联合脏器切除应用于局部进展期右半结肠癌的疗效

目的探讨右半结肠联合周围脏器切除治疗局部进展期右半结肠癌的疗效。方法回顾性分析13例因局部进展期结肠癌并侵犯邻近组织器官而行联合脏器切除的右半结肠切除患者的临床资料。结果13例患者中男8例,女5例,年龄39-76（平均58．6）岁。原发肿瘤位于结肠肝曲6例。升结肠5例．横结肠2例。肿瘤仅侵犯十二指肠3例,同时侵犯十二指肠和其他组织器官9例,另1例侵犯胰腺和胃。手术均采用右半结肠联合胰十二指肠和（或）其他脏器切除术。13例患者术后1年、3年及5年生存率分别为69％、54％和30％。结论右半结肠联合脏器切除术对于局部进展期右半结肠癌具有积极的治疗意义。     

联合脏器切除治疗局部进展期结肠癌

目的探讨对局部进展期结肠癌患者行联合脏器切除的疗效及影响预后的因素。方法回顾性分析1988～1998年对47例结肠癌患者进行联合脏器切除治疗的临床资料,对其肿瘤复发模式及患者生存率进行统计分析。结果本组患者有7例(14.9%)术后出现并发症,无死亡病例。病理证实周围组织器官有肿瘤侵犯30例(63.8%);局部复发8例(17.0%),远处转移16例(34.0%);5年生存率为40.4%。多因素分析,肿瘤UICC分期及淋巴结转移是影响预后的重要因素(P<0.05)。结论对于局部进展期结肠癌累及周围组织脏器的患者,应力争联合脏器切除治疗。     

原发性腹膜后恶性肿瘤的诊断和治疗(附23例报告)

目的提高腹膜后恶性肿瘤的诊疗水平。方法对23例原发性腹膜后恶性肿瘤进行回顾性分析。23例腹膜后恶性肿瘤的临床表现各异,其中例无周围脏器侵犯,14例有周围脏器侵犯。手术根治性切除14例(其中包括9例无周围脏器侵犯和5例联合脏器切除)。姑息性切除6例,仅做术中活检3例。结果手术后并发症仅有1例,是由于术中大出血引起。本组无发生围手术期死亡的病例。手术后复发是5例。复发时间是从术后3个月至1年。5例术后复发均行再手术切除。结论腹膜后恶性肿瘤临床表现缺乏特异性,易侵犯周围腹腔脏器。其首选治疗方法为根治性切除术,如果病人的全身及局部情况许可,应考虑行姑息性切除术．对术后局部复发病例亦应争取再手术切除。     

恶性十二指肠结肠瘘7例报道并文献复习

目的探讨因结肠癌侵犯所致十二指肠结肠瘘的诊疗方法。方法收集笔者所在医院1990年1月至2011年12月22年间收治的7例结肠癌并发十二指肠结肠瘘患者的临床资料，对其手术处理方式及愈后情况进行分析。结果7例均行手术治疗，其中6例肿瘤切除，术后临床症状及体征消失，存活8～39个月后死亡，平均存活时间15．3个月；另1例未能行肿瘤切除，术后37d因营养不良及多脏器功能衰竭死亡。结论十二指肠结肠瘘为结肠癌晚期并发症，手术根治效果差，术后生存时间由原发肿瘤特性决定；合理选择手术方式可以有效缓解患者痛苦，提高其生存质量并延长生存期。     

右半结肠癌侵犯十二指肠的外科处理

目的：探讨右半结肠癌侵犯十二指肠的外科处理方法，方法：在近１０年中对１０例右半结肠癌侵犯十二指肠病人根据不同病理特点作了处理，术式包括十二指肠局部切除，穿孔修补，扩大胰头十二指肠联合切除等，根据肿瘤浸润十二指肠程度，提出将浸润程度分为３型，结果：术后９例一期恢复，另１例在处理并发症后也恢复出院，其中２例已生存３年以上，结论：根据临床分型作出积极的外科处理将有助于改善病情或使病人得以痊愈。     

原发性腹膜后脂肪肉瘤23例报道

目的总结原发性腹膜后脂肪肉瘤(primary retroperitoneal liposarcoma,PRL)的临床病理特征、诊断及治疗方法。方法回顾性分析经手术和活检证实的23例PRL患者的临床病理资料。结果首发症状及体征表现为腹部肿块(91.3%,21/23),腹胀(56.5%,13/23)及腹痛(30.4%,7/23)。B超及CT的定位诊断准确率分别为66.7%(12/18)和85.7%(12/14)。首次手术肿瘤完整切除16例(69.6%),其中8例联合脏器切除;部分切除3例(13.0%);仅行活检4例(17.4%)。PRL肿瘤完整切除术后复发率为75.0%(12/16),该12例中再次手术8例(66.7%)可完全切除肿瘤。结论CT是诊断PRL的重要手段,优于B超;手术以完整切除肿瘤为主,对侵犯脏器者采用累及脏器一并切除;术后复发者可再次手术。     

谈难切性肝癌的切除方法

手术切除至今仍是治疗肝癌最重要有效手段。对与相邻解剖结构无侵犯或无严密粘连的周围型肝癌可按常规方法切除。而对术野显露困难、侧支循环丰富或肿瘤紧邻甚至侵犯主要血管者按常规方法切除则极为困难,甚至可造成无法控制大出血;肿瘤侵犯膈肌或腹部脏器时,强行将肿瘤组织分离,既不能完整切除肿瘤,又可造成肿瘤组织脱落种植,若先切除腹腔脏器再切断肝脏又易造成术野污染。这类病例笔者统称为难切性肝癌,主要包括:①癌肿巨大尤其与膈肌或邻近脏器紧密粘连甚至侵犯者;②肝癌累及下腔静脉、门静脉主要分支或主干者;③特殊部位肝癌,如Ⅰ段、Ⅳa…     

逆行肝切除术及其方法探讨

目的　探索难切性肝癌的切除方法。方法　先离断肝脏,分离被切肝脏与膈肌间的粘连或切除部分被肿瘤侵犯的膈肌,切断相关韧带、取出被切除肝脏。如果邻近脏器与肿瘤紧密粘连或被侵犯则最后分离粘连或一同切除被侵脏器。如邻近脏器之肿瘤侵犯肝脏亦先离断肝脏再将原发肿瘤的器官与肝脏一并切除。结果　１９９４ 年６ 月至１９８８ 年１０ 月,应用该法成功地切除了７４ 例常规肝切除术显露困难或肿瘤与膈肌、相邻脏器紧密粘连以至侵犯的巨大肿瘤（ 甲组） 。同期用常规肝切除术切除１３ 个相似病例（ 乙组） ,二组相比甲组所需手术时间短、术中失血量少、围手术期并发症发生率低（Ｐ＜０－０５） 。结论　逆行肝切除术适合于难切性肝癌的切除。     

联合脏器切除在外科治疗贲门癌中意义的探讨

目的探讨联合脏器切除在外科治疗贲门癌中的意义。方法回顾性随机分析手术切除贲门癌217例。根据能满足肿瘤切除的安全范围而进行近端胃切除186例，全胃切除31例。以肉眼观察有无侵犯及便于淋巴结清扫为标准决定联合切除的脏器。其中联合脏器切除92例，包括联合脾及胰尾切除82例，单纯脾切除10例。结果将全部病例分为三组，即无联合脏器切除组125例，联合单纯脾切除组10例，联合胰脾切除组82例。三组的手术时间分别为3．07h、3．09h及3．77h：术后住院时间分别为23．8d、31．2d及25．9d；术后并发症三组差异无统计学意义（P〉0．05）。联合脾切除（包括胰脾切除）92例中，切除第10组淋巴结共92枚，乎均每例1枚；无联合脾切除125例中，无第10组淋巴结切除。联合腺胰切除82例，共切除第11组淋巴结107枚，乎均每例1．3枚。二者差异有统计学意义。三组的生存率相似，差异无统计学意义。但在Ⅲ期联合切除组的生存率较高，而在Ⅳ期则无联合切除组的生存率较高，二者差异均无统计学意义。结论术中难以以肉眼准确判断肿瘤周围脏器是否受累。联合脏器切除不增加贲门癌手术的并发症。联合脾及胰尾切除对清扫第10、11组淋巴结及提高生存率有积极意义，尤其对Ⅲ期的病例意义似乎更大，但联合脏器切除的原则是在确保肿瘤学根治性的前提下．最大限度地减少创伤和并发症。     

右半结肠癌侵犯十二指肠的外科处理(摘要)

作者在近10年中对10例右半结肠癌侵犯十二指肠者根据不同病理特点作了处理,术式包括十二指肠局部切除,穿孔修补,扩大胰十二指肠联合切除等,术后9例一期恢复,1例在处理并发症后也恢复出院。2例已生存3年以上。作者根据肿瘤浸润十二指肠程度,提出将浸润程度分为三型:Ⅰ型,癌肿小范围浸润十二指肠,直径在1.5~2cm以内,比较活动;Ⅱ型,肿瘤浸润十二指肠直径大于2cm,受累部分比较固定,十二指肠周围组织可同时受累;Ⅲ型,十二指肠存在肿瘤性穿孔。文中根据临床分型就相应的手术处理进行了探讨,强调在结肠癌侵犯十二指肠时,积极的外科处理将有助于改善病情或使病人得以痊愈。     

Synchronous hepatic metastasis and metachronous Krukenberg tumor from advanced colon cancer. A case report with an unexpected disease-free survival

BackgroundIn the international literature we have never found a long survival in patients treated for a colon cancer with synchronous hepatic metastases and for a metachronous Krukenberg tumor.Presentation of caseA 46-year old woman for an advanced colon cancer with a synchronous hepatic metastases was subjected to a left hemicolectomy and a resection of liver segment V (R0 resection; T4N2bM1; stage IVa according AJCC 2010). After one year a CT of the abdomen revealed an expansive formation of the left ovary. The patient was subjected to a bilateral ovariectomy, hysterectomy and hiperthermic intraperitoneal chemotherapy (HIPEC). The patient, after several cycles of adjuvant chemotherapy, is disease-free 13 years after surgery.DiscussionTo our knowledge, in the literature there do not appear to be cases of such disease-free survival. The survival of patient despite the prognostic indexes is discussed. The authors discus the importance of an adequate surgical treatment especially for liver metastases simultaneously treated to colon cancer. The authors also focus on chemotherapy (FOLFOX and then FOLFIRI) performed in a pre-biological era. Furthermore, the degree to which the HIPEC may have had an impact is still unknown, although it seems to be the gold standard for the treatment of the microscopic peritoneal neoplastic remnant.ConclusionThe authors emphasize that the long term survival in colon cancer with hepatic and ovarian metastases is possible as long as it has an adequate surgical approach, a tailored chemotherapy and an intensive follow-up. Most likely new prognostic markers will have to be identified.     

Evaluation of the Seventh Edition of American Joint Committee on Cancer TNM Staging System for Gastric Cancer: Results from a Chinese Monoinstitutional Study

Background

To investigate the validity of the 7th edition of American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer with special attention paid to pT2/pT3, pN1/pN2, and pN3a/pN3b category.

Materials and Methods

Clinicopathologic data of 1998 patients underwent R0 surgery for histologically proven gastric cancers with >15 lymph nodes retrieved were retrospectively reviewed.

Results

Prognoses were significantly different between pT2 and pT3 categories, between pN1 and pN2 categories, or between pN3a and pN3b categories. Each stage in the 6th edition was divided into the 7th edition stage with different survival rates. Moreover, stage IIIA, IIIB, and IIIC in the 7th edition system was divided into the 6th edition stage with different survival rates. Prognoses for patients in 7th edition T4aN1M0/T3N2M0/T2N3aM0, T4bN0-1M0/T4aN2M0/T3N3aM0, and T4aN3aM0/T4bN2M0 were similar to that of patients in T1N3bM0, T2N3bM0, and T3N3bM0, respectively, but significantly better than that of patients in T2N3bM0, T3N3bM0, and T4aN3bM0, respectively. However, no significant difference could be observed among patients in T4bN3aM0, T4aN3bM0, T4bN3bM0, and stage IV. A revised TNM system was proposed, in which T1N3bM0 was incorporated into stage IIIA, T2N3bM0 into stage IIIB, T3N3bM0 into stage IIIC, T4bN3aM0/T4aN3bM0/T4bN3bM0 into stage IV. Further analyses revealed the revised TNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the 6th and the 7th edition system.

Conclusions

It is reasonable to subclassify the 6th edition pT2 category and pN1 category into the 7th edition pT2/pT3 category and pN1/pN2 category, respectively. However, for better prognostic stratification, it might be more suitable for pN3a and pN3b categories to be considered individual determinants of the 7th edition TNM staging system.     

Ⅱ~Ⅲ期结肠癌根治术后复发危险因素分析及其列线图预测模型的应用价值

目的:探讨Ⅱ~Ⅲ期结肠癌根治术后复发危险因素及其列线图预测模型的应用价值。方法:采用回顾性病例对照研究方法。收集2013年1月至2016年6月西安交通大学第一附属医院收治的228例行根治性切除术治疗Ⅱ~Ⅲ期结肠癌病人的临床病理资料;男118例,女110例;中位年龄为62岁,年龄范围为25~87岁。所有病人行开腹或腹腔镜...     

Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon

BACKGROUND: There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma. STUDY DESIGN: The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence. RESULTS: The study population comprised 167 men and 149 women, mean age 70+/-12 years (range 22 to 95 years). Median followup was 63+/-25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n= 17, 5%); pulmonary embolism (n=4, 10%); death (n=2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage. CONCLUSION: Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.     

Prognostic Factors Assessed for 15,096 Patients with Colon Cancer in Stages I and II

Background

We focused on the risk factors for poor outcome after curative resection of a colon cancer in UICC stages I and II based on the data of the Germany-wide quality assurance study “colon/rectum cancer (primary tumor).” In some countries, all stage II colon cancer patients are encouraged to participate in a clinical trial. We feel that this approach is too broad.

Methods

Using the data of 15,096 patients operated on from January 1, 2000 to December 31, 2004, the following factors were analyzed with the Cox regression model: age, comorbidities, ASA score, gender, localization of the tumor (left colon vs. right colon), perioperative complications (yes/no), pT stage, grading (G1/G2 vs. G3/G4), L-status (lymph vessels invasion yes/no), and V-status (venous invasion yes/no).

Results

The probability of a local relapse in stages I and II was 1.5 and 4.6%, respectively, or distant metastases 4.7 and 10.2%, respectively. Only pT stage [hazard ratio (HR) for pT1?=?1, pT2?=?1.821, pT3?=?2.735, and pT4?=?5.881], L-status (HR for L1?=?1.393), age (HR per year?=?1.021), as well as ASA score IV (HR?=?4.536) had significant influence on tumor-free survival.

Conclusions

Despite favorable prognosis and R0 resection, a small percentage of patients will still relapse. The most important risk factor comprising the tumor-free survival is the pT stage followed by L-status and age. These results should be taken into consideration when determining the course for adjuvant chemotherapy, especially if the course includes the recommendation of clinical trial participation for stage II colon cancer patients after an R0 resection.     

Actual standards and controversies in colorectal cancer surgery

In early colorectal cancer, the standard treatment for superficial carcinoma limited to the mucosa is endoscopic polypectomy or local resection. If the carcinoma invades the submucosa, the standard surgical procedure is bowel resection with lymph node dissection. In advanced colon cancer, the ideal extent of bowel resection is defined by removing the blood supply and lymphatics at the level of the origin of the primary feeding arterial vessels. When the primary tumor is equidistant from two feeding vessels, both vessels should be excised at the origin. It is desirable to remove is more than 10 cm of the bowel on either side of the primary tumor. The value of no-touch isolation is controversial. Laparoscopic-assisted colectomy should be limited to clinical trials. For patients with advanced rectal cancer, 4-6 cm clearmargins from the attached mesorectum distal to the tumor are desirable. The ideal distal margin length is 3 cm or greater from the transected mucosal edge to the distal edge of the primary tumor. The inferior mesenteric artery should be excised at its origin. Extended lateral lymph node dissection is indicated for patients with lower rectal cancer invading the muscularis propria or deeper. In stage IV and recurrent cancer, surgical resection is recommended if it appears to offer cure.     

腹腔镜右半结肠根治性切除术

患者取仰卧分腿位,扶镜手站在患者两腿之间,术者站在患者左侧,助手站在患者右侧。腹腔镜观察孔位于脐下10 cm。首先,腹腔镜探查肝脏及腹盆腔,没有发现明确转移灶。先沿Toldt’s线打开升结肠侧方解剖间隙,游离回盲部,以利于更好地牵拉右半结肠。随后,打开回结肠血管与肠系膜下血管之间的系膜,显露肠系膜下静脉,并以此作为标志,自下向上、自中间向右侧进一步解剖并扩大手术平面。良好的游离后,首先分离、夹闭并切断回结肠静脉和动脉,随后处理右结肠血管和结肠中血管,此过程中清扫胰腺前方淋巴脂肪组织。因为肿瘤位于结肠肝曲,我们将幽门下区淋巴结一并切除。完成游离后,脐上方取6 cm纵行切口,将病变肠管提出腹腔外完成切除和回结肠端侧吻合。术后病理回报:p T4b N2b M0(Ⅲc期)。患者恢复顺利,术后第8天出院。     

Resection of Pulmonary Metastases from Colon and Rectal Cancer: Factors to Predict Survival Differ Regarding to the Origin of the Primary Tumor

Background

The purpose of the present study was to determine differences in prognostic factors for survival of patients with pulmonary metastases resected in curative intent from colon or rectum cancer.

Methods

Between 1980 and 2006, prognostic factors after resection of pulmonary metastases in 171 patients with primary rectum or colon tumor were evaluated. Survival of patients after surgical metastasectomy was compared with that of patients receiving standard chemotherapy by matched-pair analysis.

Results

Median survival after pulmonary resection was 35.2 months (confidence interval 27.3–43.2). One-, 3-, and 5-year survival for patients following R0 resection was 88.8, 52.1, and 32.9 % respectively. Complete metastasectomy (R0), UICC stage of the primary tumor, pleural infiltration, and hilar or mediastinal lymph node metastases are independent prognostic factors for survival. Matched-pair analysis confirmed that pulmonary metastasectomy significantly improved survival. Although no difference in survival for patients with pulmonary metastases from lower rectal compared to upper rectal or colon cancer was observed, factors to predict survival are different for patients with lower and middle rectal cancer (R0, mediastinal and/or hilar lymph nodes, gender, UICC stage) compared with patients with upper rectal or colon cancer (R0, number of metastases).

Conclusions

Our results indicate that distinct prognostic factors exist for patients with pulmonary metastases from lower rectal compared with upper rectal or colon cancer. This supports the notion that colorectal cancer should not be considered as a single-tumor entity. Metastasectomy, especially after complete resection resulted in a dramatic improvement of survival compared with patients treated with chemotherapy alone.     

Intra-abdominal desmoid tumor mimicking locoregional recurrence after colectomy in a patient with sporadic colon cancer: report of a case

Desmoid tumors are rare, benign fibromatous lesions that result from the abnormal proliferation of myofibroblasts. A 61-year-old man underwent laparoscopyassisted right hemicolectomy for ascending colon cancer. The final TNM stage was stage IIIB (T3N1M0). Follow-up computed tomography (CT), done 12 months after primary surgery, showed a nodular, enhancing soft-tissue density mass, 12 mm in size, in the mesentery, near the anastomosis. Another CT scan, done 4 months later, revealed that the tumor had enlarged to 27 mm in size. We suspected locoregional recurrence of colon cancer and resected the tumor, together with the distal ileum and colon, including the previous anastomotic site. The tumor was histologically diagnosed as a desmoid tumor. The patient remains well 24 months after his last operation. Differentiating between the desmoid tumor and locoregional recurrent tumor was difficult, and surgical resection was the optimal treatment.