26例直肠癌术后局部复发原因分析

近年来，直肠癌外科治疗取得了很大进展。首先，中下段直肠癌经腹会阴切除术(Miles)的比例明显下降，保肛手术明显增多，但术后生存率并未降低；其次，直肠癌术后复发率呈下降趋势，但局部复发仍是导致直肠癌根治术失败的重要原因。现将我院1995--2001年收治的26例直肠癌根治术后局部复发病例的复发原因分析如下。     

术前放疗与直肠癌术后局部复发的临床观察

目的:探讨直肠癌术前放疗与术后局部复发的关系.方法:直肠癌患者男536例,女226例,年龄21.73(平均48)岁;病理分型:高分化腺癌320例(42.0%),中分化腺癌195例(25.6%),黏液腺癌84例(11.0%),乳头状腺癌40例(5.2%),低分化腺癌50例(6.6%),未分化癌34例(4.5%),腺鳞癌18例(2.4%),印戒细胞癌21例(2.7%).分期:Duckes A期115例,B期399例,C期210例,D期38例.762例行手术(n=589)或手术加术前放疗(n=173)治疗.随访(58-143 mo),了解术前放疗与预后的关系.结果:在762例中,术后局部复发142例(18.6%).其中术前放疗者173例中,术后局部复发19例(11.0%),术前未进行放疗的589例中,局部复发123例(20.9%),两者比较有统计学意义(P<0.05).术前未进行放疗的5 a生存率48.1%,手术前施行放疗的5 a生存率58.4%,两者比较有统计学意义(P<0.05),结论:直肠癌术前放疗可以降低术后局部复发率,提高5 a生存率.     

中药保留灌肠促进腹部术后肛门排气32例效果观察

年老体弱或病情较危重的腹部手术患者，术后肠道功能恢复较迟缓。1998～2004年，我们采用中药煎剂对32例腹部手术后48小时肛门未排气者行保留灌肠治疗，疗效满意。现报告如下。     

双吻合器直肠系膜全切除保留盆腔脏器功能的研究

目的探讨双吻合器直肠系膜全切除保持盆腔脏器功能的效果。方法在1995—01／1998—05之间,作者采用Heald提出的直肠系膜全切除再加双吻合器治疗中下段直肠癌57例并随访患者排尿及性功能的变化3年。结果本组无手术死亡病例,无吻合口漏;局部复发率为3．5％,吻合口狭窄两例,发生率为3．5％。无一例出现排尿及性功能障碍。结论直肠系膜全切除加双吻合器保持盆腔脏器功能的有效方法,能提高病人的生活质量。     

喉癌术后患者的生活质量及影响因素

目的探讨喉癌术后患者的生活质量及其影响因素。方法选取2011年11月至2014年3月于该院进行手术治疗的56例喉癌患者,采用世界卫生组织生存质量测定量表简表(WHOQOL-BREF)进行评估,将其中不同术式、年龄、性别、疾病认知度及社会支持程度者的量表评分分别进行统计及比较。结果 56例喉癌患者术后生活质量评分均较低,且其中不同术式、年龄、疾病认知度及社会支持程度者的量表评分也存在明显的差异(均P<0.05),而男女患者之间则无显著性差异(均P>0.05)。结论喉癌术后患者的生活质量较差,其中术式、年龄、疾病认知度及社会支持程度均是其重要的影响因素。     

四肢软组织肉瘤术后局部复发的临床观察

目的探讨影响软组织内瘤（STS）手术后复发的因素，进一步确定STS的切缘。方法分析在我院行扩大切除术后局部复发的25例STS患者，记录肿瘤复发时间、大小、深浅位置等。重点观察肿瘤术后复发的类型和解剖部位。结果肿瘤复发类型为单发，两处复发，多发（≥3处），中位复发时间为7个月。近侧复发率为18．9％（11／60），复发构成比为39．3％（11／28）。原位复发率21．7％（13／60），复发构成比为46．4％（13／28）。远侧复发率为8．3％（5／60），复发构成比为10．7％（5／28）。结论控制STS术后复发应扩大切除近侧范围及严格无瘤操作。     

直肠癌Dixon术后局部复发相关因素分析

研究报道,直肠癌根治性手术后的局部复发率在10%～30%左右[1].直肠癌经腹直肠切除吻合术(Dixon术)术后局部复发率虽然不高,但其病死率高达80%～90%,成为直肠癌术后主要致死原因.随着患者对生活质量要求的提高以及国内对直肠癌手术技术的改进,直肠下段癌包括距肛门3～4 cm肿瘤也尽可能实现Dixon,由此而产生的术后局部、尤其是吻合口复发的发生率相对增多.在局部复发的病例中,只有22%～47%可以再次手术,改行不保留肛门的腹会阴联合切除术(Mi-les术),但再次手术后的5年生存率仅10%,全部复发的病例再次治愈的机会仅3%～5%,预后极差,严重影响了治疗效果[2].因此,如何在保证疗效的前提下行保肛手术,降低Dix-on术后局部复发率具有重要的临床意义.关于手术操作可能引起的脱落于肠腔、腹腔中的癌细胞是否为直肠癌术后局部复发的危险因素的临床研究未见报道.本文对术后局部复发可能的危险因素进行统计分析,并特别对术中肠腔、腹腔冲洗液中的肿瘤细胞进行定量分析,探索直肠癌行Dixon术后局部复发的可能相关因素.     

直肠癌手术后的局部复发：完整切除直肠系膜的重要性

本介绍了直肠系膜完整切除术与传统的直肠癌切除术的不同处，并建议推广直肠系膜完整切除术。     

原发性肝癌术后复发患者再次手术切除与射频消融治疗的临床疗效比较

目的 探讨原发性肝癌手术治疗后复发再次手术切除与射频消融治疗的临床疗效.方法 选取原发性肝癌初次手术治疗后复发患者58例.按照治疗方式的不同分为再次手术组24例与射频消融组34例.再次手术组行腹腔镜肝癌切除术、开腹肝癌切除术,射频消融组行腹腔镜联合超声肝癌射频消融、超声引导下经皮肝癌射频消融.比较两组再次治疗前的临床资...     

直肠癌手术后的局部复发:完整切除直肠系膜的重要性

本文介绍了直肠系膜完整切除术与传统的直肠癌切除术的不同处,并建议推广直肠系膜完整切除术。     

Continent urinary diversion and low colorectal anastomosis after pelvic exenteration. Quality of life and complication risk

INTRODUCTION: Pelvic exenteration is one of the most destructive gynecologic operations performed on an elective basis, with consequent detrimental effects on the quality of life. The use of reconstructive surgery has significantly improved the quality of life of women undergoing this type of procedure. In this paper we review our experience with continent urinary diversion (Miami Pouch) and low colorectal anastomosis at the Division of Gynecologic Oncology of the University of Miami. METHODS: Patients who underwent creation of the continent urinary diversion Miami Pouch from 1988 to 1997 and supralevator pelvic exenteration with low colorectal resection and primary anastomosis from 1990 to 1997 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared. Analysis of complications in irradiated and nonirradiated patients was performed. RESULTS: 77 patients who underwent creation of the Miami Pouch entered this study. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. The most common urinary complications were ureteral stricture/obstruction (22.1%), difficult catheterisation (19.5%) and pyelonephritis (16.9%). Conservative management strategies were successfully used in 80% of the complications. Analysis of breakdown and fistula formation after low colorectal anastomosis was performed on 77 patients. Thirty-five percent of the irradiated patients developed anastomotic breakdown or fistulas, while the occurrence of this type of complications was only 7.5% in the nonirradiated group. CONCLUSIONS: Reconstructive procedures after pelvic exenteration present a significant risk of complications, especially in irradiated patients. Most of the complications related to the creation of continent urinary diversion can safely be treated conservatively. Low colorectal anastomosis carries an acceptable risk of complications in nonirradiated patients, but the risk in irradiated patients is very high, therefore, detailed patient selection and extensive counselling in these groups of patients is mandatory.     

Fascial space priority approach for laparoscopic supralevator posterior pelvic exenteration with nerve sparing: anatomy and technique

Techniques in Coloproctology -     

Surgery for local pelvic recurrence after resection of rectal cancer

This retrospective study evaluated outcome with regard to procedure, local control, and survival after curative surgical resection with and without preoperative radiotherapy for local pelvic recurrence. A total of 58 consecutive patients with local pelvic recurrence of rectal cancer after previous curative resection for primary tumors were reviewed. Of these, 36 underwent both initial resection and follow-up in our department; the remaining 22 had initial surgery and follow-up elsewhere. Of the 58 patients 27 underwent curative re-resection, 9 had palliative resection, and 22 were treated by conservative therapy. Among the 27 patients with curative resection 17 received preoperative radiotherapy (40 Gy) plus surgery and 10 surgery only. No patients were lost to follow-up; median follow-up time was 36.3 months. The overall rate of curative resection was 46.6%: 55.6% in our own follow-up group and 31.8% in the others. With regard to surgical procedure, abdominoperineal resection (APR) with or without sacral resection was standard following previous low anterior resection, and total pelvic exenteration (TPE) with or without sacral resection was common following APR. There was a high incidence of morbidity (71.4%) after TPE. Re-recurrence was observed in 12 (44.4%) after curative re-resection. There was local re-recurrence in 6 (22.2%). The local re-recurrence rate was 11.8% (n = 2) with radiotherapy plus surgery, and 40.0% (n = 4) with surgery alone. The estimated 5-year survival following curative re-resection was 45.6% (61.2% with radiotherapy plus surgery, 29.6% with surgery alone). Both survival and local control with radiotherapy plus surgery tended to be better than with surgery alone. Thus, in selected patients pelvic local recurrence of rectal cancer can be re-resected curably by APR or TPE (with or without sacral resection) combined with preoperative radiotherapy. Accepted: 10 October 1997     

Robotic supralevator total pelvic exenteration with lateral pelvic sidewall dissection for rectal cancer

Techniques in Coloproctology -     

Sphincter preservation with chemoradiation in anal canal carcinoma

PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against Cancer Classification T1–4, N0–3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m² per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m² on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87vs. 59 percent;P=0.03) and colostomy-free survival (94vs. 73 percent;P=0.05). N category (N0vs. N1–3) influenced actuarial cancer-related survival (85vs. 58 percent;P=0.002) and no evidence of disease survival (80vs. 53 percent;P=0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90vs. 50 percent;P=0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P=0.03) and no evidence of disease survival by N category (P=0.03) and mitomycin C dose (P=0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.Supported by a grant from the Wilhelm Sander Foundation (Nr. 94.061.1).Presented at the European Cancer Conference (ECCO9), Hamburg, Germany, September 14 to 18, 1997.     

Preoperative hyperthermia combined with chemotherapy and radiotherapy for patients with rectal carcinoma may prevent early local pelvic recurrence

We examined retrospectively the results of hyperthermia combined with irradiation and chemotherapy (HCR) prescribed preoperatively for patients with adenocarcinoma of the rectum. We compared two groups of patients: Group A: 23 were treated surgically between 1986–1988 and received HCR therapy; group B (controls) 48 were treated with surgery alone or surgery plus chemotherapy from 1980–1985. The recurrence rate within 2 years was compared. Although there was a difference in follow-up time, the two groups were comparable with regard to various prognostic factors. The incidences of local recurrence and of lung metastasis were nil in those given the HCR therapy. In group B, however, the incidences were 15% and 10%, respectively. These differences were statistically significant (P<0.05). The incidence of liver metastasis was much the same between the two groups. All patients tolerated the HCR therapy well except for one with myelosuppression and who refused local hyperthermia because of mild anal pain. There were no other side effects requiring cessation of this treatment. These findings suggest that preoperative HCR therapy for patients with rectal carcinoma decreases the frequency of local recurrence and the likelihood of tumour cell spread during surgical procedures.

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Résumé Nous avons examiné rétrospectivement les résultats de l'hypothermie combinée à l'irradiation et à la chimiothérapie (HCR) préopératoire chez des malades présentant un adénocarcinome du rectum. Nous avons comparé deux groupes de patients: groupe A 23 malades ont été traités chirurgicalement entre 1986 et 1988 et ont reçu HCR; groupe B (contrôle) 48 malades ont été traités avec la chirurgie seule ou la chirurgie plus chimiothérapie entre 1980 et 1985. Les taux de récidives dans les 2 ans ont été comparés. Bien qu'il y ait eu une différence dans le temps de suivi, les deux groupes étaient comparables en ce qui concerne les facteurs pronostics variés. Les incidences de récidives locales et de métastases pulmonaires étaient nulles dans le groupe ayant reçu HCR. Dans le groupe B, par contre, les incidences étaient respectivement de 14.6% et de 10.4%. Ces différences étaient statistiquement significatives (P<0.05). L'incidence de métastases hépatiques était la même dans les deux groupes. Tous les patients ont bien toléré HCR excepté un avec myelosuppression et qui a refusé l'hyperthemie locale en raison d'une douleur anale modérée. Il n'y a pas eu d'autre effet secondaire nécessitant l'arrêt du traitement. Ces résultats suggèrent que HCR pré=opératoire chez les patients ayant un cancer du rectum diminue la fréquence des récidives locales et la possibilité de dissémination de cellules tumorales durant l'acte chirurgical.