc-tuven-ket-hoD-dong-tay-y-hieu-qua--trong- dieu-tri-benh.html
, Nguyin The Hue (2004J^ "Thi/c trang siTc khoe va ddi song ngu'di cao tuoi d Hai Du'dng, Quango Binh va Dak Lak'; Tap chf Dan sd & Phat trien. 10,1
tr 12-15. ^ . Hoang Thi Hoa Ly (2015). Danh gia thu'c trang
va hieu qua can thiep Y hpc co truyen tai tuyen xa d 3 tinh mien Trung. Luan an Tien sy Y hoc Trirdng Oai hoc Y Ha Noi.
. Vien Chi^n lu'dc va Chinh sach y te (2016), Nghien ciru thi/c trang va mpt so yeu to anh hu'dng tdi sU khac biet ve thyc trang sire khoe, kliS nan^ tiep can va sir dung dich vu y te tai 6 tinh thuoc 6 viing kinh te xa hoi ciia Viet Nam nam 2014-2015, HSPI: Ha Npi].
. G. R. Falsarella, et al. (2013), "Prevalence and factors associated with rheumatic diseases and chronic joint symptoms in the elderly", Geriatr Gerontol Int.
KET QUA SaM CUA P H A U THUAT NOI SOI CAT CUT TRIJC TRANG TREN BENH NHAN UNG THlf TRUC T R A N G T H A P
DUaC HOA XA TRI TRUCTC MO TAI BENH VIEN K
T O M TAT
Muc tieu: Danh gia ket qua sdm ciia phau thuat npi soi cat cut trifc trang dieu tri benh nhan ung thu"
tri/c trang thap dirpc hoa xa tri tru'dc mo tai benh vien K. Doi tu'dng va phu'dng phap nghien cu'u: Mo ta cat ngang tren 49 benh nhan ung thu" tru'e trang thap, duHc dieu tri hoa xa dong thdi tru'dc mo va chi dinti phlu thuat noi soi cat cut tru'e trang du'dng bung ting sinh mon tai b§nh vien K tir 1/2015 den 7/2017.
Ket qua: Jhdi gian md 139,7 ± 29,6 (phut), co 1 Bn tai bien ton thu'dng day bang quang, 3 tru'dng hpp chuyen md md (do u xam lan rong), thdi gian cd nhu dpng rupt 2,2 ± 0,9 (ngay), thdi gian diing thuoc giam dau 3,4 ± 0,9 (ngay), thdi gian riit sone tieu la 3,3 ngay, thdi gian hau phau ia 8,6 ± 2,2 ngay. Bien chirng sau mo 8,7%, tron^ do bi tieu gap d 2 "BN (4(3%), 1 Bn chay mau tang sinh mon sau khi nit meche, 1 Bn phai chuyen mo lai do tac ruot cao sau mo 8 npay. Ket luan: PTNS la phu'dng phap ngoai khoa hieu qua, an toan trong phau thuat dieu tri Bn ung thutri/c trang thap da du'dc hoa xa tn tien phau.
TCfkhoa: phau thuat npi soi, ung thu'VuC trang tjiap SUMMARY
EARLY RESULT OF ABDOMINAL PERINEAL
*Benh viin K
Chiu trach nhiem chinh: Pham Van Binh Email: binhvaigiyahoo.fr Ngay nhan bai: 4.11.2017 Ngay phan bien khoa hoc; 2.01.2018 Ngay duyet bai: 10.01.2018
Pham Van Binh*
RESECTION BY LAPAROSCOPIC S U R G E R I N I PREOPERATIVE CHEMORADIATION |
PATIENTS AT K HOSPITAL j Objective. Assess the earlv result of abdominati oerineal resection fAPRl bv Laparoscopic sumery In preoperative chemoradiation patients at K Hospital.
Methods. Cross sectional survev-with 49 preoperative chemoradiation patients with lower rectal cancer, who were underqone APR bv Laparoscopic suraerv at K Hospital from Januarv/2015 to 3uly/2017. Results.
Operating duration was 139,7 ± 29,6 (mins), 1 case was sufferred from bladder lesion in accident, 3 cases were changed to laparotomy, bowel movement recovery duration was 2,2 ± 0,9 (days), pain-relief using duration was 3,4 ± 0,9 (days); urine drainage remove time was 3,3 days, postoperative duration was 8,6 ±2,2 (days). 8.7% of postoperative complication^
induding urinary retention seen in 2 patients (4.3%),i 1 patient with perineal bleeding after withdrawal^
meche, 1 patents must be operated again due to ileus obstruction. Conclusion. The laoanKCODie surqerv is an effective, safe surqical approach to lower rectal cancer patients treated preoperative chemoradiation theraoy.
Key words: Laparoscopy, Low recta! cancer.
I. OAT VAN DE
Ung thu- dai triTc trang (UTDTT) la binh ly ac tinh ciia dai triTc trang, diing thu' 4 ve ti le mac mdi va diJng thir 5 ve ti le t i i vong trong so cic benh ly ae tinh thu'dng gap. Khoang mdt phan ba trong sd dd la ung t W tri/c trang (UTTT)';
TAP CHl Y HOC VIET NAM TAP 463 - THANG 2 - SO 1 - 2018 [1],[3],[6],[7]. Tai Viet Nam, t i le mac mdi va ti
le tir vong do benh UTBTT nam 2012 lan lu'dt la 10,1 va 7,0/100.000 dan [1],[2]. €)ieu tn benh L m r can phdi hdp da mo thu'c de dat du'dc ket qua eao nhat, trong dd, phau thuat ddng vai trd chinh, hda chat va xa tri cd tac dung bo trd (tru'dc hoac sau phau thuat). Cac nghien cu'u cho thay khi tien hanh hda xa tr; dong thdi tru'dc md se ed ti le dap irng eao, tang kha nang phlu thuat triet can, giam tai phat tai cho va nang eao chat lu'dng sdng cho benh nhan (BN) [1], [2], [3], [6],[7]. Phau thuat npi soi (PTNS) ra ddi da danh dau mpt ky nguyen mdi trong dieu tri phau thuat benh UTTT. Nam 1992, Sackier J.M. tien hanh thanh eong PTNS cat cut tru'e trang. Sau hdn hai thap ky, PTNS da du'dc chdng minh la khdng ehi dem lai ket qua eao hdn ve giam dau sau md', phuc hdi nhanh va tinh tham my ma cdn an toan, hieu qua khi so sanh vdi md md kinh dien [1].
Tai Viet Nam, PTNS dieu tn UTTT da du'dc tien hanh tai eac trung tam Idn d Ha Ndi, Hue, TP Ho Chi Minh tir dau nhutig nam 2000. I^dt sd nghien cu'u ve ket qua PTNS trong dieu tri UTTT da du'dc bao cao [1]. Tuy nhien, chu'a ed nhieu nghien cu'u danh gia kha nang ap dung PTNS cho cac doi tu'dng mac ung thu" triTc trang thap du'dc hda xa trj dong thdi tru'dc md. Xuat phat nhiJhg van de neu tren, ehiing tdi tien hanh thde hien Se tai ''ket qua sdm cua phau thuat noi soi cat cut tru'e trang tren benh nhan ung thu" tru'e trang thap dddc hoa xa tri tru'dc mo tai benh vien k".
II. OOl TLTONG VA PHLtaNG PHAP NGHIEN CU'U Tliu chuan Ida chon BN: Co ehan doan xac djnh UTTT thap (cu'c du'di u each ria hau mdn <
5cm) vdi md benh hoc la ung thu" bieu md tuyen.
Giai doan lam sang tru'dc dieu tri T3-4 va/hoac Nl-2 va" MO theo phan loai AJCC 2010 [5]. Du'dc hoa xa trj dong thdi tru'dc phau thuat. Ddde ehi djnh phau thuat npi soi cat cut tru'e trang du'dng bung tang sinh mon. Cd benh an ghi chep day dii, bien ban phau thuat chi tiet, ed md ta tdn thu'dng trong mo va theo doi Bn den it nhat 30 ngay sau phau thuat.
Phu'dng phap nghien cui/: Md ta cat ngang, hoi eiru ket hdp tien ciru
III. KFT QUA
3 . 1 . Danh gia ket q u a p h a u thuat Bangl: Thdi gian mo
Thdi gian 1 Trungbinh Ngan Dai mo(phut) ( X S 5 0 nhat nhat
139,7
±29,6
philt, dai nhat 210 phiit, trung binh 139,7 phiit tinh trong so 46 BN PTNS thanh eong.
Bang 2: Tai bien trong md Tai bien
Ton thi/dng tiet nieu Kllonq tai bien
Tong
So BN ( n ] 1 18 4 9
Ti le »/o 2,0 98,0 100 Nhan xet: 1 BN (2,0%) cd tai bien trong mo tdn thu'dng day bang quang khi p h l u tich cat toan bp MTTT, BN du'dc khau phuc hoi bang quang qua npi soi.
3.2 Chuyen mo md
Nhan xet: 3 tru'dng hdp (6,1%) chuyen mo md deu do ton thu'dng lan rong, xam lan vao ed quan xung quanh. Khong ed tru'dng hdp nao chuyen mo md do tai bien.
Bang 3: Sdhach nao vet du'dc So
lu'dng hach N = 46
Trung - b i n h (X
±SD)
8,4 ± 2,2
Nhieu nhat
14 Nhan xet: Tong sd hach nao vet du'dc tren 46 BN PTNS thanh cong dat 387 hach, tinh trung binh 8,4 hach/BN,
Bang 4: Thdi gian co nhu dong rupt trd Thdi gian
1 ngay 2 ngay
> 3 nqay Tong
So BN (n) 8 24 14 4 6
Ti le % 17,4 52,2 30,4 100 Nhan xet:Thii\ gian cd nhu ddng rupt trd lai ngan nhat la 1 ngay. 52,2% BN cd nhu dpng rudt sau 2jTgay. Thdi gian ed nhu dong rudt tinh chung la ( x ± SD) 2,2 ± 0,9 ngay.
Ban^ 5: Thdi gian dung thudc giam dau sau mo
Thdi gian
< 3 ngay 4 ngay
> 4 nqay Tong
S a B N ( n ) 25 19 2 4 6
Ti le % 54,3 41,3 4,4 100 Nhan xet: 95,6% BN dimg thudc giam dau trong 4 ngay sau mo. Thdi gian trung binh 3,4 ± 0,9 ngay.
Thdi gian (ngay) 2 ngay 3 ngay
> 4 nqay Tong
saf
BN
(n) 3 32 11 46Ti le »/o 6,5 69,6 23,9 100
Nhan xet: Thdi gian mo ngan nhat la 110
Nhan xet: Thdi gian rut sone tieu sau mo ngan nhat la 2 ngay. 69,6% BN riit ong thdng tieu sau 3 ngay. Thdi gian riit sone tieu 3,3 ± 0,9 ngay.
VIETNAM MEDICAL JOURNAL N°1 - FEBRUARY - 2018
Banq 7: Thdi gian nan Thdi gian 1 Trung hau phau : r ^ ' " h
(nqav) I f X i5Z?)
n = 46 1 8,6 ± 2,2hau phau Ngan nhat 7
Dai n h a t 19 Nhan xet: Thdi gian hau phau tu" / aen l y ngay, trung binh 8,6 ngay.
3.2. Bien chii'ng sau mo Bang 8: Bien chiJtnq sau mo
Bien chu'ng Chav mau Nhiem triinq tanq sinh mon Roi loan chiTc nang banq quang
Tac ruot Hau phau thu'dng (khonq bien chiTnq)
Tong
So BN 1 0 2 1 42 46
T i l e («/o) 2,2 0,0 4,3 2,2 91,3 100 Nhan xet: Ti le bien chirng ehung la 8,7%.
Bien chiing hay gap nhat la roi loan chiic nang bang quang 2 BN 'ehlem 4,3%. Tru'dng hdp duy nhat phai chuyen mo lai bj tac rupt do^qual rupt non ket xudng khe hd phuc mac tieu khung.
Khong'cd tru'dng hdp nao t d vong trong thdi gian hau phau.
IV. BAN LUAN
Ky thuat nao vet hach: Trong PTNS eat cut tru'e trang, nao vet hach lien quan tdi viec that cac mach mau eiia tru'e trang va eat toan bd I^'ITTT. Theo nguyen tac, that mach mau d vi tri cang gan nguyen iiy hdn thi sd lu'dng hach vet du'dc cang nhieu hdn [1]. Ngay nay, cae phau thuat vien tren the gidi deu dong thuan that mach du'di cho chia ciia dpng mach dai trang trai tren la dii trong phau thuat eat cut triet can UTTT thap [1], [4]
Khai niem TME chi mdi du'dc Heald, phau thuat vien ngu'di Anh, du'a ra tir nam 1982. Mpt trong nhu'ng khd khan khi tien hanh ky thuat TME la ti le bien chirng eao hdn, dac biet la tren ddi tu'dng nam gldl khung chau hep hay benh nhan beo phi [1],[3]. Ap dung PTNS trong ky thuat TME giup han che du'dc khd khan tren nhd quan sat tot cau triie giai phlu vimg tieu khung, tang kha nang bao ton than kinh tiet nieu sinh due ma van dam bao tinh nguyen ven ciia MTTT.
Ky thuat TME trong PTNS ciia chiing tdi cung giong nhu" cac tac gia nu'dc ngoai md ta: sau khi that mach MTTD d du'di cho chia dpng mach dai trang t^i tren va giai phdng dai trang slgma, tiep tue phau tfch xudng mat sau MTTT theo mot Idp giai phau ngoai can tri/c trang khdng cd mach mau, cac tac gia nu'dc ngoai gpi la dien phau tfch
"Holy plane", tranh lam tdn thu'dng mach mau
tru'dc xu'dng ciing xuong tdi tan san day chau, Dien phau tich mat tru'dc xuong den car Denonvilliers d nam hay vach tri/c trang am dao d n i j - E l ] .
So hach nao vet du'dc: khia canh de dang lu'dng gia nhat ciia ky thuat nao vet hach trong PTNS eat cut trdc trang ehinh la sd lu'dng hach nao vet ddde. t a c gia Aziz 0 . tap hdp lai cac nghien eiru lien quan tu" 1993 den 2004 vdi so lu'dng benh nhan len den 2071 ea UTTT. Ket qua phan tich khang djnh cho gia thiet "kha nang nao vet hach ciia PTNS trong UTTT tu'dng du'dng vdi md md truyen th6ng"[4]. Tiep do, tac giS Loureneo T. va CS bao eao mpt tdng ket mang tinh he thong ve hieu qua ciia PTNS so vdi mo md UTTT tren 4500 BN tir 1997 den 2005.
Theo ket qua nghien cu'u, so lu'dng hach trung binh vet du'dc ciia chiing tdi thap hdn so vdi so lu'dng hach tdi u'u can de danh gia gia1 doan benh sau mo la 12 hach [5]. Chiing toi thay rang dieu trj bo trd tru'dc mo chinh la mdt trong eac yeu t d anh hu'dng tdi so lu'dng hach nao vet du'dc. Trong nghien cii'u eiia ehiing tdi, ti le hach di can sau md la 21,8%, ket qua nay phii hpp vdi tac gia Pham Cam Phu'dng vdi 22,1% nhu'ng cao hdn so vdt tac gia Pham Van Binh (31,1%). Sif khac biet nay du'dc giai thich do ddi tu'dng nghien ciiu cua chung tdi va tac gia Pham Cam Phu'dng ehi bao gom cac BN du'dc hda xa tnrdc md, eon cac tac gia tren nghien ciru tren ca cac BN khong du'dc hda xa tru'dc md[2].
Thdi g i a n moV t a i bien t r o n g mo v i chuyen mo m d : Trong nghien eiru ciia ehung tdi, thdi gian mo la 139,7 ± 29,6 phiit. Ca mo.
ngan nhat 110 phiit, dai nhat 210 phut (bang 1).
So sanh thdi gian PTNS tru'e trang vdi phau t h u | mo md, tac gia Loureneo T. nghien eiftJ tr§n 4125 tru'dng hdp cho ket qua PTNS tri/c trang lau hdn mo md tri/c trang khoang 40 phut [4].
Tai bien trong mo: Chimg toi gap duy nhat mpt tru'dng hdp gap tai bien ton thu'dng day bang quang khi phau tich mat tru'dc tru'e trang, BN da &\l^c khau phuc hoi lai thanh bang quang qua npi soi va khdng phai chuyen md md, nhS kha nang quan sat tot cac cau true giai phau trong tieu khung trong PTNS [1].
Chuyen mo md Cd hai nguyen nhan chinh dan tdi chuyen md md la do tai bien trong mo va do khdi u da xam lan rdng xung quanh.^ Ca 3 tru'dng hdp chuyen md" md trong nghien ciftj cua ehung toi deu do nguyen nhan khdi u xam lan rong xung quanh khong eon ehi dinh PTNS. Cac nghien cu'u ve tl le ehuyen mo md trong PTNS
* tryc trang cho ket qua thay ddi tiT 0% den 15%
[4]. Tuy vay khong nen coi ehuyen md md IB
TAP CHI Y HOC VIET NAM TAP 463 - THANG 2 • SO 1 - 2018 mpt that bai hoac tai bien ciia PTNS ma nen coi
la viec lam de tranh tai bien, bien chu'ng va keo dai cude mo dem lai ket qua khong ed ldi cho benh nhan.
Ket qua sdm sau m o : Thdi gian cd nhu dpng rupt trd lai sau mo: Trong nghien cu'u eua chimg tdi, thdi gian ed nhu dpng rupt tinh chung la 2,2 ± 0,9 ngay (bang 4). Cac nghien cu'u so sanh thdi gian cd nhu dpng rupt trd lai eiia PTNS va mo md trong UTTT deu cho ket qua thdi gian cd nhu dpng rudt trd lai ciia PTNS it hdn cd y nghla thong ke [ 4 ] . Day cung chinh la mpt trong cac u'u diem ciia PTNS 6 bung ndi chung.
Thdi gian dimg thuoc giam dau: Ciing vdi thdi gian cd lai nhu dpng ruot ngan, thdi gian diing thudc giam dau ngan cung la mpt u'u diem ciia PTNS. Trong PTNS UTTT, benh nhan ft dau hdn so vcfl mo md do vet md' dat trocar va vet md lay benh pham ngan. Trong nghien cdu ciia chiing tdi thdi gian diing thuoc giam dau chung cho 46 BN la 3,4 ± 0,9 ngay. Ket qua nay tu'dng dong vdi ket qua do t^c gia Zhou Z.G. va CS (3,9 ngay), thap hdn ed y nghTa so vdi nhdm mo md [7].
Thdi gian rut sonde tieu sau md: Trong phau thuat UTTT, ngoai viec cat rong rai khoi u vao nao vet he thong hach vimg de dam bao nguyen tac ve mat ung thii hpc thi viec bao ton tdi da than kinh ha vi du'di de tranh suy giam chu'c nang tiet nieu, sinh due cung la van de het sire quan trpng, anh hu'dng tru'e tiep tdi chat lu'dng song cua BN sau mo. Ket qua nghien cu'u ciia chimg toi cho thay (bang 7) 7 6 , 1 % BN dude riit dng thdng tieu trong vdng 3 ngay sau mo, thdi gian trung binh rut onp thong tieu la 3,3 ngay, tu'dng du'dng vdi cae tac gia khac [ l ] , [ 2 i . Khi so sanh glUa thdi gian rut dng thdng tieu sau phau thuat UTTT bang hai phu'dng phap PTNS va md md kinh dien, eac tac gia Stamopoulos P. va Lim R.S. deu di den ket luan chirc nang tiet nieu sau md tdt hdn d nhdm BN du'dc FTNS [7]
Bien chu'ng sau mo: t r o n g nghien cu'u ciia chiing tdi, tl le bien chu'ng chung la 8,7% (bang 8). Bien chiing gap nhieu nhat la roi loan chirc nang bang quang gap d 2 BN (4,3%). Hal BN nay bieu hien bf tieu sau khi rut dng thong bang quang, eac BN du'dc dat iai dng thdng tieu, hu'dng dan tap phuc hoi chu'c nanci bang quang tfch cu'c va du'dc rut ong thong tieu sau 6 va 7 ngay. Mdt tru'dng hdp bi chay mau tang sinh mon sau khi rut meche, BN^ du'dc khau cam mau tai cho va khong phai chuyen md lai. Tru'dng hdp duy nhat phai chuyen mo lai la BN cd bleu hien tae rupt cao hau phau ngay thu" 8. Tdn thu'dng trong mo xac djnh nguyen nhan tac la do qual
rudt non ket xudng khe hd phuc mac tieu khung, qual rupt non chu'a cd dau hieu hoai tu". 15 phiit sau khi giai phdng quai rupt va danh gia lai chirc nang quai ruot cdn tdt, BN chi phai khau lai khe hd phuc mac tieu khung va bao ton dddc quai rudt tae. BN hau phau on dinh va chuyen khoa sau md 11 ngay. Nghien cu'u CLASSIC tren 268 BN du'dc PTNS dieu tri UTTT cho thay ti le bien chirng la 39% [4].
Thdi gian hau phau: Theo ket qua nghien ciru ciia ehiing tdi, thdi gian hau phau la 8,6 ± 2,2 ngay. Thdi gian hau phau lau nhat la tru'dng hdp BN bi bien ehiing tac rudt sau mo. Theo tac gia Zhou Z.G. thdi gian hau phau ciia md md va PTNS lan lu'dt la 13,3 ± 3,4 ngay va 8,1 ± 3,1 ngay (p<0,001) [7]. Thdi gian hau phau ngan chfnh la bleu hien liu diem" hau phau nhe nhang" ciia PTNS.
V. KET LUAN
PTNS la phu'dng phap ngoai khoa hieu qua, an toan trong dieu tri BN ung thu" tru'e trang thap da du'dc hda xa tri tien phlu vdi thdi gian md' trung binh 139,7 ± 29,6 (phut), Tai bien trong mo thap 2%, ty le chuyen mo md 6%, thdi gian ed nhu dpng rupt 2,2 ± 0,9 (ngay), thdi gian diing thudc giam dau 3,4 ± 0,9 (ngay), thdi gian hau phau la 8,6 ± 2,2 ngay. Bien ehiing sau mo 8,7%, khdng od tir vong sau md. Tuy nhien ran nghien ciiu dai hdn de danh gia k&i qua ung thu" hpc.
TAI UEU T H A M KHAO
1. Pham van Binh (2013). Nghien eiru irng dyng phau thuat noi soi cat cut tru'e trang du'dng biing tang sinh mon dieu tn ung thU tru'e trang thap, Hoc vien Qu3n Y, Ha Npi.
£. Pham Cd'm Phu'Ong (2013). Danh gia hiSu qua ciia xa tri kSt hpp Capecitabine tru'dc md trong ung thu' true trang thap tien trien tai cho, Tru'dng Dai hoe Y Ha Noi, Ha Noi.
J. Li Y, Wang J, Ma X, et al. (2016). A Review of Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Int J Biot Sci. 12(8), 1022-1031.
t. Loureneo T, Murray A, Grant A, et al. (2008).
Laparoscopic surgery for colorectal cancer: safe and effective' - A systematic review, Surg Endose,
22(5), 1146-1160.
5. Wittekind C, Sobin L (2010), Colon and Rectum, 7th TNM Classification of Malignant Tumors, Wiley Liss.
6. Wolff B, Fleshman J, Wexner S (2009). Surgical Treatment of Rectal Cancer: TYie ASCi^ Textbook of Colon and Rectal Surgery, Springer, London.
/ . Zhou Z.G, Hu M, Li Y, et al. (2004).
Laparoscopic versus open total mesoreetal excision with anal sphincter preservation for low rectal cancer. Surg Endosc.l8(8), 1211-1215,
