腹腔镜与开腹结直肠癌根治术临床疗效对比研究

目的:探讨腹腔镜结直肠癌根治术的安全性、有效性及可行性。方法:将大连大学附属中山医院腹腔镜外科2005年3月—2010年8月行腹腔镜结直肠癌根治术41例患者及同期行开腹结直肠癌根治术的41例患者临床资料进行对照研究。结果:两组术中、术后均无严重并发症和死亡病例,腹腔镜组有2例中转开腹手术。腹腔镜组手术时间长于开腹组([180.73±19.06)min vs(136.15±11.82)min,P=0.00]。腹腔镜组术中失血量明显少于开腹组([103.59±20.90)mL vs(201.34±28.96)mL,P=0.00]。清除的淋巴结总数量2组间差异无统计学意义([12.73±0.85)vs(13.1±1.49)枚,P=0.183]。直肠前切除远端切缘长度腹腔镜组明显长于开腹组([3.86±0.51)cm vs(3.48±0.51)cm,P=0.001]。腹腔镜组术后排气时间和下床时间明显早于开腹组([2.96±0.57)d vs(3.35±0.45)d,P=0.001]([4.91±0.82)d vs(5.67±0.95)d,P=0.00]。腹腔镜组住院时间明显短于开腹组([10.62±0.43)d vs(14.54±0.97)d,P=0.00],但住院费用仍明显高于开腹组([3.59±0.71)×104元vs(2.42±0.41)×104元,P=0.00]。2组的3年生存率差异无统计学意义[87.1%(27/31)vs 88.57%(31/35),P=0.286]。结论:腹腔镜技术在结直肠癌治疗上安全、可行,并具有创伤小、恢复快,痛苦少等优点,是目前结直肠癌的一种有效、安全且微创的治疗方式。     

Implementation and usefulness of single‐access laparoscopic segmental and total colectomy

Aim Single‐access laparoscopic surgery is a recent vogue in the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we prospectively examined its usefulness for resectional surgery in routine practice. Method All patients undergoing laparoscopic colorectal resection over a 12‐month period were considered for a single‐access approach by a single surgical team in a university hospital. This utilized a ‘glove’ port via a 3–5 cm periumbilical or stomal site incision, with standard rigid laparoscopic instruments then being used. Results Of 76 planned laparoscopic colorectal resections, 35 (47%) were performed by this single‐incision laparoscopic modality without disruption of theatre list efficiency or surgical training obligations. The mean (range) age and body mass index of these 25 consecutive right‐sided resections, eight total colectomies (seven urgent operations) and two anterior resections was 58 (22–82) years and 23.9 (18.6–36.2) kg/m², respectively. The modal postoperative day of discharge was 4. For right‐sided resections, the mean (range) postoperative stay in those undergoing surgery for benign disease was 4.0 days, while for those undergoing operation for neoplasia (n = 18, mean age 71 years) it was 5.8 days and the average lymph node harvest was 13. Use of the glove port reduced trocar cost by 58% (€60/£53) by allowing the use of trocar sleeves alone without obturators. Conclusion Single‐incision laparoscopic surgery is an effective option for abdominal surgery and seems especially suited for laparoscopic‐assisted right‐sided colonic resections. The glove port technique facilitates procedural frequency and familiarity and proves economically favourable.     

Long-term outcome and health-related quality of life after laparoscopic and open colectomy for benign disease

Background: The benefits of laparoscopic colectomy (LC) vs open colectomy (OC) for the treatment of benign disease have not yet been clearly demonstrated with regard to long-term consequences and health-related quality of life (HRQL). The aim of this study was to compare LC and OC in terms of outcome and HRQL and to determine whether a generic nonspecific instrument for HRQL assessment is valid in postoperative follow-up. Methods: Forty-nine patients who underwent LC for elective right hemicolectomy (RH) or sigmoid resection (SR) for benign polyps or uncomplicated diverticular disease between 1992 and 2000 were evaluated and compared to 50 controls treated by OC in the same period. All patients were evaluated by postal questionnaire to determine recurrence rates and surgery-related complications. HRQL was assessed by the SF-36 Physical and Mental Component Summary Score (PCS, MCS) and by the SF-36 Health Survey, which measures eight different health-quality domains, including physical and social functioning (PF, SF), general health perception (GH), physical and emotional role limitations (RP, RE), body pain (BP), vitality (VT), and mental health (MH). Results: The LC and OC patients were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and diagnosis. There were significant differences between the two groups in resection type (26 RH:23 SR in LC vs 16 RH:34 SR in OC, p = 0.03) and length of follow-up (median, 39 and 53.5 months, respectively, p = 0.04), but neither parameter was predictive of the main SF-36 scores (PCS and MCS). There were no differences between the groups in recurrence rates (8% in LC vs 11% in OC) or surgery-related complications, including incisional hernias (16.3% in LC vs 17% in OC) and small bowel obstructions (2% in LC vs 10.4% in OC). None of the eight SF-36 Health Survey domains or the PCS or MCS scores showed significant differences between LC and OC patients in HRQL. However, occurrence of hernia after surgery was predictive of lower SF-36 scores, specifically in PF (p = 0.047), GH (p = 0.045), SF (p = 0.047), MH (p = 0.041), and MCS (p = 0.037). In addition, small bowel obstruction was significantly associated with lower scores in BP (p = 0.008), GH (p = 0.008), SF (p = 0.013), RE (p = 0.026), MH (p = 0.003), and MCS (p = 0.003). Conclusion: LC was not different from OC for selected indications that measure long-term outcome and HRQL. SF-36 appears to be an appropriate instrument to measure postoperative HRQL, showing responsiveness to changes in objective outcome measures. Presented at the annual meeting of the Society of Gastrointestinal Endoscopic Surgeons (SAGES), New York, NY, USA, 13–17, March 2002     

A comparison of the complication rates between laparoscopic colectomy and laparoscopic low anterior resection

Background This study compared the short-term outcomes, including the complication rate and minimum surgical invasiveness, between patients with colon and rectal carcinomas, who underwent laparoscopic surgery.Methods A review evaluated 151 patients who underwent laparoscopic colectomy (Lap-colectomy; n = 120) and laparoscopic low anterior resection (Lap-LAR; n = 31) between July 2001 and December 2003. The short-term outcomes were compared between the two groups.Results The mean operative time and blood loss were significantly greater in the Lap-LAR group. However, the complication rates and postoperative course between the two approaches were similar, and no anastomotic leakage was observed. There was no significant difference in the serum C-reactive protein level and white blood cell count between the two groups in the early postoperative period.Conclusions Lap-LAR for rectal carcinoma can be performed safely without increased morbidity or mortality, and its short-term benefits are comparable with those conferred by Lap-colectomy.     

结直肠癌患者血浆血栓调节蛋白的检测及其意义

目的检测结直肠癌患者血浆血栓调节蛋白(TM)的水平,探讨血浆TM与结直肠癌临床特征及转归的关系。方法用酶联免疫吸附夹心法检测62例结直肠癌患者的血浆TM水平,并动态观察50例手术前后血浆中血栓TM的水平。结果结直肠癌组血浆TM水平(8.41±5.87)ng/ml,明显高于正常人对照组(5.30±0.86)ng/ml(P<0.01);分层分析发现,早期患者血浆TM水平(5.36±0.53)ng/ml,与正常人对照组比较,差异无统计学意义(P>0.05);随病情进展,血浆TM水平进行性升高[Ⅲ期组(11.20±0.66)ng/ml,Ⅳ期组(13.65±2.41)ng/ml](P<0.01)。手术后血浆TM水平(4.86±0.60)ng/ml,比手术前(8.26±1.36)ng/ml,明显降低(P<0.01)。结论结直肠癌患者血浆TM水平明显高于正常人,并且与结直肠癌的进展呈正相关,监测其水平变化对判断预后有一定参考价值。     

结直肠癌患者ERAS方案和术后住院时间的相关性分析

［摘要］ 目的 研究结直肠癌患者实施ERAS流程后影响术后住院时间的相关因素。方法 收集2015年5月~2018年9月间广东省第二人民医院普外二科接受手术治疗的结直肠癌患者411例，将患者根据《结直肠手术应用加速康复外科中国专家共识（2015版）》方案，完成ERAS标准流程。观察术后住院时间与术前肠道准备、术前碳水化合物摄入、预防性抗生素使用、术中预防低体温措施、目标导向性液体治疗、硬膜外置管、术后早期活动、术后早期进食、非甾体镇痛药使用、早期拔除引流管、年龄、性别、体重指数、美国麻醉医师协会麻醉分级、贫血、手术部位、手术方式、手术时间、术后有无ICU监护、并发症发生情况之间的相关性。利用二分类Logistic回归分析各变量与术后住院时间之间的相关性。结果 年龄、性别、糖尿病、体重指数、新辅助化疗、术前贫血均与术后住院时间无显著相关性，其P值分别为0.705、0.563、0.078、0.674、0.323、0.782。而术前延长术后住院时间的因素为美国麻醉医师协会麻醉分级≥3分（P<0.001， OR=8.000， 95% CI 4.080~15.686）。手术相关因素如手术的方式、手术时间长于180 min与术后住院时间延长密切相关（P=0.025， OR=0.464， 95% CI 0.237~0.907；P<0.001，OR=15.370， 95% CI 7.828~30.175）。而术后的重症监护室监护治疗并不显著影响术后住院时间（P=0.645， OR=0.791，95% CI 0.291~2.148）；术后早期活动延迟与术后住院时间延长相关（P<0.001， OR=12.149， 95% CI 5.284~27.931）；而术前碳水化合物的摄入也对术后住院时间有影响（P=0.001， OR=0.343， 95% CI 0.179~0.658），当然其可使术后患者的住院时间缩短（相关系数为?1.050）。而硬膜外置管镇痛、术中液体平衡及术后早期进食及术后并发症与住院时间并无显著关联。结论 制定更加高效合理的结直肠癌围手术期ERAS方案可缩短患者住院时间，加速患者康复。     

hTERT和C-myc在结直肠癌组织中的表达及其意义

目的　探讨端粒酶逆转录酶 (hTERT)在结直肠癌的表达及其与癌基因C myc的关系。方法　应用免疫组化PowerVisionTM二步法检测 2 0例正常人结直肠粘膜 ,4 2例结直肠腺瘤和 5 8例结直肠癌组织中hTERT和C myc的表达情况。结果　在正常结直肠粘膜、结直肠腺瘤和结直肠癌组织中 ,hTERT阳性表达率分别为 0 0 %、2 6 2 %和 82 8% ,C myc阳性表达率分别为 0 0 %、33 3%和 70 7%。二者在结直肠腺瘤组和结直肠癌组中的表达与正常组比较均有显著差异 (P均 <0 0 1) ,且结直肠腺瘤组与结直肠癌组比较也分别具有显著性 (P均 <0 0 1)。结直肠癌中hTERT和C myc表达呈明显正相关 (r =0 31,P <0 0 5 )。结论　结直肠癌中hTERT和原癌基因C myc表达均增强且呈显著正相关 ,C myc对hTERT基因调控可能是诱发结直肠癌的重要途径。     

Laparoscopic-assisted colectomy with lymph node dissection for invasive carcinoma of the colon

The results of performing laparoscopic-assisted colectomy in 20 patients with invasive carcinoma of the colon were analyzed in this study. The site of the lesion was the right colon in 5 patients, the transverse colon in 1, the left colon in 13, and the rectosigmoid in 1. In 2 patients, the laparoscopic procedure needed to be converted to an open laparotomy. Limited lymph node dissection (R1+, R2) was carried out in 10 patients and extensive node dissection (R3) was carried out in 9 patients. The histological depth of invasion in the 18 patients who underwent laparoscopic-assisted colectomy was the submucosa in 9, the muscularis propria in 2, and the extramuscular layer in 7. There were 3 patients who developed postoperative complications, 1 of whom underwent reoperation due to perforation of the colon. The postoperative course of the patients who underwent laparoscopic surgery was compared with that of a retrospectively selected control group of patients who had undergone open laparotomy. The postoperative recovery of the patients who underwent laparoscopic surgery was significantly faster than that of those who had undergone open laparotomy. Thus, we consider that laparoscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected. This procedure may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.     

The feasibility of laparoscopic colectomy in urgent and emergent settings

Background  Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. However, the use of LC in the emergency setting is relatively unstudied. The authors describe their experience with a series of emergent and urgent LC cases for a variety of colorectal pathologies. Methods  This study reviewed 20 consecutive patients who had a laparoscopic emergent or urgent colectomy over a 2-year period. Patient demographics, indications for surgery, operative details, and postoperative complications were examined. Results  Two cases were converted to open procedure, and the mean operative time was 162 min (median, 163 min). The average postoperative length of hospital stay was 8.1 days (median, 6 days). There was one reoperation and three readmissions within 30 days, with no mortality during the follow-up period. Six patients required intensive care unit (ICU) stays after surgery, and 40% of the patients had one or more postoperative complications. Conclusions  With increasing experience, LC is a feasible option in nonelective situations. Further prospective and comparative studies will improve our understanding of the outcomes for emergency LC.     

Audit of definitive colorectal surgery in patients with early and advanced colorectal cancer

Background : The role of surgery in patients with advanced colorectal cancer may be questioned in the era of specialized intensive palliative care. Should patients with advanced disease be advised against surgery because of the risks of the surgery itself? In this study, the perioperative outcomes in patients undergoing definitive surgery for early (Dukes’ stages A, B and C) and advanced colorectal cancer (stage D) were examined. Methods : All patients undergoing definitive surgery for colorectal cancer during a 15‐year period were identified. Details of tumour site and stage, surgery performed, perioperative complications and postoperative mortality were compared. Results : A total of 374 patients underwent definitive surgery. There were 193 men, a male : female ratio of 1:0.9. Seventy‐one patients had advanced disease. There were no differences between the early and advanced groups in perioperative requirements for either blood or total parenteral nutrition. In the advanced group, more operations were performed as emergencies than in the early group (32.4 vs 17.5%; P < 0.01) and more patients presented with bowel obstruction in the advanced group (23.9 vs 10.2%; P < 0.01). There were no site differences between the early and advanced groups and no differences between the operations performed except that endo‐anal destruction was not performed in advanced patients. There were no differences in perioperative morbidity or mortality in the groups studied. Conclusion : Resection rates, operation type and postoperative morbidity and mortality were similar in patients with both early and advanced colorectal cancers. In terms of perioperative outcome, the presence of advanced cancer, per se, should not, therefore, be a justification to decline surgery.     

Treatment strategy for multiple hepatic metastases of colorectal carcinoma

We describe the treatment strategy for multiple hepatic metastases of colorectal carcinoma based on a review of the literature and our own results. Although a number of studies have suggested that multiplicity or bilobar distribution of metastases is associated with poor outcome, liver resection is thought to be the only potentially curative treatment. The only contraindications to surgery are the presence of extrahepatic metastases (with the exception of resectable lung metastases) and if radical removal of all detectable tumors is not possible. Hepatectomy should be performed with the aim of maintaining a delicate balance between radical removal of tumors and the preservation of as much residual hepatic mass as possible with minimal blood loss. Surgeons should be familiar with the use of intraoperative ultrasonography, a standard adjunct to liver resection. Preoperative portal vein embolization may be indicated in selected patients as a means of inducing hypertrophy in the remaining hepatic parenchyma. Received for publication on Aug. 30, 1998; accepted on Nov. 2, 1998     

Simultaneous laparoscopic descending colectomy and nephroureterectomy for descending colon carcinoma and left ureteral carcinoma: Report of a case

To our knowledge, there is no case report of the synchronous resection of colon and ureteral carcinomas by laparoscopy, because of the rareness of this combination and the technical difficulties involved. We report a case of simultaneous descending colon and left ureteral carcinomas, both of which were judged to be relatively early stage carcinoma, which we resected successfully laparoscopically. The patient, a 65-year-old man, recovered uneventfully and was discharged on postoperative day 8. For simultaneous abdominal primary malignancies, laparoscopic surgery should be considered proactively if the procedure is technically feasible and judged to be curative.     

Comparison of thrombotic biomarkers in surgical patients undergoing open or laparoscopic colectomy for colorectal carcinoma

Aim-Background

Though there is evidence to suggest the benefit of laparoscopic surgery for colon cancer, the potentially less thrombogenic effect of the method compared to open surgery has not been investigated. The objective of the study was to compare thrombogenic factors in patients with colorectal adenocarcinoma subjected to open or laparoscopic surgery.

Methods

During 2010, forty-nine consecutive patients with colorectal adenocarcinoma, who had been referred to a university hospital, were included in a prospective study to undergo either open (Group A-OP, n=26) or laparoscopic (Group B — LS, n=23) resection. Outcome measures included the endogenous thrombin potential (ETP) and D-dimer values at baseline and 1 and 10 days postoperatively.

Results

ETP values changed significantly in time (p<0.001). Although overall treatment effect was not significant (p=0.45), the interaction between treatment and time was significant (p=0.002). With regard to D-dimer values, significant changes are detected at 24h (p=0.005) and 10d (p<0.001). Overall, the treatment effect on D-dimer is significant (p<0.001), with the open group values being higher than those of the laparoscopic group. The interaction between treatment and time is significant (p=0.001). At 24h, the D-dimer increase for OP patients is significantly higher than the respective D-dimer change for LS patients (p<0.001). At 10d, the D-dimer decrease for the OP group is significantly different from the D-dimer change in the LS group (p<0.001).

Conclusions

The surgical method does not influence ETP values; however, values are significantly differentiated between groups. D-dimer values are significantly raised after open surgery. Open surgery may carry the risk of bleeding in the very early postoperative period, most likely due to the consumption of coagulation factors. The introduction of ETP measurement in surgical patients may prove to be a valuable tool in the future in individualizing thromboprophylaxis postoperatively.