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。     

直肠癌侧方淋巴结清扫的效果分析

目的　探讨下部直肠癌侧方淋巴结清扫与生存率和生存质量的关系。方法　对 780例腹膜返折处及其以下进展期直肠癌患者实施根治性切除术 ,其中腹腔内清扫 35 2例 ;腹腔内加腹膜外清扫 4 2 8例。二组在年龄、性别、Dukes′分期 ,病理组织学类型等方面差异无显著意义。结果　出现排尿功能损伤的患者 ,腹腔内清扫组为 12例 ,占 3 6 % ;腹腔内加腹膜外清扫组 2 2 5例 ,占 5 2 6 5 %(P <0 0 1)。性机能损伤 (仅统计男性 ) ,腹腔内清扫组 2 3例 ,占 12 6 % ( 2 3/183) ;腹腔内加腹膜外清扫组 12 7例 ,占 5 3 4 % ( 12 7/2 38) (P <0 0 1)。局部复发率腹腔内清扫组为 15 .9% ( 5 6 /35 2 ) ;腹腔内加腹膜外清扫组为 9 6 % ( 4 1/42 8) (P <0 0 5 )。 5年生存率腹腔内清扫组为 5 2 2 % ;腹腔内加腹膜外清扫组为 5 8 5 % (P <0 0 5 )。结论　二组患者相比 ,腹腔内加腹膜外清扫组虽然能减少局部复发和提高 5年生存率 ,却严重影响术后生存质量     

直肠癌侧方淋巴结清扫与预后关系的META分析

目的探讨直肠癌根治术后进行侧方淋巴结清扫对患者局部复发率、5年生存率的影响，从而为临床直肠癌根治性手术中是否应常规进行淋巴结清扫提供依据。方法利用META分析的方法综合国内外1994至2006年关于直肠癌侧方淋巴结清扫与患者预后关系的文献。结果符合要求纳入分析的文献共8篇，累计病例2669例，其中行侧方淋巴结清扫1324例。直肠癌根治术后行侧方淋巴结清扫患者与未行侧方淋巴结清扫的局部复发率比较，其合并ORs值分别为0．52（95％CI=0．39～0．68，P〈0．01）；患者5年生存率合并ORs值分别为1．99（95％CI=1．78～2．12，P〈0．01）。结论直肠癌根治术后进行侧方淋巴结清扫可降低患者局部复发率，提高5年生存率。     

中低位直肠癌侧方淋巴结转移的危险因素分析

目的探讨影响中低位直肠癌患者侧方淋巴结转移的相关因素。方法回顾性分析新疆医科大学附属肿瘤医院2004年6月至2010年6月间行根治性切除并侧方淋巴结清扫的203例中低位直肠癌（距肛缘10cm以内）患者的临床资料,采用多因素Logistic回归模型分析侧方淋巴结转移的危险因素。结果203例中低位直肠癌患者共清扫侧方淋巴结3349枚,平均清扫17枚／例,阳性淋巴结数221枚。侧方淋巴结转移度为6．6％（221／3349）。单因素分析显示,年龄、家族史、肿瘤长度、大体类型、组织类型、分化程度、浸润深度、侵犯周径、术前CEA、脉管癌栓、上方淋巴结转移与中低位直肠癌侧方淋巴结转移有关（均P〈0．05）。多因素分析显示,低龄、低分化、浸润型、T4期及存在上方淋巴结转移是中低位直肠癌患者侧方淋巴结转移的独立高危因素（均P〈0．05）。结论对于低龄、低分化、浸润型、T4期及存在上方淋巴结转移等中低位直肠癌患者,由于具有较高的侧方淋巴结转移概率．采用选择性侧方淋巴清扫的手术方案更为合理。     

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。     

腹腔镜腹膜外乙状结肠造口的制作及应用

目的探讨腹腔镜下腹膜外乙状结肠造口的安全性和可行性。方法前瞻性入组2011年7月至2012年7月间南京中医药大学第三附属医院肛肠中心收治的36例行腹腔镜腹会阴联合切除术的低位直肠癌患者,按随机数字表法分为腹膜内造口组和腹膜外造口组,每组18例。术后随访4～16（中位7）月,比较两组患者造口并发症情况。结果腹膜外造口组1例患者因乙状结肠近端拖出后肠壁血供障碍而改行腹膜内造口,故后续的分析中予以剔除。腹膜外造口组手术时间[（25．3±8．5）min]稍长于腹膜内造口组[（14．7±6．4）min],但差异无统计学意义（P〉0．05）。两组各有1例术后早期（4周以内）出现造口缺血,均行造口重建手术;腹膜外造口组术后造口水肿发生率明显高于腹膜内造口组[35．3％（6／17）比0,P〈O．05];两组术后早期总并发症发生率差异无统计学意义[58．8％（10／17）比27．8％（5／18）,P〉O．05]。腹膜外造口组后期（超过4周）未出现并发症;腹膜内造口组出现1例造口脱垂、1例造口狭窄和2例造口旁疝,并发症发生率为22．2％（4／18）,两组比较,差异有统计学意义（P〈0．05）。结论腹腔镜腹膜外乙状结肠造口操作并不比腹膜内造口复杂。且其后期造口并发症明显少于腹膜内造口。     

462例中下段直肠癌淋巴转移规律与淋巴清扫范围的分析

目的 探讨中下段直肠癌的淋巴转移规律和淋巴清扫范围。方法 对1990－1999年行传统直肠癌根治术的373例和行传统直肠癌根治术加盆腔侧方淋巴清扫术（简称侧方清扫术）的89例中下段直肠癌患者进行回顾性分析。结果 全组淋巴转移率为41．8％,患者年龄、癌灶浸润深度、大体分型、癌灶大小是影响淋巴转移率的重要因素（P＜0．05）。89例侧方清扫术的盆腔侧方淋巴转移率为15．7％,其中85．7％位于癌灶同侧。有盆腔侧方淋巴结转移者均为浸润深度T3、T4者;癌灶＞3cm、溃疡型或浸润型、年龄＜60岁者盆腔侧方淋巴结转移较高。侧方清扫术组的盆腔复发率为5．6％,明显低于传统直肠癌根治术组的17．7％（P＜0．05）;侧方清扫术组和传统直肠癌根治术组的5年生存率分别为46．7％和47．9％（P＞0．05）。结论 应提高对中下段直肠癌淋巴转移规律的认识,对怀疑或证实有淋巴结转移、癌灶侵犯浆膜或穿透肠壁、癌灶＞3cm、溃疡型或浸润型、年龄＜60岁者建议行侧方清扫术。     

低位直肠癌保肛手术中直肠冲洗治疗对预后的影响

目的研究低位直肠癌保肛术中应用直肠冲洗对预后的影响。方法随机选择98例低位直肠癌患者分为冲洗组（A组）和单纯手术组（B组）,各49例。在经腹低位直肠前切除中,A组进行远端直肠冲洗并将冲洗液进行细胞学检查。将两组2年局部复发率和1、3、5年生存率进行比较。结果A组有27例找到癌细胞,术后局部复发率为1413％,B组为30．6％,两组比较差异有统计学意义（P〈0．05）;A组术后1、3、5年生存率分别为96．8％、72．3％、52．3％,B组分别为95．7％、65．4％、43．0％,两组术后3、5年生存率比较,差异有统计学意义（P〈0．05）。结论低位直肠癌保肛术中远端直肠冲洗是必要的,可以提高低位直肠癌的治疗效果。     

侧方淋巴结清除在直肠癌根治术中的临床意义

目的：探讨侧方淋巴清除在直肠癌根治术中的临床意义。方法：对36例低位进展期直肠癌患者行根治术，清除上方3组淋巴结的同时行侧方淋巴结清除，对分组淋巴结的转移情况进行评价。结果：36例中有19例有侧方淋巴结转移，其中侧方淋巴转移5例，占阳性淋巴结病例的26．3％（5／19），占全部病例的13．9％（5／36），结论：为保证根治手术的彻底性，减少肿瘤复发，对腹膜返折部以下的进展期直肠癌除上方淋巴结必须清除达第3站外，有必要同时进行侧方淋巴清除。     

直肠癌系膜切缘和盆腔侧方转移规律的研究及生存分析

目的研究直肠癌系膜切缘和盆腔侧方转移的规律，为合理施行外科手术提供病理学依据。方法运用大组织切片技术，研究62例手术标本，并分析随访资料。结果有8例（12．9％）标本判定为环周切缘肿瘤浸润（CMI），其术后无病生存率低于切缘无肿瘤者（P=0．003）。12例（19．4％）标本存在盆腔侧方区域肿瘤转移，其中有8例（66．7％）为单一区域受累，4例（33．3％）为多重区域受累；术后无病生存率低于直肠系膜转移及无转移者（P=0．026）。本组盆腔侧方区域肿瘤转移中以直肠中动脉根部受累率最高（6／12，50．0％），其次为髂内动脉部（4／12，33．3％）和闭孔动脉区（3／12，25．0％）。结论直肠系膜CMI和盆腔侧方癌转移对直肠癌患者的术后生存时间有影响，应合理制定手术清扫范围，选用术后辅助治疗。     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

The long-term voiding function and sexual function after pelvic nerve-sparing radical surgery for rectal cancer

BACKGROUND: The aim of the present study is to symptomatically analyze the extent to which pelvic nerve-sparing radical surgery for rectal cancer impacts on long-term voiding and male sexual function. METHODS: A self-administered questionnaire was mailed to 68 patients who underwent pelvic nerve-sparing radical surgery for invasive rectal cancer with 52 responses (28 men and 24 women; 27 complete and 25 incomplete preservation; response rate 76.5%). Each patient was asked to record if there had been any changes in lower urinary tract symptoms after surgery. Sexual function was also investigated in men. RESULTS: Of the 52 patients, 48 (92%) maintained voluntary voiding without catheterization in the long term. Clean intermittent self-catheterization was performed in only four patients with incomplete preservation because of persistent voiding dysfunction. Subjectively, approximately 60% of the patients remained unchanged in lower urinary tract symptoms after surgery. The satisfaction rate regarding the current voiding status was significantly higher in women than in men (83% versus 61%, P = 0.0294), but was not significantly different between those with complete (76%) and incomplete preservation (64%). Despite the acceptable urinary status, 88% of men had some deterioration in the erectile function, regardless of the types of surgical procedures. Overall, 64% of men were unsatisfied with the current sexual function. CONCLUSIONS: Pelvic nerve-sparing radical surgery for rectal cancer preserved the long-term voiding function in the majority of patients. In completely preserved patients and in women, symptomatic outcomes were more satisfactory. Postoperative erectile dysfunction was found to be a serious problem, even in complete nerve-sparing procedure.     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。     

Autonomic nerve-sparing surgery combined with preoperative radio-chemotherapy in advanced lower rectal cancer patients

Since 1985, we have studied autonomic nerve-sparing surgery combined with preoperative radiochemotherapy in patients with advanced rectal cancer to preserve genitourinary function without compromising radicality. The aim of this study was to evaluate postoperative genitourinary function and prognosis. A total of 84 patients with advanced rectal cancer underwent curative surgery combined with preoperative radio-chemotherapy. Of them, 76 underwent curative nerve-sparing surgery using radiation (42.6 Gy) and tegafur suppository. Postoperative genitourinary function, survival, and pelvic recurrence were investigated in these patients. The 5-year and 10-year disease-free survival rate was 80.7%, and the pelvic recurrence rate was 7.9% in patients receiving curative nerve-sparing surgery combined with radio-chemotherapy. All of these patients could micturate spontaneously, but preservation of sexual function was not as successful. Although this combined therapy is useful for curability and good postoperative quality of life, a new approach is needed to preserve sexual function.     

侧方淋巴结清扫对进展期低位直肠癌预后的影响

目的 应用治疗指数(therapeutic index,TX)(TX=肿瘤相关5年生存率×区域淋巴结转移的概率)评估侧方淋巴结清扣对于改善进展期低位直肠癌预后的价值.方法 回顾性分析直肠癌行根治性切除+全直肠系膜切除+侧方淋巴结清扫的96例进展期低位直肠癌患者的临床资料.结果 进展期低位直肠癌直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移率分别为21%(20/96),13%(12/96),10%(10/96)和15%(14/96).检出直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移阳性的进展期低位直肠癌患者5年生存率分别为35%,25%,20%和36%.TX:清扫直肠系膜淋巴结和侧方淋巴结的TX分别为7.4和5.4,明显高于清扫直肠上动脉和肠系膜下动脉旁淋巴结的3.3和2.0.侧方淋巴结转移阳性者术后局部复发率为64%(9/14),TX明显高于侧方淋巴结转移阴性者的11%(9/82)(x2=22.308/P=0.000).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月(95%置信区间:24.8～51.2个月),明显短于侧方淋巴结转移阴性的(80.9±2.1)个月(95%置信区间:76.7～85.1个月),两者差异有统计学意义. 结论侧方淋巴结清扫可降低进展期低位直肠癌根治性切除术后局部复发率以及改善预后.除全直肠系膜切除外,进展期低位直肠癌术中还应进行侧方淋巴结清扫.     

侧方淋巴结清扫在低位直肠癌手术中的应用研究

目的探讨低位直肠癌手术中侧方淋巴结清扫的临床价值。方法将112例在我院施行直肠癌根治术的低位直肠癌患者随机分为两组,观察组(n=54)行全直肠系膜切除(total mesorectalexcision,TME) 侧方淋巴结清扫,对照组(n=58)单纯行TME,比较两组的平均手术时间、术中失血量、局部复发率、远处转移率及生存率等指标。结果两组平均手术时间、失血量比较差异无统计学意义(P>0.05),观察组局部复发率、远处转移率及3年生存率分别为6.1%、8.2%、87.8%,对照组分别为19.2%、23.1%、71.2%,两组比较有统计学差异(P<0.05)。结论低位直肠癌手术时施行侧方淋巴结清扫可有效降低局部复发率及远处转移率,提高患者的生存率,改善生存质量,值得提倡。     

结直肠癌复发再手术60例报告

目的为探讨结直肠癌术后复发的原因、诊断和术后复发的治疗效果。方法笔者回顾性分析10年间收治的60例结直肠癌术后复发患者的临床资料。结果手术后2年内复发40例(66.7%)。60例中吻合口处复发15例,腹腔、盆腔内复发20例,会阴部复发10例,肝脏转移8例,腹壁切口复发7例。全组患者均再次行手术治疗,其中根治性切除38例,姑息性切除22例。再手术后的1,3,5年生存率根治性切除分别为93.6%,48.8%,36.3%;姑息性切除为54.5%,0,0。结论重视术中无瘤技术、切除足够的肠管、彻底清除淋巴结及其所在的肠系膜、消灭微小转移灶是预防结直肠癌术后复发的主要措施。对复发患者应根据复发部位、病期早晚选择以手术为主的综合治疗方案。     

Nerve-sparing Surgery for Advanced Rectal Cancer Patients: Special Reference to Dukes C Patients

Several nerve-sparing operations for advanced rectal cancer that aim to preserve genitourinary function without compromising tumor clearance have been developed in Japan. The aim of this study was to evaluate the survival and local recurrence of these procedures in Dukes B and C patients. A total of 177 patients with advanced rectal cancer underwent curative nerve-sparing surgery (NSS) over the last 11 years; 52 were Dukes B patients and 54 were Dukes C. Altogether 36 had Dukes C1 and 18 had Dukes C2 tumors, 13 with lateral lymph node metastases, designated lateral LN(+). The 5-year survival rate was 92% for Dukes B, 67% for Dukes C1, and 39% for Dukes C2 patients: 11% for Dukes C2 patients with lateral LN(+). The local recurrence rate was 6% for Dukes B, 11% for Dukes C1, and 33% for Dukes C2 patients: 20% for the lateral LN(−) group and 39% for the lateral LN(+) group. Almost all of the patients undergoing NSS could micturate spontaneously, but preservation of sexual function was not as successful. Although there is no guarantee of preserving satisfactory sexual function, our NSS is an acceptable procedure for Dukes B, C1, and C2 patients without lateral lymph node metastases.     

Adjuvant radiotherapy in rectal cancer and total mesorectal excision

Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done "en-bloc" and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphincter saving operations are also allowed.