低位直肠癌侧方淋巴结清扫的临床意义

目的：探讨侧方淋巴结清扫在低位直肠癌治疗中的意义。方法：回顾性分析782例低位直肠癌以扩大淋巴结清扫的方法清扫直肠癌上方、侧方及部分下方的淋巴结。应用常规病理学的方法观察其侧方淋巴结转移的规律,并以直接方法统计侧方转移阳性病例的生存率。结果：①侧方淋巴结转移是腹膜返折以下直肠癌的转移途径,约占该部位直肠癌的12．5％;②侧方淋巴结转移易发生在低分化腺癌及粘液腺癌。肉眼见有浸润倾向者,侧方淋巴结转移与浸润深度有关;③侧方转移者5年生存率为42．2％。结论：腹膜返折以下的进展期直肠癌应该在上方淋巴结清扫的同时行侧方淋巴结清扫,可以避免转移淋巴结的残留,提高生存率。     

中低位直肠癌侧方淋巴结清扫的争议

<正>外科手术仍是目前直肠癌的主要治疗手段。直肠癌手术微创的理念已为大多数外科医师接受,尽管如此,直肠癌扩大根治术也有着重要的临床应用价值。直肠癌扩大根治术的选择和评价,是基于提     

低位直肠癌术中侧方淋巴结清扫的应用价值

目的探讨侧方淋巴结清扫应用于低位直肠癌的价值。方法对41例低位直肠癌患者随机分为侧方清扫组30例，行直肠癌扩大根治术（包括上方、侧方淋巴结清扫）；传统清扫组11例，行传统直肠癌根治术。结果侧方清扫组7例发生侧方淋巴结转移，转移率23．33％，低分化腺癌及黏液腺癌发生侧方淋巴结的转移率比高、中分化腺癌高出4倍多，差异有统计学意义（P〈0．05）。两组手术时间、失血量比较差异无统计学意义（P〉0．05），但侧方清扫组3年生存率比传统清扫组高22．12％。结论对低位直肠癌行侧方淋巴结清扫可降低盆腔复发，改善患者的生存质量，提高生存率，具有临床应用价值。     

保留自主神经的腹腔镜侧方淋巴结清扫在中低位直肠癌的应用

目的探讨保留自主神经的腹腔镜侧方淋巴结清扫术的可行性及安全性。方法对6例保留自主神经的腹腔镜侧方淋巴结清扫的病例资料进行回顾性分析。结果腹腔镜低位或超低位直肠前切除5例．腹腔镜腹会阴联合切除1例。平均手术时间320min,平均出血量117．5ml．平均切除淋巴结为19．7枚。术后并发症4例．包括会阴切口感染1例,泌尿系感染1例,短期尿储留1例,髂窝血肿1例。中位随访时间7．3个月。全部病例均未发现转移复发．均无远期排尿功能和性功能障碍。结论腹腔镜保留自主神经的侧方淋巴结清扫术既达到根治目的又能保留排尿和性功能．在技术上是安全可行的。     

关于中低位直肠癌侧方淋巴结清扫的争论

直肠癌的侧方淋巴结清扫的范围、指征及疗效,不同国家、不同学派的医生的观点存在一定差异。目前认为侧方清扫主要适用于中低位、病理为低分化或T3~4的直肠癌病人,术前可应用放射性核素显像、腔内超声或PET-CT等评估侧方淋巴结情况。侧方清扫对外科技术要求很高,术中应注意在髂内血管和盆壁及闭孔筋膜之间进行分离,直至暴露闭孔神经,清扫淋巴结总数至少应在10枚以上。目前侧方清扫可以降低肿瘤复发率已得到肯定,但侧方淋巴结清扫已达第3、4站,其必要性国际上仍存在争论。笔者认为侧方淋巴结清扫仍有生命力及存在价值,TME基础上改良清扫或选择性侧方淋巴结清扫。腹腔镜下的TME及侧方清扫等均是直肠癌手术今后若干的方向之一。     

131例乳腺癌腋窝淋巴结清扫术中保留肋间臂神经的探讨

1997年 3月至 1999年 12月 ,我们对 131例乳癌患者试行术中保留肋间臂神经 (ｉｎｔｅｒｃｏｓｔｂｒａｃｈｉａｌｎｅｖｅｒ,ＩＣＢＮ) ,现报告如下。临床资料1.一般情况 :本组 131例 ,均为女性 ,年龄 2 5～ 79岁 ,平均 4 6岁。病变位于左侧 94例 ,右侧 37例。临床分期为Ⅰ期18例 ,Ⅱ期 81例 ,Ⅲ期 2 7例 ,Ⅳ期 5例。手术方式 :Ｈａｌｓｔｅｄ手术 2 4例 ,Ａｕｃｈｉｎｃｌｏｓｓ术 10 2例 ,乳腺腺段切除加腋淋巴结清扫术 5例。 131例ＩＣＢＮ的各临床分型示意图见图 1～ 4 ,例数及ＩＣＢＮ的保留情况见表 1。表 1　 各临床分型的肋间臂神经…     

直肠癌切除术淋巴结清扫

随着人类生活水平的不断提高,直肠癌的发病率也在不断提升,据统计,直肠癌由原来的次于肺癌、胃癌的第三位已越至第二位,而且每年都在增加,有可能发展至首位.在我国,直肠癌是最常见的消化道恶性肿瘤,而且不断年轻化,这就意味着越来越多的人面临直肠癌的影响,生活质量将会下降.随着对直肠癌的认识不断加深,手术治疗直肠癌得到了不断的提高,本文结合我们的临床实践和近年来国内外文献对直肠癌切除术淋巴结清扫这一领域加以阐述.     

低位直肠癌侧方淋巴结清扫相关问题

对于低位直肠癌的治疗,在是否选择侧方淋巴结清扫为标准治疗,或将侧方淋巴结转移视为远隔转移而以放化疗为治疗策略等方面,东西方学者的观点仍存在诸多差异。JCOG0212试验并未证实预防性侧方淋巴结清扫的非劣性,其仍具争议。腹腔镜手术技术、辅助治疗等正在改变低位直肠癌的治疗策略,侧方淋巴结清扫的合理应用仍是未来研究的重要课题。     

中低位直肠癌选择性侧方淋巴结清扫策略

侧方淋巴结转移是中低位进展期直肠癌的较常见转移方式,也是亚洲人群新辅助放化疗后常见的局部复发方式,侧方型复发预后极差。侧方肿大淋巴结是放化疗后侧方型复发的独立危险因素,东西方国家关于放化疗与侧方淋巴结清扫等在中低位进展期直肠癌中的应用存在巨大争议。有限的研究显示,对可疑淋巴结转移病人联合应用放化疗与选择性侧方淋巴结清扫,有望进一步降低局部复发率及改善病人生存。对未接受侧方淋巴结清扫的病人,理论上有必要进行更严密的随访,早期发现侧方型复发,及时手术治疗可能带来长期生存。目前,关于新辅助放化疗后侧方淋巴结转移的诊断及选择性侧方淋巴结清扫的手术指征尚无统一意见,亟需大宗病例前瞻性队列研究加以阐明,以进一步改善病人的局部复发及长期生存,并减少因过度手术带来的并发症及生活质量下降。     

腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响

目的 探讨腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响.方法 将2006年8月至2007年8月西南医院收治的119例男性直肠癌患者,按随机数字表法分为开腹组(59例)和腹腔镜组(60例).术后3个月采用尿流动力学和国际前列腺症状(IPSS)评分的方法,分析两组患者术后排尿功能情况.计量资料采用配对t检验.结果 腹腔镜组与开腹组术后IPSS评分分别为(10.9±2.9)分和(11.5±3.1)分,两组比较差异无统计学意义(t=-1.309,P>0.05).腹腔镜组与开腹组术后最大尿流率分别为15.2 ml/s和15.0 ml/s,排尿量分别为150.1 ml和140.9 ml,残余尿量分别为6.1 ml和6.4 ml,最大逼尿肌收缩压分别为43.3 cm H2O(1 cm H2O=0.098 kPa)和45.6 cm H2O,最大尿道压分别为77.5 cm H2O和72.3 cm H2O,以上指标两组比较差异无统计学意义(t=1.22,-2.12,-1.73,-1.35,-1.64,P>0.05).结论 采用腹腔镜技术进行的D3淋巴结清扫同时保留盆腔自主神经的直肠癌根治术是可行的,该技术没有增加自主神经损伤的几率,疗效与开腹手术相当.     

直肠癌Miles术中行腹膜外结肠造口的临床应用价值

为探讨腹膜外结肠造口在直肠癌Miles术中的临床应用价值,回顾直肠癌Miles术中行腹膜外结肠造口者（治疗组,20例）和腹膜内结肠造口者（对照组,20例）资料,就造口并发症的发生率进行对比分析。结果显示,术后随访6～12个月,治疗组造口感染1例,其余造口愈合良好,无其他并发症;对照组造口感染1例,造口回缩2例,腹腔内疝1例,造口旁疝5例,造口狭窄1例,肠梗阻1例。治疗组造口并发症发生率（5．0％）明显低于对照组（55．0％）,P〈0．01。结果表明,与腹膜内结肠造口相比,直肠癌Miles术中行腹膜外结肠造口术后并发症更少,具有较高的临床应用价值。     

直肠癌Miles与Hartmann根治术腹膜外隧道结肠造口38例

为探讨直肠癌Miles与Hartmann根治术腹膜外隧道结肠造口术的疗效,回顾分析38例行该术式治疗的患者的资料。结果显示,38例患者均顺利完成手术,术后未发生造口肠管脱出、回缩,无坏死出血、造口周围感染、造口狭窄、内疝等并发症和后遗症。结果表明,直肠下段恶性肿瘤行Miles、Hartmann根治术腹膜外隧道结肠造口简单易行,并发症少,效果满意。     

经肛门局部切除治疗低位直肠癌28例报告

目的：评价低位直肠癌经肛门局部切除的安全性及效果。方法：回顾性分析1995～2003年间经肛门局部切除治疗28例低位直肠癌的临床资料。结果：(1)围手术期死亡率为0。(2)术后排便功能良好，泌尿及性功能正常。(3)复发率14．3％(4／28)。(4)5年生存率为92．1％。结论：低位直肠癌经肛门局部切除术应选择合适的病例，可获得很好的疗效，且并发症少。     

直肠癌腹腔镜手术与开腹手术的疗效比较

为探讨腹腔镜手术根治直肠癌的安全性、可行性及有效性,随机选取2011年1月至2012年12月于我院接受腹腔镜直肠癌根治术（腹腔镜组）和传统开腹直肠癌根治术（开腹组）治疗的患者各70例,就手术时间、切口长度、术后住院时间、淋巴结清除数目、总住院费用和术后肠道功能恢复时间进行对比分析。结果显示,腹腔镜组切口长度、术后肠道功能恢复时间、住院时间均明显短于开腹组,P〈0．05;在手术时间、淋巴结清除数目方面两组差异无统计学意义,P〉0．05;腹腔镜组总住院费用明显高于开腹组,P〈0．05。结果表明,直肠癌腹腔镜手术可达到与开腹手术同样的根治性治疗效果,近期疗效满意,而且创伤小、患者术后恢复快。     

Retroperitoneal and Lateral Pelvic Lymphadenectomy Mapped by Lymphoscintigraphy and Blue Dye for Rectal Adenocarcinoma Staging: Preliminary Results

Background Total mesorectal excision (TME) is the standard surgical choice for rectal adenocarcinoma. Better prognostic results, achieved with a retroperitoneal and lateral pelvic lymphadenectomy (RLPL), have questioned that TME might not be satisfactory for adequate patient staging, affecting therapeutic definitions. The aims of the ongoing study are to define the accuracy of dye and probe search in the detection of metastatic retroperitoneal and lateral pelvic nodes (RLPN) resected with RLPL, and to evaluate the metastasis frequency in these nodes and its eventual upstaging impact.Methods Thirty rectal adenocarcinoma patients were submitted to RLPL, with RLPN mapping using technetium (Tc 99 m) and patent blue, having nodes examined histopathologically and immunohistochemically.Results Eight hundred and two nodes were analyzed, mean of 26.7 per patient; RLPL was responsible for 41% (330) of the examined nodes, mean of 11 per patient. Metastatic RLPN have occurred in 20% of the patients; the RLPN were metastatic in only 6.7% of the patients; RLPL upstaged 13.3%. For identification of metastatic RLPN with technetium, sensitivity was 33%, specificity 79%, positive predictor value (PPV) 29%, negative predictor value (NPV) 83% and false negative (FN) rate 67%. For patent blue and technetium metastatic RLPN identification, sensitivity was 17%, specificity 92%, PPV 33%, NPV 82% and FN 83%.Conclusions Preliminary results have pointed out technetium and blue dye low accuracy to identify metastatic RLPN; no metastatic RLPN were reported in the patients submitted to preoperative chemoradiation and important upstaging with RLPL. Considering no increase in morbi-mortality rates with RLPL, definitive conclusions will be obtained as the study carries on.     

Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therapy

Objective This is a phase II study, the aim of which is to determine if a laparoscopic approach can be used in pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer following chemoradiation therapy. Methods Patients with T3 lower rectal cancer treated by preoperative chemoradiation were recruited and subjected to laparoscopic pelvic autonomic nerve-preserving surgery with total mesorectal excision and a sphincter-saving procedure. This study was performed with the approval of the ethics committee of National Taiwan University Hospital. Because the quality of a surgical trial is highly dependent on the skill of the surgeon with respect to the technique under study, it is imperative that a surgical trial only be implemented after the surgical technique has been judged to be mature. Before the start of this clinical trial, we gained a sound knowledge of surgical anatomy through conventional open surgery for rectal cancer and mastered the related laparoscopic skills from other sound and proven laparoscopic approaches, including right hemicolectomy, left hemicolectomy, among others. We determined that the learning curve for this surgical technique necessitated that colorectal surgeons carry out at least 20 such procedures. At this point we conducted this clinical trial. The details of the surgical procedures have been shown in the attached video. Briefly, the dissection commences at the pelvic promontory with exposure and preservation of the superior hypogastric plexus. The pre-aortic plexus and inferior mesenteric plexus are preserved by sparing the pre-aortic connective tissue and leaving a 1– to 2-cm-long stump of the inferior mesenteric artery in situ. Subsequently, the “holy plane” at the transition of the mesosigmoid to the mesorectum is meticulously dissected to progressively displace the hypogastric nerves dorsally and laterally and, therefore, preserving them. Following adequate dorsal and lateral dissection down to the floor of the pelvis, the so-called lateral ligament is reached at which the mesorectum appears to be adherent, anteriorly and laterally, to the inferior hypogastric plexus (at roughly 10:00–2:00 O’clock or within an angle of 60° about symphysis on both sides). The ligaments are divided immediately at the endopelvic fascia of the mesorectum to avoid damage to the inferior hypogastric plexus (pelvic plexus). Finally, great care was taken to dissect the lateral border of Denonvilliers’ fascia where the inferior hypogastric plexus joins the neurovascular bundle described by Walsh. Postoperatively, only patients successfully operated on by total pelvic autonomic nerve-preserving surgery were included in the statistical analysis of surgical outcomes. Preoperatively, all patients were screened for their genitourinary function by a questionnaire-based interview. Patients with abnormal preoperative baseline functional data were excluded from further postoperative assessment of sexual or urinary function. The male sexual function was evaluated by potency and ejaculation. In female patients, the sexual function was assessed by vaginal lubrication, dyspareunia, sexual arousal, and orgasm. The reason for these four parameters is because the influence of pelvic autonomic nerve damage on female sexual function has been ambiguous but would most likely result in impairment of vaginal lubrication and congestion of the genitals. We evaluated sexual function at 6 months postoperatively, when the temporary colostomy had been closed and the patients were completely recovered from surgical disability. In evaluating urinary function, the duration between initial voiding trial and spontaneous voiding was recorded. The questionnaire used for the assessment of urinary dysfunction was based on the International Prostate Symptom Score and the following parameters from this Score were used: incomplete emptying, frequency, intermittency, urgency, week stream, straining, and nocturia. Any voiding problems recovered within 3 months after the operation were considered to be transient bladder voiding dysfunction; all other voiding problems were deemed persistent. The interview and scoring of the questionnaire were done by the research assistant blinded to operation procedures. The genitourinary function was ranked as good, fair (decreased), and poor (impaired). Results Between June 2003 and December 2005, a total of 98 patients (stage II: n = 44; stage III: n = 54; male: n = 50; female: n = 48) were enrolled in this study. Technically, although the dissection plane is a little blurred by preoperative chemoradiation therapy, the laparoscopic pelvic nerve-preserving procedure with total mesorectal excision was successfully performed in 89 (90.8%) patients with an acceptable operation time (284.4 ± 44.8 minutes; mean ± standard deviation) and little blood loss (114.5 ± 24 ml). The number of dissected lymph nodes was 16.4 ± 4.0. With respect to scrutiny of surgical specimens, the distal safety margin was adequate (mean: 2.4 cm; range: 1.2–5.6 cm), and the circumferential resection margins were free of tumor invasion (mean: 8.6 mm; range: 2–18 mm). A total of 74 patients completed the evaluation of urinary function. For these 74 patients, the median duration of training for the Foley catheter was 7 days (range: 4–64 days). The voiding function after removal of the Foley catheter were good in 53 (71.6%) patients, fair in 17 (23.0%), and poor in four (5.4%). Of the 17 patients with fair bladder function, eight were transient dysfunction and recovered thereafter. Thirty-two male and 28 female patients who were sexually active before the operation responded to the assessment of sexual function. In male patients, the ejaculation was good in 18 (56.3%) patients, fair (decrease in ejaculatory amounts) in six (18.7%), and poor (retrograde ejaculation, failure to ejaculate) in eight (25%). The potency was good in 20 (62.5%) patients, fair in five (15.6%), and poor in seven (21.9%). In female patients, the sexual function was good in 15 (53.6%) patients, fair in four (14.3%), and poor in nine (32.1%). Specific sexual problems in women included lubrication (46.6%, n = 13), dyspareunia (39.2%, n = 11), sexual arousal (28.6%, n = 8), and orgasm in (32.1%, n = 9). Conclusions By the laparoscopic approach, total preservation of pelvic autonomic nerves without compromise of the radical extirpation of tumor is technically feasible in the vast majority of patients with lower rectal cancer who have undergone concurrent chemoradiation therapy, thus facilitating the retention of genitourinary function in a significant proportion of such patients. Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Oncologic Results of Laparoscopic D3 Lymphadenectomy for Male Sigmoid and Upper Rectal Cancer with Clinically Positive Lymph Nodes

Background Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach. Methods The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection. Results The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6–76.9] months in the N0 group; 56.8 [48.3–65.2] months in N1; 46.8 [37.5–56.1] months in N2; and 43.9 [28.3–59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean ± standard deviation, 27.4 ± 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 ± 44.5 mL), but at the expense of a long operation time (294.4 ± 34.8 minutes). Conclusions The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.     

Vesicourethral Dysfunction Following Radical Surgery for Rectal Carcinoma: Change in Voiding Pattern on Sequential Urodynamic Studies and Impact of Nerve-Sparing Surgery

Objectives Urodynamic studies were performed to clarify vesicourethral dysfunction and recovery after rectal surgery for cancer.
Materials and Methods At 1, and 6 to 12 months after rectal surgery interviews and urodynamic studies (UDS) were performed on 51 consecutive patients, all without a prior history of voiding disorder (40 males and 11 females; median age, 60 years). Patients were divided into 2 groups, either with (preserved group, n = 17) or without (nonpreserved group, n = 34) preservation of the bilateral pelvic plexus during surgery. Comparisons of voiding status and urodynamic parameters were made between the 2 groups.
Results By 1 and 6 months after the operation normal voiding was achieved in 71 % (12/17) and 100% (13/13) of patients in the preserved group, and 6% (2/34) and 30% of patients (9/30) in the nonpreserved group, respectively (P< 0.001). Attainment of normal voiding in the nonpreserved group was preceded by the recovery of bladder sensation, while UDS demonstrated increases in vesical compliance and the disappearance of vesical denervation supersensitivity.
Conclusion A nerve-sparing procedure during radical surgery for rectal carcinoma preserved vesicourethral function. The urodynamic parameters relevant to postoperative recovery of voiding function were improved vesical compliance, disappearance of vesical denervation supersensitivity, and recovery of a bladder filling sensation.     

低位直肠癌保肛术围手术期的护理

为总结使用双吻合器技术行低位保肛手术的护理体会，回顾性分析60例低位直肠癌患者实施该术前后的护理特点，阐述对用双吻合器的患者进行的心理护理、充分的肠道准备、提高患者的营养状况、卧位及活动指导及出院指导等内容。结果显示，60例低位直肠癌患者保肛术后吻合口的愈合均一次成功。术后出现吻合口漏2例，经过治疗和护理均痊愈出院。结果表明，根据双吻合器技术的特点，实施有针对性的护理措施，可减少低位直肠癌保肛术后吻合151漏的发生。