保留盆腔自主神经全直肠系膜切除术在直肠癌中的应用

目的 探讨保留盆腔自主神经全直肠系膜切除术（TME）及术后对患者泌尿生殖功能及根治效果的影响。方法 采用病例对照的方法．回顾性分析了36例在直肠癌根治术中保留盆腔自主神经保留（R州P）组和非保留盆腔自主神经保留（非PANP）组病人31例术后性功能障碍的发生率以及局部复发率。结果 研究组36例患者术后性功能和排尿功能指标优于对照组31例患者（P〈0．05），两组术后局部癌肿复发率分别为8．3％和6．5％，差异无显著性（P〉0．05）。结论 保留盆腔自主神经全直肠系膜切除术在肿瘤根治和保持术后功能方面是适宜的术式。     

Dixon与Miles直肠癌根治术后局部复发率的比较

目的比较保肛与非保肛两种直肠癌根治术应用全直肠系膜切除（total mesorectal excision, TME） 术后的局部复发率（local recurrence rate, LRR）,为临床直肠癌根治术提供参考依据. 方法回顾性分析直肠癌患者术后的局部复发率,将101 例直肠癌患者分2 组：Dixon 组53 例,Miles 组48 例,按Heald 法行TME. 结果 Dixon 组与Miles 组的LRR 分别为：7.5 %与18.8 %（P〈0.05）,1997 年以前Miles 组的LRR 为31.6 %, 1997年以后Miles 组的LRR为10.3%（P〈0.05 ）;Dixon 组的LRR为7.5 %,与前者比较相差非常显著（P〈0.01）,与后者比较无显著性差异（P〉0.05）. 结论 TME 是降低Dixon 、Miles直肠癌根治术后LRR 的重要因素.     

腹腔镜结直肠癌根治术的临床分析

目的：探讨腹腔镜结直肠癌根治术的可行性。方法：2007年5月-2008年11月我院完成腹腔镜结直肠癌根治术8例,选取同期开腹手术8例,对其临床资料进行对照分析。结果：手术时间腹腔镜组长于开腹组（210min±56minvs160min±32min,P〈0．05）;术中失血量、清扫淋巴结数目、术后并发症发生率两组间无统计学差异（P〉0．05）;术后肠蠕动恢复时间、镇痛时间及术后住院时间腹腔镜组分别为（2．3±0．8）d、（1．7±0．7）d、（8．8±1．1）d,开腹组分别为（3．4±0．9）d、（2．4±0．6）d、（10．2±1．2）d,腹腔镜组短于开腹组（P〈0．05）;两组术后随访均未出现穿刺孔或切口种植转移。结论：腹腔镜结直肠癌根治术安全可行,疗效可靠;与开放手术相比,具有创伤小、微创、疗效好等优势。     

右美托咪定对老年人直肠癌根治术后认知功能的影响

目的观察老年人直肠癌根治术中应用右美托咪啶（DEX）对术后认知功能的影响。方法将60例择期行直肠癌根治术的老年患者按数字表法随机分为2组：DEX组（n=30）和对照组（n=30）。均采用静脉麻醉,将DEX 2 ml（200μg）加入48ml生理盐水中,配成4mg／L的溶液。DEX组在气管插管成功后10min内泵入0．5μg／ks的DEX溶液,继续以0．5μg·kg^-1·h^-1持续泵入至手术结束前30min;对照组在气管插管成功后的10min内泵入0．125ml／kg生理盐水,继以0．125ml·kg^-1·h^-1持续泵入至关腹前。记录2组术前（T0）、术毕（T1）、拔管后5min（T2）、拔管后30min（T3）的收缩压（SBP）、舒张压（DBP）、心率（HR）,并记录停全麻药至自主呼吸恢复的时间、至拔管的时间,术前24h、术后24h采用简易精神状态量表（MMSE）评价两组患者认知功能。结果与T0比较,DEX组T1～T3的SBP及HR降低,而对照组T1-T3的SBP升高,差异均有统计学意义（P值均〈0．05）;与对照组比较,DEX组T1-T3的SBP及HR减低,差异均有统计学意义（P值均〈0．01）。DEX组发生术后认知功能障碍（POCD）2例（6．7％）,对照组9例（30．0％）,两组POCD发生率差异有统计学意义（χ^2=5．46,P〈0．01）。结论DEX能改善老年直肠癌根治术患者的术后认知功能,且使血流动力学更稳定。     

侧方淋巴结清扫保留植物神经术治疗直肠癌的效果分析

目的分析腹腔镜下侧方淋巴结清扫保留植物神经术在治疗直肠癌中的效果。方法将46例中低进展期直肠癌患者分为侧方清扫组和对照组,侧方清扫组行腹腔镜下侧方淋巴结清扫保留植物神经术,在清除淋巴结时注意对腹前神经丛、盆神经丛和盆内脏神经的保护。对照组行传统的直肠癌根治术（不作侧方淋巴结清扫）。对两组手术时间、出血量、严重并发症、性功能、排尿情况、机体的免疫状况及淋巴结转移率进行比较。结果两组的平均手术时间、出血量差异具有统计学意义（P〈0.05）;术后两组排尿、性功能、外周血CD3＋、CD4＋、IL-6、IgM、IgA、IgG水平两组间差异具有统计学意义（P〈0.05）;侧方清扫组23例中发生侧方转移5例,占21.7%,对照组的侧方转移率为53.8%。结论侧方淋巴结清扫保留植物神经术在直肠癌患者的治疗中有一定的临床价值,其创伤小,大大提高了患者的术后生活质量,值得推广。     

腹腔镜左结直肠癌根治术经自然腔道取标本的临床疗效

目的 研究腹腔镜左结直肠癌根治术经自然腔道取标本(NOSE)的临床应用效果。方法 纳入我院普通外科收治的左结直肠癌患者133例,根据术中取标本方式的不同将其分为NOSE组及常规组。比较2组患者围术期指标,包括手术时间、术中出血量、淋巴结清扫数目、首次排气时间以及术后住院时间;比较2组患者术后并发症发生情况;比较2组患者术后1个月肛门功能情况。结果 NOSE组手术时间较常规组更长,术中出血量以及首次排气时间更少/短,差异有统计学意义(P 0. 05);而2组淋巴结清扫数目及术后住院时间比较,差异无统计学意义(P 0. 05)。2组患者术后并发症总发生率比较,差异无统计学意义(P 0. 05)。2组患者术后1个月肛门功能Kirwan分级情况比较,差异无统计学意义(P 0. 05)。结论 NOSE在腹腔镜左结直肠癌根治术中适用性较好,保证了腹壁的美观性,患者术后恢复较快且不影响肛门功能。     

羟乙基淀粉130／0．4溶液术前扩容对结肠癌患者围术期血液流变学及术后深静脉血栓形成的影响

目的观察羟乙基淀粉（HES）130／0．4溶液术前扩容对结肠癌患者围术期血液流变学及术后深静脉血栓发生率的影响。方法择期行结肠癌根治术的40例患者随机分为两组（n=20）。麻醉诱导时于30min内给两组患者分别输注15ml·kg^-1 HES 130／0．4溶液（HES组）和乳酸钠林格氏（RL）溶液（RL组）。分别于麻醉诱导前（T0）、扩容结束后即刻（T1）、扩容结束后1h（T2）、手术结束后1h（T3）抽取静脉血，检测全血黏度、血浆黏度、红细胞聚集指数（EAI）、纤维蛋白原、血细胞比容（HCT）。采用彩色多普勒超声于术后第7天检查双下肢深静脉血栓形成（DVT）的发生情况。结果与T0比较，HES组T1、T2和T3时全血黏度、血浆黏度、EAI、纤维蛋白原、HCT降低（P〈0．05）。与T0比较，RL组T1时全血黏度、血浆黏度、EAI、纤维蛋白原、HCT降低（P〈0．05），T3时全血低切黏度、红细胞聚集指数增加（P〈0．05）。与RL组比较，HES组T2和T3时全血黏度、EAI、纤维蛋白原和HCT均显著降低（P〈0．05）。HES组术后DVT发生率明显低于RL组（P〈0．05）。结论术前采用HES130／0．4溶液扩容能明显改善结肠癌根治术患者围术期血液流变学指标，并能降低术后DVT的发生率。     

高血压脑出血救治中超早期锁孔手术的疗效分析

目的分析高血压脑出血救治中超早期锁孔手术的疗效。方法回顾性分析2010年4月至2012年10月在我院接受外科治疗的高血压脑出血患者的临床资料,依据患者手术方式不同分为观察组（锁孔手术组）和对照组（小骨窗手术组）。比较2组患者手术时间、血肿清除率、术后并发症及神经功能恢复等指标。结果观察组手术时间显著短于对照组（P〈0．001）;观察组患者拔管时血肿清除率与对照组患者相比差异无统计学意义（P〉0．05）;观察组患者术后并发症显著低于对照组（P〈0．05）;观察组术后代谢及电解质紊乱发生率显著低于对照组（P〈0．05）;术后28d观察组患者SSS评分显著高于对照组患者（P〈0．05）。观察组患者术后6个月ADL评分优于对照组（P〈0．05）。结论高血压脑出血的外科治疗中,锁孔手术与小骨窗手术相比具有术中损伤小、术后并发症及代谢紊乱发生率低、近期及远期（6个月）神经功能恢复良好等优点。     

乳腺癌改良根治术中保留肋间臂神经的临床研究

目的：探讨保留肋间臂神经在乳腺癌改良根治术中的可行性及临床意义。方法：采用改良根治术治疗I、II期乳腺癌患者76例,术中清扫时保留肋间臂神经42例（实验组）,切除肋间臂神经34例（对照组）。术后对两组患者上臂内侧感觉功能进行对比分析。结果：实验组和对照组患者上臂感觉障碍率术后1月时分别为19．1％和73．5％,术后3月时分别为7．1％和61．8％,术后12个月分别为2．4％和50．0％,组间相比差异均有统计学意义（P〈0．01）;而两组手术时间、出血量、清除淋巴结数目及复发率比较,差异均无统计学意义（P〉0．05）。结论：保留肋间臂神经在I、II期乳腺癌改良根治术中是安全可行的,能有效保留患者上臂内侧皮肤感觉功能,提高患者术后生活质量。     

食管癌患者手术前后机体免疫调节与反应性蛋白表达的分析

目的 研究淋巴细胞及其分泌的因子和几种时相蛋白在食管癌患者手术前后的变化及意义。方法 采用流式细胞术、酶联免疫吸附法及速率散射比浊法检测食管癌根治术患者手术前后的T细胞亚群和NK细胞，血清中IL-6和TNF-α，以及C反应蛋白（CRP）、前白蛋白（PAB）、转铁蛋白（TRF）的水平。结果 与健康对照组比较，食管癌患者组CD3^＋CD4^＋细胞明显增高（P〈0．05），CD3^＋CD8^＋T细胞明显减少（P〈0．05），二者比例增高（P〈0．05），术后较术前更明显（P〈0．05）；术后NK细胞较术前明显减少（P〈0．05）；手术前后血清中IL-6和TNF-α水平与健康对照组比较显著增高（P〈0．05）；CRP水平显著增高（P〈0．05），PAB和TRF平显著降低（P〈0．05），术后较术前更明显（P〈0．05）。结论 食管癌患者T细胞亚群的平衡紊乱导致其细胞因子合成分泌紊乱，具有B细胞活化刺激和炎症活化刺激效应的IL-6和TNF-α因子在调节急性时相性反应蛋白的合成过程中起重要作用。当CRP持续升高，负性时相蛋白PAB、TRF水平持续性降低可提示患者预后不良。对恶性肿瘤患者检测血浆中IL-6和TNF-α可了解其细胞免疫功能状态，而CRP、PAB和TRF同样可作为肿瘤治疗监测和预后判断的参考指标。     

直肠上动脉插管注射美蓝染色在直肠癌根治术中的应用

目的探讨直肠上动脉插管注射美蓝对直肠癌根治术中全直肠系膜切除(TME)的指示作用及染色后清除淋巴结数量的变化。方法将我科2002年1月至2003年12月行直肠癌手术的病人58例随机分为两组,其中经直肠上动脉插管注射美蓝组28例,普通根治组30例,观察两组淋巴结清除情况。结果注射美蓝组患者直肠系膜染色良好,骶前间隙界限清楚,无输尿管损伤及骶前静脉丛损伤,淋巴结检出数明显高于对照组。结论直肠癌术中经直肠上动脉插管注射美蓝能清楚显示直肠系膜,避免输尿管和骶前静脉丛的损伤,同时能提高系膜淋巴结检出数,便于病理分期。     

Anatomic basis of sharp pelvic dissection for curative resection of rectal cancer

The optimal goals in the surgical treatment of rectal cancer are curative resection, anal sphincter preservation, and preservation of sexual and voiding functions. The quality of complete resection of rectal cancer and the surrounding mesorectum can determine the prognosis of patients and their quality of life. With the emergence of total mesorectal excision in the field of rectal cancer surgery, anatomical sharp pelvic dissection has been emphasized to achieve these therapeutic goals. In the past, the rates of local recurrence and sexual/voiding dysfunction have been high. However, with sharp pelvic dissection based on the pelvic anatomy, local recurrence has decreased to less than 10%, and the preservation rate of sexual and voiding function is high. Improved surgical techniques have created much interest in the surgical anatomy related to curative rectal cancer surgery, with particular focus on the fascial planes and nerve plexuses and their relationship to the surgical planes of dissection. A complete understanding of rectum anatomy and the adjacent pelvic organs are essential for colorectal surgeons who want optimal oncologic outcomes and safety in the surgical treatment of rectal cancer.     

Prognostic Factors and Treatment of Recurrence after Local Excision of Rectal Cancer

PurposeIndications for local excision in patients with rectal cancer remain controversial. We reviewed factors affecting survival rate and treatment effectiveness in cancer recurrence after local excision among patients with rectal cancer.Materials and MethodsA total of 831 patients was enrolled. Of these, 391 patients were diagnosed with primary rectal cancer and underwent local excision. A retrospective observational study was performed on patients who underwent full-thickness local excision for rectal cancer.ResultsThe median duration of follow-up was 61 months. The overall recurrence rate was 11.5%. The rate of local recurrence was 5.1%. Five-year overall survival rate among recurrent patients was 66.8%; the rate among patients who underwent salvage operation due to recurrence was 84.7%, compared with 44.2% among patients treated with non-operative management (p<0.001). Multivariate analysis of disease-free survival identified distance from the anal verge (p=0.038) and histologic grade (p=0.047) as factors predicting poor prognosis. Multivariate analysis of overall survival showed that age (p<0.001), serum carcinoembryonic antigen (CEA) levels (p=0.001), and histologic grade (p=0.013) also affected poor prognosis. In subgroup analysis of patients with recurrence, 25 patients underwent reoperation, while 20 patients did not. For 5-year overall survival rate, there was a significant difference between 84.7% of the reoperation group and 44.2% of the non-operation group (p<0.001).ConclusionThe risk factors affecting overall survival rate after local excision were age 65 years or older, preoperative CEA level 5 or higher, and high histologic grade. In cases of recurrence after local excision of rectal cancer, salvage operation might improve overall survival.     

Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer

BACKGROUND: Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision. METHODS: We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and quality-control measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques. RESULTS: Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001). CONCLUSIONS: Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.     

保留肛门的扩大根治术在低位直肠癌中的应用

目的 探讨扩大根治术在低位直肠癌保肛手术中的临床意义。方法 对282例低位直肠癌实施保肛手术，对其中136例行扩大根治术，另146例行一般根治术。结果 一般根治组：总转移率48．6％。N1淋巴结转移率44．5％，N2淋巴结转移率26．0％。转移度19．7％。扩大根治组：总转移率50．7％。N1淋巴结转移率46．3％，N2巴结转移率25．7％，M3淋巴结转移率5．1％，侧方淋巴结转移率13．2％。转移度15．1％。两组未见下方淋巴结转移。术后随访结果：一般根治组3年生存率72．3％，局部复发率14．1％；扩大根治组3年生存率81．7％，局部复发率5．3％。排便功能：一般根治组优83．6％，尚可11．6％，差4．8％。扩大根治组优83．1％，尚可11．0％，差5．9％。结论 扩大根治术可有效防止低位直肠癌保肛术后局部复发，术后排便功能良好，不增加手术合并症。     

腹腔镜保留盆腔自主神经直肠癌根治术与开腹手术术后患者生存质量的对比研究

目的保留盆腔自主神经直肠癌根治术较传统手术对提高患者生存质量进步显著,但仍不能使人满意,因此在临床中需要寻求新的手术方式提高患者生存质量。方法118例直肠癌男性患者,年龄35~60岁,平均年龄47岁。随机分为腹腔镜组63例,开腹组55例。利用腹腔镜操作保留盆腔自主神经直肠癌根治手术,与开腹式手术进行对比观察,分析患者术后排尿功能与性功能情况。结果尿管拔除时间、排尿量、残尿量、性功能综合情况比较,腹腔镜组[(2.3±1.6)d,(11.8±3.1)mL,性功能Ⅰ级37例(58.7%)]均优于开腹组[(4.5±1.3)d,(20.6±2.7)mL,性功能Ⅰ级28例(50.9%)],其中排尿量腹腔镜组为(327.5±37.6)mL,开腹组为(243.6±36.8)mL,两组比较差异有统计学意义(P<0.05)。结论腹腔镜能够观察到开腹手术的死角,更加精确地保留盆腔神经,提高直肠癌患者生存质量。     

腹腔镜与传统开腹术治疗直肠癌的手术并发症比较

目的分析腹腔镜下全系膜切除术(TME)与开腹TME手术治疗直肠癌在并发症发生率方面的差别。方法回顾43例腹腔镜和50例传统开腹手术治疗直肠癌患者的临床资料,分析并发症的发生原因及其发生率。结果腹腔镜治疗组较传统开腹组在术后肠功能恢复、早期下床活动、住院时间等方面均占优势。在术中损伤吻合口瘘、术后性功能保护、排尿功能障碍、局部复发和切口转移上与传统开腹组均无明显差别。结论腹腔镜下TME治疗直肠癌的效果同传统开腹术,术后患者自觉症状较开腹手术良好。     

Recurrences after Local Excision for Early Rectal Adenocarcinoma

Purpose

The role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of local excision for early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients.

Materials and Methods

Between March 1992 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated by local excision with curative intent. The mean tumor distance from the anal verge was 5 cm (range, 1-10 cm).

Results

The median follow-up was 66 months (range, 17-161 months). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Recurrence had developed in 10 patients (6 local recurrences, 4 systemic recurrences). Purely extrapelvic recurrence was observed in only two (5.7%) patients. Of the eight recurrent patients with surgical salvage, five survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively.

Conclusion

Local excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported and may not be a valid modality. Either the use of adjuvant therapy with local excision, even in patients with T1 lesions or the use of preoperative therapy followed by local excision has good promise.