盆腔脏器切除术治疗复发直肠癌

目的：探讨盆腔脏器切除术治疗复发直肠癌的疗效。方法：对1984年至2000年复发直肠癌患49例行盆腔脏器切了作术的临床资料及生存资料进行分析，结果：全组无手术死亡，R0切除率为91．8％，手术并发症发生率为12．2％，本组总的3年生存率为82．4％，5年生存率为48．7％，其中45例获得R0切除患的3年生存率为83．5％，5年生存率为59．5％，17例行全盆腔脏器切除术患的3年生存率为72．7％，5年生存率为45．5％，结论：盆腔脏器切除术是治疗复发直肠癌的有效方法，严格选择病例，确保R0切除，妥善重建泌尿和消化通道及妥善覆盖盆腔，是获得满意疗效，降低术后并发症发生率的关键。     

直肠癌局部复发行全盆腔脏器切除术的临床意义及适应证选择

随着全直肠系膜切除术（TME）及新辅助治疗的普遍应用,近10年来直肠癌的局部复发率已经从20％～40％降低至4％～8％。直肠癌局部复发（LRRc）治疗方式的选择是临床决策的难点。据统计,大约50％的局部复发患者不伴有远处脏器转移,而最理想的治疗方法是将复发肿瘤完整切除（R0切除）。目前的手术方式包括腹会阴联合切除术（APR）、低位前切除术（LAR）、全盆腔脏器切除术（TPE）、后盆腔脏器切除术（PPE）等,其中TPE的R0切除率可达30％～40％,是目前治疗LRRC的主要术式。     

应用盆腔脏器联合切除术治疗局部复发型直肠癌

目的 评价盆腔脏器联合切除术对局部复发型直肠癌的治疗意义。方法 对我院33例局部复发型直肠癌应用盆腔脏器联合切除术治疗的病例进行回顾性总结。结果 33例患中17例接受全盆腔脏器切除术治疗，14例接受后盆腔脏器切除术；2例为直肠癌合并输尿管下段切除。29例（87．9％）手术为根治术，手术死亡率3．0％。盆腔受累最多的器官是骶前组织和阴道。术后约88．9％的患疼痛症状消失。8例（24．2％）再次复发，并再用手术。全组2、3、4年生存率分别为36．4％、21．2％、18．2％。结论 积极的盆腔脏器联合切除术可以明显改善局部复发型直肠癌的预后，提高术后生活质量。     

全盆腔脏器切除术治疗局部进展期及复发直肠癌的进展

全盆腔脏器切除术治疗进展期及复发直肠癌已有半个多世纪的历史。其适应证、切除范围、重建相关技术、疗效等近年来均有较大进展。但由于该技术操作复杂、创伤大、术后并发症多 ,在国内推广缓慢。本文就这方面进展作一综述     

直肠癌的全盆腔脏器切除术

文献报道,6%～10%的直肠癌患者就诊时已局部扩散,无法常规切除犤1犦。直肠癌手术后约有10%～25%的局部复发率犤2犦。对这些患者,放疗或化疗只能暂时缓解症状,扩大手术切除范围则可能为患者提供治愈机会。1948年Brunshwig等犤3犦最先提出用全盆腔脏器切除术(totalpelvicexenteration,TPE)治疗复发宫颈癌,次年Appleby等犤4犦将该术式用于治疗直肠癌。全盆腔脏器切除术包括整块切除远侧乙状结肠、直肠、膀胱、输尿管远端、男性前列腺与精囊腺或女性子宫阴道、盆腔淋巴结、盆腹膜、肛提肌及会阴受累组织犤5犦。1981年,Wanebo等犤6犦借用骨肿…     

全盆腔脏器切除术在局部复发直肠癌中的应用

随着全直肠系膜切除术（total mesorectal excision,TME）及新辅助放化疗的运用,直肠癌切除术后局部复发率虽然有所下降,但仍高达5%～15%.局部复发直肠癌（locally recurrent rectal cancer,LRRC）,尤其是经腹会阴切除术（APR）后确诊时,多已侵及盆腔脏器,尤其是膀胱等泌尿生殖系统,常规手术常难以切除或达到根治性切除.     

全盆腔脏器切除术治疗局部直肠癌

１９８９年－１９９５年，作者对２０例局部进展期直肠癌进行了全盆腔脏器切除术（ＴＰＥ）。手术残废例（５％），合并症发生率为６５％。１９例随３－４２个月，死亡的７例平均自下而上１４．１个月；６例复发。本组结果提示，对局部进展期直肠癌常规治疗效果往不，ＴＰＥ中缓解症状，延长生存。作者还就ＴＰＥ手术适应证和手术方法要点进行讨论。     

新辅助治疗联合盆腔脏器切除术治疗复发直肠癌

目的 探讨新辅助治疗联合盆腔脏器切除术对复发直肠癌的临床治疗价值。方法 对35例复发直肠癌患者,采用新辅助治疗方案。常规分次放疗,放疗总剂量（DT）46Gy,每周5次,每次2Gy。全身化疗2个疗程,每次予以奥沙利铂130mg／m^2,第1天静脉点滴;甲酰四氢叶酸钙（CF）200mg／m^2,第1～3天静脉点滴;氟脲嘧啶（5-Fu）500mg／m^2,第1～3天静脉点滴。治疗结束后4～6周进行盆腔脏器切除手术。结果 经新辅助治疗后,病理完全缓解6例,肿瘤平均缩小38．4％,65．7％的病例T期下降。全组无手术死亡,R0切除率为88．5％,手术并发症发生率为13．3％。本组总的3年生存率为82．8％;5年生存率为48．5％;其中获得R。切除的患者,3年生存率为90．3％,5年生存率为54．6%。结论 新辅助治疗联合盆腔脏器切除术是治疗复发直肠癌的有效方法。通过降低肿瘤病期,提高手术切除率,从而提高患者生存率。     

全盆腔脏器切除术治疗局部进展期直肠癌

１９８９年～１９９５年，作者对２０例局部进展期直肠癌进行了全盆腔脏器切除术（ＴＰＥ）。手术死亡１例（５％），合并症发生率为６５％。１９例随访３～４２个月，死亡的７例平均生存１４．１个月；６例复发。本组结果提示，对局部进展期直肠癌常规治疗效果往往不佳，ＴＰＥ可缓解症状，延长生存。作者还就ＴＰＥ手术适应证和手术方法要点进行讨论。     

新辅助治疗联合盆腔脏器切除术治疗复发直肠癌

目的探讨新辅助治疗联合盆腔脏器切除术对复发直肠癌的临床治疗价值。方法对35例复发直肠癌患者,采用新辅助治疗方案。常规分次放疗,放疗总剂量(DT)46Gy,每周5次,每次2Gy。全身化疗2个疗程,每次予以奥沙利铂130mg/m2,第1天静脉点滴;甲酰四氢叶酸钙(CF)200mg/m2,第1~3天静脉点滴;氟脲嘧啶(5-Fu)500mg/m2,第1~3天静脉点滴。治疗结束后4~6周进行盆腔脏器切除手术。结果经新辅助治疗后,病理完全缓解6例,肿瘤平均缩小38.4%,65.7%的病例T期下降。全组无手术死亡,R0切除率为88.5%,手术并发症发生率为13.3%。本组总的3年生存率为82.8%;5年生存率为48.5%;其中获得R0切除的患者,3年生存率为90.3%,5年生存率为54.6%。结论新辅助治疗联合盆腔脏器切除术是治疗复发直肠癌的有效方法。通过降低肿瘤病期,提高手术切除率,从而提高患者生存率。     

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目的 评价盆腔脏器联合切除术（PE）对局部进展期直肠癌的疗效。方法 对12年中79例局部进展期直肠癌PE术后结果进行回顾性总结。结果 全盆腔脏器切除术（TPE）46例，其中保肛TPE5例，TPE联合骶骨切除1例，TPE联合半骨盆切除1例，后盆腔脏器切除术（PPE）33例。根治性切除65例（82．8％），合并症发生率48．6％，手术死亡2例（2．5％），根治术后再复发36例（58．1％），术后1、3、5年生存率75．8％、39．3％、35．8％。根治性切除与大体根治切除术后3年、5年生存率分别为44．2％、40．8％与11．1％、0。结论 PE是目前治疗局部进展期直肠癌有效的方法，积极的根治性切除病灶，可以有效提高其治愈率，改善生活质量。     

后盆腔次全切除术治疗女性低位直肠癌273例

目的探讨在女性低位直肠癌患者中行后盆腔清除术时兼行保肛手术的可能性。方法自 195 4年 1月至 1999年 12月共收治女性直肠癌 10 2 7例 ,其中 718例为低位直肠癌 ,能行根治性切除者 5 70例 ,占 79 4% ,行后盆腔清除术者 2 73例占 47 9%。按不同时期分二组 ,Ⅰ组 195 4～ 1989年 ,低位直肠癌 36 6例 ,行后盆腔清除术者 2 0 6例 ,占 5 6 3% ,其中 2 2例行后盆腔清除低位前切除 (后盆腔次全切除 ,简称次全切除组 ) ,占 10 7%。Ⅱ组 1990～ 1999年 ,低位直肠癌 2 0 4例 ,行后盆腔清除术 6 7例 ,占 32 8% ,其中 2 6例行次全切除 ,占 38 8%。二组病例在病理学类型、组织学分类和病理分期上均无差异。结果总手术死亡率 3 3% ,二组之间无差异 ,分别为 3 4%和 3 0 %。 48例行清扫保肛手术者发生吻合口漏 4例 (8 3% ) ,均发生于Ⅰ组 ,故Ⅰ组吻合口漏发生率高达 18 2 %。全组术后局部复发 13例 ,占 4 8% ,其中Ⅰ组复发 9例 (4 4% ) ,Ⅱ组 4例 (6 0 % ) ,P >0 0 5。 13例均复发于盆腔 ,无吻合口复发。Ⅰ组 5年生存率 (5 3 2± 1 9) % ,Ⅱ组 (6 7 3± 1 6 ) % ,P <0 0 5。结论女性低位直肠癌患者在行后盆腔清除时 ,对合适的病例兼行保肛手术不但可行 ,而且不会增加局部复发率。Ⅱ组 5年生存率的提高则是我们     

A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database

Aim The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long‐term outcome. Method There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database. Results The median age was 63 (32–75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P = 0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P = 0.007). Forty‐four (49%) patients had no postoperative complications. Fifty‐five major complications were registered. Two (2.2%) patients died within 30 days, and the total in‐hospital mortality was 5.6%. The median follow‐up was 12 (0.4–91) months. The 5‐year survival was 46% for PARC and 17% for LRRC (P = 0.16). Conclusion Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long‐term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.     

Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma

Background: Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy. Methods: Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n=7) and TPE (n=2). Results: Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only. Conclusion: Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.Results of this study were presented at The 48th Annual Cancer Symposium of the Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

The role of pelvic exenteration in the management of recurrent rectal cancer

BACKGROUND: Use of extirpative surgery in the setting of recurrent rectal cancer is controversial given the poor overall outcome of such patients and the morbidity associated with exenteration. METHODS: A retrospective review of patients treated for recurrent rectal cancer from 1990 to 2002 was performed. RESULTS: Twenty-two patients underwent pelvic exenteration. Seventeen underwent potentially curative resection, 5 were for palliation only. There was 1 operative death. Fifteen suffered at least 1 complication; 9 suffered multiple complications. Ten patients required readmission to the hospital. The overall disease-free interval was 11 months. Potentially curative and palliative resections resulted in median survivals of 20.4 and 8.4 months, respectively (P = 0.049). CONCLUSIONS: While patients may derive oncologic and palliative benefits from exenteration, the price in terms of operative morbidity remains high. Newer measures of operative morbidity are necessary to better appraise the value of this radical approach to recurrent rectal cancer.