家族性腺瘤性息肉病患者结直肠癌变的外科预防

目的 探讨家族性腺瘤性息肉病(FAP)患者结直肠癌变外科预防的手术时机和术式选择.方法 回顾性分析我院近年来连续诊治的43例FAP患者结直肠癌的发病状况及预防性手术治疗的疗效.结果 未经手术干预的FAP患者,20岁、25岁、30岁、35岁、40岁、45岁、50岁时的累积结直肠癌变风险分别约为0、10.4%、25.3%、32.4%、63.0%、76.9%、86.2%;发生结直肠癌变的病例中有84.6%发生直肠癌变.11例患者在我院接受了预防性手术治疗,无手术死亡,3例全结直肠切除、回肠J-Pouch肛管手工吻合术患者术后并发吻合口瘘.1例结肠次全切除的患者于术后13年直肠癌变.3例回肠J-Pouch肛管吻合患者无肛门失禁,每日排便4～6次.结论 FAP患者预防性手术治疗时机应在20岁之前,最迟不超过25岁,全结直肠切除、回肠J-Pouch肛管吻合器吻合术预防结直肠癌变安全有效,适合作为预防性手术的首选术式.     

遗传性非息肉病性结直肠癌九个家系的诊治和随访

目的 总结遗传性非息肉病性结直肠癌（ HNPCC） 9个家系的诊断、治疗和随访经验。方法 对我院经治的 9个 HNPCC家系的诊治情况和随访结果进行回顾性分析。结果 9个家系中共有患者 35例 (结直肠癌患者 28例 ),平均发病年龄为 47岁。 35例患者共被诊断为各种恶性肿瘤 55例次,其中结肠癌 29例次（右侧结肠癌 23例次）,直肠癌 12例次,胃癌 4例次,子宫内膜癌和宫颈癌 5例次,食管癌 2例次,乳腺癌、胰腺癌、脑恶性胶质瘤各 1例次。在本组诊断多原发癌患者 11例 ,含异时性多原发结肠癌 8例。 28.5％的结直肠癌患者首次手术 10年内再发异时性结直肠癌而需手术治疗。随诊中发现 2例多原发性结直肠癌患者继发肝转移,另 2例患者发现有 4枚结肠息肉,均经结肠镜切除。结论 常规根治手术不适于本病结直肠癌患者的治疗 ,对已发生结直肠癌的 HNPCC患者应行全结肠（直肠）切除术。对术后患者和可能的突变基因携带者应积极随访,及时切除发现的息肉。     

完全腹腔镜结直肠切除术20例报告

目的:探讨完全腹腔镜结直肠切除术的手术方法、适应证及其安全性和应用价值。方法:回顾分析2007年4月至2008年11月我院为20例患者行完全腹腔镜结直肠切除术的临床资料。结果:行完全腹腔镜全结肠部分直肠切除术2例,次全结肠切除术1例,乙状结肠癌根治性切除术6例,乙状结肠癌姑息性切除术1例,直肠癌根治性切除术10例。术中平均出血116.5ml,平均手术时间183.5min,术后平均住院8d,无严重并发症发生。随访1～19个月无复发。结论:完全腹腔镜结直肠切除术切口小,应用于全结肠部分直肠切除、乙状结肠癌、直肠癌根治术,近期疗效良好,远期疗效有待研究。     

同时性多原发结直肠癌的诊断和治疗

目的:探讨同时性多原发结直肠癌的诊断和外科治疗方法.方法:回顾性分析36例同时性多原发结直肠癌患者的临床资料.结果:全部病例均行同期手术切除,其中姑息性切除1例.根治性切除35例.其5年、10年生存率分别为58.3%及41.7%,与同期单结直肠癌病例相比无显著性差别.结论:结直肠癌患者术前或术中应常规行全程结肠镜检查,术中应常规解剖标本.根治性切除是治疗同时性多原发结直肠癌的治疗原则.     

腹腔镜结直肠次全切除治疗轻中度家族性腺瘤性息肉病

由于家族性腺瘤性息肉病（FAP）患者结直肠恶变的风险大．保留直肠或部分结肠二期手术切除率高．临床上倾向于行全结直肠切除术,并在防止息肉复发、癌变上体现出良好的治疗效果。但患者术后的生活质量较低,术后水电解紊乱、排粪失禁、反复腹泻或肛门湿疹等并发症时有发生。而且FAP也可表现为结肠外病变．结直肠全切除并不能防止结肠外病变的发生。因此．部分学者认为。保留直肠或部分结肠手术（结直肠次全切除）对轻中度病例也是可以选择的术式．在严密随访下．能改善术后排粪情况,提高生活质量．如有癌变再二期行残留结直肠切除术。浙江中医药大学第一临床医学院自2006年9月起．对轻中度FAP患者实施腹腔镜结直肠次全切除术,至2010年7月．成功实施4例,临床效果满意。     

结直肠癌合并急性肠梗阻的外科治疗

目的 探讨结直肠癌并发急性肠梗阻的外科治疗方法及效果。方法 回顾性分析1993年7月至2003年7月间297例结直肠癌并发急性肠梗阻行急症手术治疗患者的临床资料。结果 右半结肠癌并梗阻103例，左半结肠癌和直肠癌并梗阻194例。其中一期切除吻合126例(右半结肠一期切除吻合98例，左半结直肠一期切除吻合28例)，全结肠切除或次全切除吻合者108例，Hartmann手术36例，Dixon手术9例，回乙状结肠或回直肠吻合捷径11例，肿瘤近端肠管造瘘7例。术后出现并发症53例(17．8％)，为切口感染、腹腔感染和肠瘘；死亡17例；280例(94．3％)痊愈出院。结论 一期切除吻合和结肠次全切除及全切除吻合手术治疗结直肠癌并发急性肠梗阻，是方便可行而安全有效的。     

单孔腹腔镜结直肠肿瘤手术操作技巧

目的总结笔者单孔腹腔镜结直肠手术的经验,对该方法的手术操作技巧进行讨论。方法回顾性分析2010年1月至2011年6月期间于笔者所在医院行单孔腹腔镜手术的21例结直肠恶性肿瘤患者的病例资料,总结手术体会。结果 21例患者中,行右半结肠切除者5例,行乙状结肠切除者2例,行经骶前直肠癌切除术者9例,行经腹会阴直肠癌切除术者2例,行全结肠切除者1例,行结肠造瘘术者2例。其中20例患者顺利完成单孔腹腔镜手术,另1例在离断低位直肠时增加了一处12 mm的穿刺切口。手术操作时间40～335 min,(189±75)min;术后住院时间7～16 d,(11.5±3.4)d。术后无出血、吻合口漏、肠梗阻等并发症发生,手术切口无感染、裂口、疝等并发症发生;术后随访6个月未见肿瘤复发。结论在合理掌握适应证条件下,单孔腹腔镜手术对结直肠肿瘤的治疗是安全可行的,其具有更好的微创与美容效果。     

腹腔镜结肠镜诊治直肠癌合并结直肠息肉22例分析

目的:探讨直肠癌合并结直肠息肉的发生率及腹腔镜结合结肠镜处理直肠癌合并结直肠息肉的方法。方法:回顾分析腹腔镜、结肠镜处理直肠癌合并结直肠息肉22例患者的临床资料。结果:9例直肠癌患者结肠镜检查结直肠息肉检出率为24.10%,显著高于同期结肠镜检查结直肠息肉的总检出率12.19%(P<0.01)。直肠癌患者行腹腔镜直肠癌根治术,术前、术中行结肠镜息肉切除术14例;术前结肠镜下注射亚甲蓝标记或术中结肠镜引导下,腹腔镜行直肠癌根治术的同时行含息肉结肠部分切除术5例;直肠癌合并升结肠息肉恶变行腹腔镜直肠癌根治术同时行右半结肠切除术1例;息肉靠近直肠癌一并行直肠癌根治性切除术2例。结直肠息肉切除率为100%,无并发症发生。22例术后随访0.5~4年,2例死于肿瘤转移,20例存活,无肿瘤或息肉复发。结论:直肠癌患者合并结直肠息肉的发生率较高。腹腔镜直肠癌根治性切除术的术前或术中有必要行结肠镜检查,根据息肉情况选择结肠镜息肉切除或腹腔镜下息肉切除。     

微创外科结、直肠肿瘤规范化手术标准(草案)

1 结、直肠微创外科手术的界定 通过腹腔镜完成结、直肠手术的主要步骤,且腹部切口明显小于常规开腹手术的长度,即属结、直肠微创外科手术范畴. 2 结、直肠癌的手术适应证、禁忌证、原则 2.1 适应证 腹腔镜结、直肠癌手术适应证与开腹手术大致相同.①姑息性手术: 对晚期伴有广泛转移的结、直肠癌病例,行腹腔镜肠造瘘、肠道转流及节段性结、直肠切除术; ②根治性手术: 结、直肠任何一段的癌肿均可在腹腔镜下切除,切除范围应包括癌肿所在肠襻、系膜及其区域淋巴结; ③主要术式: 腹腔镜右半结肠切除术; 腹腔镜左半结肠切除术; 腹腔镜直肠、乙状结肠切除术.各术式指征基本同开腹手术.     

结直肠癌并梗阻实施术中全结肠灌洗后Ⅰ期根治术的临床观察

【摘要】〓目的〓观察和分析术中全结肠灌洗后Ⅰ期肿瘤根治切除肠吻合术治疗结直肠癌并梗阻的效果。方法〓选择60例在我院接受结直肠癌根治术并肠梗阻患者分3组,术中结肠灌洗组:急诊手术,实施术中全结肠灌洗后Ⅰ期根治术;常规处理组:患者经保守治疗,肠梗阻解除后实施根治术;分期手术组:保守治疗未能解除梗阻患者,行肿瘤根治,一期肠造瘘,二期肠吻合。对比3组患者治疗的效果和并发症情况。结果〓术中结肠灌洗组的手术时间较术前结肠灌洗组和造瘘组分别延长(P<0.05),并发症发生总次数较多但没有统计学差异。3组患者在手术失血量、胃管留置时间、术后进食时间、总住院时间等没有统计学差异。结论〓对于结直肠癌并肠梗阻的患者,急诊行术中全结肠灌洗Ⅰ期肿瘤切除肠吻合是可行的,但不一定适合所有病例,应结合术前术中的判断。     

Surgery of hereditary colorectal carcinoma

Hereditary colorectal cancer syndromes account for about 7% of all colorectal carcinomas. The most frequent form is Hereditary Nonpolyposis Colorectal Cancer (HNPCC). Identification, cloning and sequence analysis of the predisposing genes enables identification of mutation carriers and non-mutation carriers, respectively. These genetic informations can be used in an individually tailored clinical surveillance program and may ultimately result in standard preventive surgical treatment. In classical FAP the surgical standard is performing a restorative proctocolectomy. It is still unclear now, if this procedure should be modified in attenuated forms (colectomy with ileorectostomy). Due to a high rate of synchronous and metachronous carcinomas a subtotal colectomy in the case of first colon cancer seems to be indicated in HNPCC patients. A proctocolectomy or a restorative proctocolectomy should be weighed in case of carcinomas in the lower rectum. These procedures should be performed under the precondition of identification of the pathogenic germline mutation in the patient, only. In addition, a synchronous prophylactic hysterectomy with oophorectomy should be recommended postmenopausal gene carriers. Intensive counseling of the patient should proceed these preventive procedures involving surgeons, gastroenterologists, geneticists, molecular biologists, gynecologists, physicians and psychologists. It is recommended to have patients treated exclusively in specialized centers. Currently, six interdisciplinary centers for cancer surveillance and early diagnosis in hereditary colorectal cancer are being sponsored in Germany by the Deutsche Krebshilfe since 1999. In the future clinical studies have to be conducted to evaluate the efficacy of extended colorectal resections versus efficacy of surveillance and conventional resections according to general oncological principles.     

Rectal cancer risk in hereditary nonpolyposis colorectal cancer after abdominal colectomy. International Collaborative Group on HNPCC.

OBJECTIVE: The authors analyzed the incidence of rectal cancer in patients with hereditary nonpolyposis colorectal cancer (HNPCC) after an abdominal colectomy. SUMMARY BACKGROUND DATA: The treatment of choice for a newly diagnosed patient with HNPCC with colon cancer is an abdominal colectomy. The incidence of rectal cancer after abdominal colectomy in HNPCC is not known. MATERIALS AND METHODS: A questionnaire was mailed to all International Collaborative Group on HNPCC members to identify patients in whom rectal cancer developed after total, subtotal or completion colectomy. Statistics were performed using the log-rank test, Kaplan-Meier method, and Cox's proportional hazards model. RESULTS: Rectal cancer developed in 8 (11%) of 71 patients a median of 158 months (range, 38-282 months) from their primary procedure. Of these eight patients, adenomas in the rectal mucosa developed in five at risk either before (4) or synchronous (1) with the diagnosis of rectal cancer. At the time of diagnosis of rectal cancer, six of eight patients were being observed. Age at first procedure and whether the patient was under surveillance were the only significant variables (p < 0.05) in the multivariate analysis in terms of rectal cancer risk. The risk of developing rectal cancer was estimated to be 3% every 3 years after abdominal colectomy for the first 12 years. CONCLUSIONS: The risk of rectal cancer in patients with HNPCC after an abdominal colectomy is approximately 12% at 12 years. Age at first surgical procedure and surveillance correlated with rectal cancer risk. Aggressive endoscopic surveillance of the rectum should be performed after abdominal colectomy.     

遗传性非从病性大肠癌24家系的临床特点和诊治

目的　回顾性调查遗传性非息肉病性大肠癌 2 4家系的诊断、治疗经验。方法　对 2 4个遗传性非息肉病性大肠癌家系的诊断、治疗和随访进行回顾性调查 ,分析恶性肿瘤部位、诊断年龄、癌的病理学资料和处理策略。结果　恶性肿瘤在家族中呈常染色体显性遗传 ,2 4个家系中共有患者75名 (多原发癌 2 4名 ) ,共诊断各种恶性肿瘤 12 5个 ,主要有结肠癌 6 3个、直肠癌 2 1个、胃癌 13个、子宫内膜癌 7个、食道癌 6个。患者平均发病年龄 5 1岁 ,较大家系的患者均存在发病年龄逐代提前现象。 2 4 %的大肠癌患者首次手术 10年内再发异时性大肠癌。结论　本病是典型的常染色体显性肿瘤遗传病 ,主要特点包括大肠癌尤其是右侧结肠癌多见 ,多原发癌多见 ;子宫内膜癌、胃癌、食道癌等也是本病的常见肿瘤 ;患者肿瘤发生早并呈发病年龄逐代提前的现象 ;常规肠段切除手术不适于本病大肠癌的治疗 ;对术后患者和可能的突变基因携带者应积极随访     

遗传性非息肉病性大肠癌家系研究

目的;分析遗传性非息肉病性大肠癌家系肿瘤的基因表达及特点,诊治经验。方法：分析24个遗传性非息肉病性大肠癌家系的诊断,治疗和随访结果。记录恶性肿瘤部位,确诊年龄,同时性和（或）异时性癌,肿瘤的病理学资料,应用聚合酶链反应和单链构像多态性方法检查家族成员hMLH1和hMSH2各外显子,对可疑突变片段测序。结果：24个家系中共有患者75例,共诊断各种恶性肿瘤125个,主要有大肠癌,胃癌,子宫内膜癌等,本组诊断大肠癌患者64例（异时性多原发大肠癌16例）,24％的大肠癌患者首次手术10年内再发异时性大肠癌,发现2个家系携带hMSH2基因,1个家系携带hMLH1基因种系突变,均产生截短蛋白,3个家族中已发现12例突变基因携带者,结论：本病主要特点是恶性肿瘤早发,多发;结肠直肠癌,尤其是右侧结肠癌为主,多原发癌,尤其是多原发性大肠癌多见,家族发病年龄逐代提前,常规肠段切除手术可能不适于此类大肠癌的治疗。已发现2个家系有hMSH2基因,1个家系有hMLH1基因突变。     

Recognition and treatment of patients with hereditary nonpolyposis colon cancer (Lynch syndromes I and II).

Primary genetic factors are etiologic in at least 5-10% of patients with colon cancer. The polyposis syndromes (FPC) are easily identified examples because of the spectacular number of polyps. The hereditary nonpolyposis syndromes (HNPCC), although five times more common than FPC, are usually not recognized because they do not have such a distinctive clinical, premonitory genetic marker. Colorectal cancer expression was surveyed in 10 extended, thoroughly documented HNPCC kindreds. One hundred sixteen patients were found to have 183 colorectal cancers. Despite the striking family history, less than 5% were correctly treated by subtotal colectomy. This provided a unique opportunity to study the natural history. Five findings differed significantly (p less than 0.05) from patients with sporadic colon cancer: (1) mean age of initial colon cancer diagnosed was 45.6 years; (2) 69.1% of first colon cancers were located proximal to the splenic flexure of the colon; (3) 18.1% had synchronous colon cancer; (4) 24.2% had metachronous colon cancer develop with life table analysis showing the risk for a metachronous lesion at 10 years to be 40%; and (5) only 23.3% of cancers were located in the sigmoid colon or rectum. Based on this data, it is recommended that the family history of all patients with a newly diagnosed colon cancer be evaluated for evidence of this syndrome. If an autosomal dominant inheritance pattern emerges, an in-depth genetic investigation is indicated. When HNPCC is confirmed, the following recommendations apply: a subtotal abdominal colectomy is indicated at the time of the initial colon cancer because of the risk of synchronous and metachronous lesions. The rectum should be spared in favor of careful lifetime surveillance because of the proclivity for proximal colon cancer involvement. As yet unaffected members of a newly diagnosed HNPCC kindred who are in the "direct genetic line" should be cautioned that they are at 50% risk and must begin an intensive surveillance program beginning in the third decade with careful attention to the right colon. Patients from newly diagnosed HNPCC families who have had a previous conventional colectomy for colon cancer should, at the very least, enter an intensive surveillance program; a prophylactic completion subtotal colectomy should be considered for patients who are less than totally compliant.     

多原发结直肠癌168例临床分析

目的 分析研究多原发结直肠癌(MPCC)在结直肠癌中的发生率及其临床病理特征,分析其漏诊原因.方法 对1985年1月至2003年12月收治的168例MPCC病例的临床和病理资料进行回顾性分析.结果 168例MPCC占同期手术治疗结直肠癌的4.6%.其中同时多原发癌(SC)81例,异时多原发癌(MC)72例,SC并MC者15例.首次诊断结直肠癌的年龄为20～82岁,中位年龄58岁.168例中共发生结直肠癌393处(平均每例2.3处),病灶于直肠和乙状结肠多见,占61.6%.其中18例(10.7%)明确为遗传性非息肉病性结直肠癌(HNPCC),9例(5.4%)高度怀疑HNPCC.14例(8.3%)合并其他器官癌,72例(42.9%)为腺瘤癌变,另有41例(24.4%)同时合并腺瘤.96例SC中,术前行纤维肠镜检查91例,65例(71.4%)获得确诊.所有MC病例均为术后纤维肠镜检查发现.全组总体5年生存率为69.8%.结论 纤维结肠镜检查在MPCC的诊断和随访中意义重大,有助于减少SC的漏诊和及时发现MC.对腺瘤的积极治疗有助于减少MPCC的发生.在MPCC中应重视HNPCC的检测和其他器官癌的监测.由于MPCC可以获得和首发癌相同的疗效,应重视积极的、规范化的手术治疗.     

多原发大肠癌的临床诊断和外科治疗

目的 探讨多原发大肠癌的临床特点、诊断和治疗方法.方法 对1998-2007年收治的47例同时性多原发大肠癌和20例异时性多原发大肠癌患者的临床病理资料进行回顾性分析.结果 67例多原发大肠癌中同时性多原发大肠癌47例(占70%),其中直肠癌占39%.Dukes分期(以病理分期最晚的一个为准):A期6例,B期22例,C期15例,D期4例.67例中伴有淋巴结转移者20例,肠腔内伴有息肉者21例,无息肉者26例.行全结肠切除术3例,结肠次全切除术10例,根治性手术加肠段联合切除术34例.异时性多原发癌20例(占30%),共有癌灶44个,以结肠癌多见,共31例(占70%),二原发癌17例,三原发癌2例,四原发癌1例.与原发癌间隔时间7个月至19年,其中<2年者7例,2～5年者5例,>5年者8例.20例异时性多原发癌的初发癌均行根治性手术,14例二次癌和2例三次癌均行根治性切除术.同时性多原发大肠癌和异时性多原发癌初发癌根治术后5年生存率分别为74%和78%.结论 治疗大肠癌切忌满足于单一肠段或单个肿瘤的诊断和治疗,应利用结肠镜对全肠道进行仔细地检查,以便于及时发现大肠的多原发肿瘤;在根治性切除肠道肿瘤的同时应尽可能多地保留残存的正常肠道,从而更好地改善患者术后的生活质量.     

Surgery for colonic cancer in HNPCC: total vs segmental colectomy

Aim The high reported risk of metachronous colon cancer (MCC) in hereditary nonpolyposis colorectal cancer (HNPCC) has led some authors to recommend total colectomy (TC) as the preferred operation for primary colon cancer, but this remains controversial. No previous study has compared survival after TC with segmental colectomy (SC) in HNPCC. The aim of this study was to determine the risk of developing MCC in patients with genetically proven HNPCC after SC or TC for cancer, and to compare their long‐term survival. Method This is a prospective cohort study of all patients referred to our unit between 1995 and 2009 with a proven germline mismatch repair gene defect, who had undergone a resection for adenocarcinoma of the colon with curative intent. All patients were offered annual endoscopic surveillance. Results Of 60 patients in the study, 39 had TC as their initial surgery and 21 had SC. After 6 years follow up, MCC occurred in eight (21%) SC patients and in none of the TC patients (P = 0.048). The risk of developing MCC after SC was 20% at 5 years. Colorectal cancer‐specific survival was better in TC patients (P = 0.048) but overall survival of the two groups was similar (P = 0.29). Conclusion Patients with HNPCC have a significant risk of MCC after SC. This is eliminated by performing TC as the primary operation for colonic cancer.     

19例异时原发结直肠癌的临床特点分析

【摘要】〓目的〓探讨异时原发结直肠癌的临床特点。方法〓回顾性分析2000年~2012年间19例异时原发结直肠癌的临床特点及治疗效果。结果〓我科在2000年~2012年施行1304例结直肠癌根治术的患者中,发现19例异时原发结直肠癌,概率约为1.4%。第二癌出现在首发癌治疗后15到135个月,中位77个月,平均时间为术后74.2±29.5个月。约68.4%的患者(13/19)第2癌发生时间超过5年。与首发癌比较,第2癌体积更小,多发于升结肠。78.6%的患者存在错配修饰基因蛋白表达缺失。5年存活率达100%,全部患者在观察期内均未发现局部复发和血道转移。 结论〓异时原发结直肠癌的发病率较低,错配修饰基因突变率较高,其预后较好。