Zusammenfassung.
Die Standardoperation beim Rektumkarzinom ist die tiefe anteriore Resektion mit Total Mesorectal Exzision und Mitnahme des Lymphabflussgebietes. Lokale tumorresezierende Verfahren können beim Rektumkarzinom nur in Ausnahmefällen zur Anwendung kommen. Voraussetzung für alle lokalchirurgischen Operationen unter einem kurativen Ansatz ist die präoperative Bestimmung des Tumorgradings und die präoperative Endosonographie zur Bestimmung der Tumorinfiltration, da von diesen beiden Parametern das Risiko eines Lymphknotenbefalls abhängt. Unter einem kurativen Ansatz sollten lediglich gut differenzierte T1-Karzinome („Low risk”, G1 und G2) lokal operiert werden. Bei diesen beträgt das Risiko eines Lymphknotenbefalls 3 %. Schon bei einem „High risk”-T1-Karzinom (G3) ist eine abdominelle Operation indiziert. Die Kombination einer lokalen Exzision mit einer postoperativen Radio- oder Radiochemotherapie bei höhergradigen Rektumkarzinomen reduziert das Risiko einer lokoregionären Rezidivrate nur marginal und kann deshalb nicht empfohlen werden. Unter einem palliativen Ansatz können ausnahmsweise auch Tumoren in einem höheren Stadium bei solchen Patienten lokal reseziert werden, bei denen aufgrund eines hohen Operationsrisikos oder einer sehr beschränkten Lebenserwartung eine Kontraindikation für ein radikales transabdominelles Vorgehen besteht.
Falls ein lokalchirurgisches Vorgehen indiziert ist, stellt die Transanale Endoskopische Mikrochirurgie (TEM) die beste verfügbare Operationstechnik dar. Die Mortalität dieser Operation ist beinahe 0 %, die Morbidität ist sehr gering.
Local treatment for rectal cancer.
Standard curative surgery in patients with rectal cancer combines sphincter saving rectal resection with total mesorectal excision (TME) and “high tie” of the inferior mesenteric vessels. Local surgical treatment is reserved for highly selected patients. Prerequisites for local treatment are preoperative histological grading (G) of tumour malignancy and preoperative endorectal ultrasound for judgement of the depth of tumour infiltration. These two parameters determine the risk of lymphnode metastasis. With the intent to cure local surgery is only indicated for “low risk” T1 tumours (G1, G2). The combination of local surgery with pre- or postoperative adjuvant chemotherapy and radiation for advanced tumours is not recommended, since local recurrence rates are high. In patients unfit for transabdominal radical surgery local surgical treatment can be performed as palliative therapy even for advanced tumours. Whenever indicated local surgical treatment should be preferably performed by transanal endoscopic micro-surgery (TEMS): Its results concerning tumour recurrence, morbiditiy and mortality as well as postoperative function are excellent.
Schlüsselwörter:
Rektumcarcinom - lokale Therapie - Transanale endoskopische Mikrochirurgie (TEM)
Key words:
Rectal cancer - Local treatment - Transanal endoscopic micro-surgery (TEMS)
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Priv. Doz. Dr. Ekkehard C. Jehle
Chirurgische Universitätsklinik
Hoppe-Seyler-Straße 3
72 076 Tübingen
Phone: 07071/2985570
Fax: 07071/295570
Email: ekkehard.jehle@med.uni-tuebingen.de
