内镜无法切除的结直肠息肉行结肠镜钛夹定位与美蓝定位的方案应用分析

目的:探讨结肠镜钛夹定位与美蓝定位在内镜无法切除结直肠息肉患者腹腔镜手术前的应用价值及临床效果。方法:共纳入50例内镜无法切除结直肠息肉患者作为研究对象,详细记录患者基本信息,采用随机数字法将患者分为钛夹组与美蓝组。腹腔镜手术前均行结肠镜检查,并分别予以钛夹1~2枚标记及息肉基底旁注射美蓝定位。结果:钛夹组成功定位23例(92.0%),美蓝组成功定位17例(68.0%),两组差异有统计学意义(P0.05)。定位失败的患者均改为术中结肠镜定位。两组患者标本长度、近切缘距息肉上缘、远切缘距息肉下缘及淋巴结清扫数量差异均无统计学意义(P0.05);术中出血量、手术时间、术后引流量、肛门排气时间及住院时间两组差异亦无统计学意义(P0.05)。结论:内镜下无法切除的结直肠息肉多为癌前病变,腹腔镜是有效的切除方式,而钛夹标记定位是腹腔镜术前定位的有效方式,其成功率较高,且操作简单、安全,可作为结直肠息肉定位的首选。     

结肠镜联合腹腔镜下结直肠息肉切除

目的：探讨腹腔镜、结肠镜联合治疗结直肠息肉的手术方式、安全性和可行性。方法：分别采用腹腔镜辅助结肠镜下电凝切除、结肠镜辅助腹腔镜下部分肠壁切除、部分肠段切除及腹腔镜下结肠癌根治等方法,对36例结直肠息肉患者进行治疗。结果：36例均顺利完成手术,无中转开腹。5例在腹腔镜辅助下行结肠镜下息肉切除。22例行结肠镜辅助腹腔镜下部分肠壁切除,其中1例在结肠镜操作过程中发生难于控制的出血,另1例造成穿孔且息肉未完全切除,也行结肠镜辅助的腹腔镜下部分肠壁切除。22例中有18例用Endo-GIA完成。6例行腹腔镜下肠段切除,其中4例因息肉基部广,游离肠段后发现血供差;2例息肉位于直肠上段,且息肉稍大。3例行结肠癌根治术。手术时间70~240 min;手术出血量在20~150 mL;肠功能恢复时间20~48 h。所有患者术后均无肠瘘、肠腔狭窄、术后肠道大出血等并发症发生。结论：结肠镜、腹腔镜联合治疗结直肠息肉,提高了手术的安全性和彻底性,是一种值得推广的微创手术方式。     

腹腔镜结直肠手术肿瘤定位方法的临床研究

目的:探讨腹腔镜结直肠手术肿瘤的定位方法。方法:2009年12月至2013年12月收治58例结直肠肿瘤患者,其中22例于术前2 h内行亚甲蓝定位,12例术前行钛夹定位,4例术前行气钡双对比造影检查,20例术中结肠镜定位。准确定位后行腹腔镜结直肠癌根治术或局部肠段切除术。结果:2例行术前亚甲蓝标记患者因腹腔面肠壁浆膜无亚甲蓝染色而无法定位,术中行结肠镜检查定位;1例行术前钛夹定位患者腹部平片见钛夹位于右下腹,结合肠镜肿瘤距肛门的距离,确定病变位于乙状结肠;1例行术中结肠镜检查准确定位患者因结肠镜检查致使小肠及结肠胀气,无手术空间,中转开腹;4例患者行气钡双对比检查准确定位。结论:腹腔镜结直肠术中可结合直肠指诊对肿瘤进行定位,直肠指诊不能触及的肿物,通过术前行亚甲蓝、钛夹标记、气钡双对比造影及术中肠镜检查对结直肠肿瘤进行定位,术中可准确、快速定位病灶,缩短手术时间,减少并发症的发生,同时避免误切肠管及保肛失败。     

腹腔镜联合结肠镜治疗结直肠息肉的临床研究

目的观察腹腔镜联合结肠镜下手术治疗结直肠息肉的临床效果。方法回顾性分析我院2007年3月至2010年6月收治的45例结直肠息肉患者,所有患者均采取腹腔镜联合结肠镜下手术切除,总结手术方法,观察治疗效果。结果本组45例患者首次手术成功42例,首次手术成功率为93.3%;再次手术成功3例,再次手术成功率为100%;2次手术成功率为100%。手术效果其中痊愈者40例,有效者5例,痊愈率为88.9%,总有效率为100%。术后1个月内出现便血1例,系术中操作不慎引起,无腹泻、腹部压痛和反跳痛以及肠鸣音减弱或消失等并发症发生,手术效果理想。术后2个月复查,除1例因手术操作所引起的并发症外,无复发情况。结论腹腔镜联合结肠镜下手术治疗结直肠息肉效果理想,手术安全性较高,手术中患者痛苦较少,且术后恢复较快,发生并发症几率较小,且易操作,值得临床推广应用。     

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。     

纤维结肠镜在腹腔镜结直肠手术中病变定位的应用

目的:探讨术中应用纤维结肠镜进行病变定位在腹腔镜结直肠手术中的应用价值.方法:回顾分析2007年1月至2010年10月为23例患者于腹腔镜术中应用纤维结肠镜辅助定位的临床资料.结果:23例患者术中均定位成功,手术顺利,术后无严重并发症发生.结论:在病变定位困难的腹腔镜结直肠手术中,使用纤维结肠镜辅助定位是一种安全、有效...     

腹腔镜结直肠手术前钛夹标记定位的指征探讨

目的:探讨腹腔镜结直肠手术前钛夹标记辅助病灶定位的应用指征。方法:2013年7月1日至2014年6月30日共行367例腹腔镜结直肠切除术,其中86例(23.4%)因病灶定位不确切行术中肠镜定位,分析并归纳其原因。结果:造成病灶定位不确切的因素包括肛检阴性、术前肠镜定位肿瘤位于非回盲部或升结肠、术前影像学检查未发现原发病灶或原发病灶T分期≤2期、肠镜下评估病灶直径≤3 cm、大体类型为隆起型(各因素均为强烈相关,P=0.000)。上述因素即为术前钛夹标记定位的初步指征,将其表述为流程图。应用此流程图预测367例研究对象是否需行术前钛夹标记定位,取得良好的效果,其灵敏度为94.2%,特异度为90.0%,阳性似然比9.42,Youden指数0.842,准确率91.0%,阳性预测值74.3%,阴性预测值98.1%。结论:应用此指征判断病灶是否需行术前钛夹标记定位方法简便且有效,可避免对无需定位的病灶进行额外操作,降低了术中肠镜定位的使用频率。但术前钛夹标记辅助定位的实际使用效果仍需大样本前瞻性研究确定。     

结直肠腺瘤性息肉和早期癌的内镜治疗

目的 评价结直肠腺瘤性息肉和早期癌的内镜治疗效果.方法 自2006年1月至2007年10月对245例肠镜发现的腺瘤性息肉,局限于黏膜层、抬举征(+)的早期癌患者分别进行息肉圈套切除术、内镜黏膜切除术、内镜分片黏膜切除术和内镜黏膜下剥离术.结果 253枚病变,大小0.5～8.5 cm(平均2.3 cm),其中<2 cm 157枚,>2 cm 96枚.内镜下成功切除249枚,内镜切除成功率98.4%(249/253).内镜治疗中未出现无法控制的创面大出血,2例术后出现迟发出血.1例长蒂息肉治疗后出现少量膈下游离气体,2例直肠病变剥离治疗后出现皮下气肿,保守治疗后气肿减退;4例病变剥离过程中创面见裂口,3例金属夹成功缝合;1例治疗后出现腹胀和腹腔大量游离气体,急诊开腹手术修补创面.总的并发症发生率3.6%(9/253).内镜治疗后8例接受外科手术(病变局部抬举不良4例,分化不良腺癌1例,高级别瘤变2例,穿孔1例).术后随访231例,随访期3～22个月(平均14.3个月),内镜黏膜下剥离术后巨大人工溃疡创面3个月基本愈合;3例分片黏膜切除术后复发.结论 内镜治疗可以有效切除结直肠腺瘤性息肉和早期癌,提供准确的病理诊断资料,内镜治疗并发症发生率有待进一步降低.     

腹腔镜与开腹结直肠手术的对比研究

探讨腹腔镜结直肠手术的临床应用疗效和可行性。回顾性总结2009年1月—2013年4月行腹腔镜辅助结直肠手术65例与同期开腹结直肠手术80例患者的临床资料。腹腔镜组手术时间长,住院费用高,但与开腹组比较,术中出血量少、术后镇痛药物用量少、术后下床活动早、手术并发症发生率低、术后禁食时间短、术后肠功能恢复快、术后住院时间短(P0.01);低位直肠癌保肛率和恶性肿瘤淋巴结清扫数目,腹腔镜组多于开腹组,差异有统计学意义(P0.01)。腹腔镜辅助结直肠手术具有操作安全,患者创伤小、恢复快等优点,恶性肿瘤根治更彻底,值得临床推广。     

腹腔镜下的结直肠手术

近年来腹腔镜手术已广泛应用于治疗各种结直肠疾病包括良、恶性肿瘤.腹腔镜下结直肠手术具有创伤小、术后肠道功能恢复快、住院时间短、疤痕小等优点,但对其治疗恶性肿瘤方面仍存在广泛争议.随着腹腔镜技术的提高和器械的发展,腹腔镜肿瘤切除范围、淋巴结清除范围及术后伤口癌细胞转移率以及短期复发率、生存率与开腹手术相当.但作为一项新技术,腹腔镜存在手术时间长、费用高、设备器械昂贵等制约因素.     

Colonoscopic-assisted laparoscopic colectomy

One of the technical difficulties during laparoscopic and laparoscopic-assisted resection of the right, transverse, and left colon is the mobilization of the splenic and hepatic flexures. We present a simple technique of colonoscopic traction of the splenic or hepatic flexure. This technique enables good exposure and facilitates dissection while laparoscopic mobilization of these segments of the colon is performed.     

Laparoscopic colectomy in the management of large, sessile, transformed colorectal polyps.

BACKGROUND: Colonic polyps are usually removed endoscopically. Surgical intervention is reserved for large, inaccessible colorectal polyps that have underdone malignant transformation. Laparoscopic management of colonic polyps has gained a well-defined role. METHODS: Since 1993, 650 laparoscopic colectomies have been performed in our department. Twenty-eight patients with large, sessile, polyps that have undergone malignant transformation underwent elective laparoscopic colectomy. Operative procedures included 14 sigmoidectomies, 10 low anterior recto-sigmoid resections, 3 right colectomies, and 1 left colectomy. Central ligation of vessels and lymph node dissection were preformed in all patients. RESULTS: The main outcome measures include conversion rate (11%), morbidity (11%), and mortality (3.5%). The mean return of bowel function was 3.1 days, liquid intake 1.4 days, solid food intake 2.5 days, and mean hospital stay 8 days. The mean specimen length was 23 cm, and the mean number of retrieved lymph nodes was 15. Malignancy according to Dukes classification was in situ, n=4; A, n=15; B, n=4; C, n=4; and D, n=1. During follow-up, 2 patients developed liver metastases. CONCLUSION: Laparoscopic colectomy is a technically feasible and effective method for treating large colorectal polyps that have undergone malignant transformation.     

Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure

INTRODUCTION

Polypectomy at colonoscopy may be difficult or dangerous. In such instances colonic resection may be indicated. Novel combined laparoscopic-endoscopic procedures have the potential to allow safe extensive extramucosal resection, thus avoiding resection. Laparoscopic colon mobilisation provides a more favourable orientation for endoscopic mucosal resection and facilitates identification of possible perforation sites with immediate laparoscopic repair or resection if necessary. This study aimed to assess the efficacy and safety of laparo-endoscopic resection (LER) of colonic polyps.

PATIENTS AND METHODS

Data were collected prospectively on consecutive patients undergoing LER. The mode of presentation, referral pattern, lesion site and size, hospital stay, procedural details, complications, histology and further treatment were recorded.

RESULTS

A total of 13 patients underwent attempted LER (16 polyps in total) and this was completed for 10, with a median hospital stay of 2 days. Five polyps were removed whole and eight piecemeal. Excision was clinically complete in all cases. Three procedures were converted to colonic resection. One lesion appeared malignant, indicating a conversion to laparoscopic right hemicolectomy. Two polyps were not amenable to LER and resection was performed. One patient underwent subsequent colonic resection based on the histological findings. There were no perforations or serious complications.

CONCLUSIONS

LER is a safe and effective treatment for large and inaccessible colonic polyps that would otherwise be treated by colonic resection.     

Intraoperative endoscopy in laparoscopic colectomy

Background: The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy. Methods: We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon. Results: Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications. Conclusion: Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.     

老年结直肠癌患者腹腔镜手术与开放手术的临床对比研究

目的:通过对老年结直肠癌患者腹腔镜手术与开放手术各项临床指标的对比研究,探讨老年结直肠癌患者行腹腔镜手术的安全性和可行性。方法:回顾分析2006年1月至2009年12月为117例≥60岁结直肠癌患者行肿瘤根治术的临床资料,其中腹腔镜辅助结直肠癌根治术(A组)55例,传统开腹结直肠癌根治术(B组)62例。对比分析两组的一般情况(ASA评分)、手术病理分级(Dukes分期)、手术时间、手术出血量、术前及术后心肺功能、术中气道压力、酸碱平衡、术后胃肠道功能恢复时间、术后并发症、标本淋巴结阳性率等围手术期情况。结果:两组患者术前ASA评分、合并症、病理分级及手术时间差异无统计学意义(P0.05)。术中患者心功能指标心脏指数、射血分数、肺功能指标动脉血PaCO2、pH值腹腔镜组均有所增高(P0.05),但术后1d再测指标差异无统计学意义。气道压力腹腔镜组明显增高,可通过麻醉改变呼吸指数调整。腹腔镜组胃肠恢复排气时间、术后住院时间显著短于开腹组(P0.05);术中出血、术后相应并发症腹腔镜组明显少于开腹组(P0.05);死亡率、术后淋巴结获取数、阳性率及直肠癌环周切缘阳性率两组差异无统计学意义。结论:为老年结直肠癌患者行腹腔镜辅助根治术具有良好的安全性及可行性,具有出血少、康复快、并发症少、住院时间短等优势。     

Is laparoscopic resection of colorectal polyps beneficial?

Background: We set out to compare the results of laparoscopic and open resections of colorectal polyps. Methods: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n= 23); and group II, open procedures for colonic polyps (n= 22). Results: No significant differences were seen between the groups relative to age [71.7 ± 10.7 versus 70.6 ± 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 ± 1.7 cm versus 2.7 ± 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 ± 5 versus 6.6 ± 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost ($22,840 versus $18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 ± 1.0 days versus 5.5 ± 1.8 days), postoperative pain (2.3 ± 1.4 versus 3.7 ± 1.9 on postoperative day 1 [patient pain rating scale 1–10]), length of hospital stay (6.5 ± 2.0 days versus 9.4 ± 2.7 days), and return to normal activity (5.2 ± 4.2 weeks versus 9.3 ± 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 ± 6.4 cm versus 29.1 ± 22.7 cm) and a shorter mean operative time (177.6 ± 52.7 min versus 143 ± 51.4 min) than patients in group I. Conclusions: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen. Received: 27 January 1997/Accepted: 2 February 1998     

Laparoscopic colectomy for apparently benign colorectal neoplasia: A word of caution

Purpose Endoscopically unresectable apparently benign colorectal polyps are considered by some surgeons as ideal for their early laparoscopic colectomy experience. Our hypotheses were: (1) a substantial fraction of patients undergoing laparoscopic colectomy for apparently benign colorectal neoplasia will have adenocarcinoma on final pathology; and (2) in our practice, we perform an adequate laparoscopic oncological resection for apparently benign polyps as evidenced by margin status and nodal retrieval. Methods Data from a consecutive series of patients undergoing laparoscopic colectomy (on an intention-to-treat basis) for endoscopically unresectable neoplasms with benign preoperative histology were retrieved from a prospective database and supplemented by chart review. Results The study population consisted of 63 patients (mean age 67, mean body mass index 29). Two out of 63 cases (3%) were converted to laparotomy because of extensive adhesions (n = 1) and equipment failure (n = 1). Colectomy type: right/transverse (n = 49, 78%); left/anterior resection (n = 10, 16%); subtotal (n = 4, 6%). Invasive adenocarcinoma was found on histological analysis of the colectomy specimen in 14 out of 63 cases (22%), standard error of the proportion 0.052. Staging of the 14 cancers were I (n = 6, 43%), II (n = 3, 21%), III ( = 4, 29%), and IV (n = 1, 7%). The median nodal harvest was 12 and all resection margins were free of neoplasm. Neither dysplasia on endoscopic biopsy nor lesion diameter was predictive of adenocarcinoma. Eight out of 23 (35%) patients with dysplasia on endoscopic biopsy had adenocarcinoma on final pathology versus 6/40 (15%) with no dysplasia (p = 0.114, Fisher’s exact test). Mean diameter of benign tumors was 3.2 cm (range 0.5–10.0cm) versus 3.9cm (range 1.5–7.5cm) for adenocarcinomas (p = 0.189, t - test). Conclusion A substantial fraction of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy will harbor invasive adenocarcinoma, some of advanced stage. This finding supports the practice of performing oncological resection for all patients with endoscopically unresectable neoplasms of the colorectum. The inexperienced laparoscopic colectomist should approach these cases with caution. Presented at the Society of Gastrointestinal Endoscopic Surgeons Annual Meeting, Las Vegas, NV, April 21, 2007     

Impact of the extraction-site location on wound infections after laparoscopic colorectal resection

Background

The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery.