结直肠癌患者术后吻合口漏的危险因素分析

目的探讨结直肠癌术后发生吻合口漏（AL）的危险因素。 方法回顾性分析2010年12月~2014年4月在上海长征医院普外科接受手术治疗的926例结直肠癌患者的病例资料,通过病例对照分析和χ²检验,在临床病理分类的变量中筛选AL的危险因素,通过Logistic回归进行多因素分析,筛选独立的危险因素。 结果高血压病史、腹腔镜手术、未预防性造口是AL的独立危险因素（OR=1.907,2.252,5.556;P=0.016,0.006,0.001）。亚组分析显示：结肠癌亚组中,左半结肠是AL的危险因素（OR=2.519,P=0.032）;直肠癌亚组中,高血压病史、腹腔镜手术和未预防性造口是AL的独立危险因素（OR=2.597,7.609,9.346;P=0.012,0.007,<0.001）;腹腔镜手术亚组中,高血压病史、未预防性造口、术中出血≥ 400 mL是AL的独立危险因素（OR=2.407,5.376,3.922;P=0.006,0.002,0.001）;未预防性造口亚组中,高血压病史、腹腔镜手术和直肠癌是AL的独立危险因素（OR=1.969,1.859,1.716;P=0.015,0.046,0.059）;直肠癌未预防性造瘘亚组中,高血压、腹腔镜和手术时间≥ 3 h是AL的独立危险因素（OR=2.796,7.346,2.287;P=0.012,0.008,0.046）;开腹手术亚组和预防性造口亚组无AL的危险因素。 结论对于存在高血压病史、腹腔镜手术且未预防性造口的直肠癌患者,需要密切关注、针对性预防,以期减少术后AL的发生。     

同时性结直肠癌肝转移患者的生存分析

目的分析结直肠癌合并同时性肝转移患者的生存状况和相关影响因素。 方法回顾性分析2000年至2010年复旦大学附属中山医院收治的1061例结直肠癌合并同时性肝转移患者的病例。收集所有患者的临床资料、病理特征、治疗策略、住院费用、随访状况等,进行生存状况分析,并采用单因素和Cox比例风险回归模型等分析影响结直肠癌肝转移生存的相关因素。 结果肝转移灶可切除患者中,同期切除肠道原发灶和肝转移灶与分期切除患者的住院费用分别为25693元、34129元(P<0.05),手术并发症(分别为24.5%、20.5%)和总生存期方面(分别为48.5月、47.0月)无显著差异。肝转移灶不可切除且原发灶无症状的患者中,原发灶切除的患者总体中位生存时间明显好于原发灶未切除的患者(分别为19.0月、9.3月,P<0.001)。肠道原发灶分化Ⅲ～Ⅳ级、肝转移灶≥4个、最大肝转移灶直径≥5 cm、肝外转移、肠道原发灶未手术切除和肝转移灶非手术治疗是影响肠癌同时性肝转移患者预后的独立危险因素。将上述6个危险因素各设定为1分,所有患者分为低风险组(0～1分)、中风险组(2～3分)和高风险组(4～6分),5年存活率分别为51%、16%和0%(P<0.001)。 结论结直肠癌合并同时性肝转移患者中,原发灶和转移灶均可切除的可予以同期切除,原发灶可切除且无出血梗阻症状的不可切除的肝转移仍建议在合适时机切除肠道原发灶。根据上述6个独立预后因素所建立的预测模型可以指导临床采取合适的治疗方案。     

结直肠癌患者术后感染的危险因素及防治

术后感染是结直肠癌术后患者最常见的并发症之一,主要包括以下几种类型：手术部位感染、腹腔感染、盆腔感染、泌尿系统感染、呼吸系统感染、膈下脓肿、菌血症等,不仅给患者带来痛苦,还增加医疗成本。目前国内外对于结直肠手术围术期感染的危险因素和预防措施进行大量的研究,不仅涉及到外科医生、手术室护士,麻醉医生也起到重要作用。本文将对结直肠癌患者术后感染的危险因素及防治进行综述。     

结直肠癌外科治疗新进展

近年来在结肠癌外科领域引入了全结肠系膜切除的概念,同时低位直肠癌的保肛手术及扩大根治术也有较多进展。新辅助治疗也在直肠癌外科治疗中发挥重要作用。     

结直肠癌术后局部复发与处理

１影响局部复发的因素１．１与肿瘤本身有关的因素那些已知的影响生存的许多因素在局部复发中同样有影响．Ｄｕｋｅｓ分期越差，局部复发的可能性越大．在大量经腹会阴切除术后的患者调查中，在ＤｕｋｅｓＡ期局部复发率约为９１％，，Ｂ期１６７％，Ｃ期４０８％［...     

直肠癌术后吻合口漏的风险因素评估

目的对直肠前切除术后发生吻合口漏风险进行评估。 方法选取2005年3月至2009年8月在第二军医大学附属长征医院普外科接受直肠前切除的338名直肠癌患者为研究对象,所有患者均接受直肠全系膜切除,评估相关因素与吻合口漏的相关性。 结果本研究的吻合口漏发生率为9.2%。通过单因素分析与多因素分析法发现年龄（OR：3.380,95%CI：1.346~8.489）、BMI（OR：11.828,95%CI：4.123~33.858）、肿瘤位置（OR：6.304,95%CI：162~18.382）、肠梗阻（OR：6.675,95%CI：2.164~20.594）是影响吻合口漏的独立因素。 结论直肠前切除术后发生吻合口漏与患者的性别、年龄、BMI指数、肿瘤位置、肠梗阻等因素相关。对于男性、高龄、肥胖、低位直肠癌、合并肠梗阻等危险因素的患者而言,术后发生吻合口漏的风险将增高。     

机器人结直肠癌手术

本文简要回顾了机器人手术系统的组成和发展史。在结直肠癌根治术中,机器人手术系统已得到了广泛的应用,手术操作时间明显缩短,手术安全。机器人手术系统优点：三维图像的稳定性和清晰性,手术操作便利性等;机器人手术的不足：力反馈缺失,手术时间延长等。     

老年结直肠癌术后长期生存的预后因素分析

目的:探索影响老年结直肠癌术后长期生存的相关因素。方法:回顾性分析SEER数据库中2004年登记注册诊断为(CRC)术后(年龄≥60岁)的病例,有随访10年以上存活记录。采用 Cox比例风险模型评估年龄,性别,种族,婚姻状况,肿瘤部位和大小,临床分期,TNM分期,淋巴结清除范围等对生存死亡的预后风险。 ...     

结直肠癌术后肠梗阻相关因素分析

背景：结直肠癌术后肠梗阻（POI）并不罕见,其影响患者术后营养状况,减缓预后。目前关于POI危险因素的研究甚少。目的：分析结直肠癌术后发生POI的危险因素。方法：纳入2009年1月～2013年3月于扬州市第一人民医院行结直肠癌手术的患者,采集18项POI可疑危险因素,筛选POI发生相关因素,行多元逐步logistic回归模型分析。结果：共187例患者纳入研究,31例（16．6％）发生POI,性别、吸烟史、慢性阻塞性肺病（COPD）史、白蛋白水平、直肠肿瘤、回肠造瘘与POI的发生相关（P〈0．05）。多元逐步logistic回归模型分析结果显示性别、COPD史、回肠造瘘是POI发生的独立危险因素（P〈0．05）。结论：性别、COPD史、回肠造瘘是结直肠癌POI的重要因素。     

结直肠癌术后吻合口瘘的诊治及预防

结直肠癌是消化道常见的恶性肿瘤,其发病率及死亡率逐年升高,手术治疗是目前治疗结直肠癌最有效的方法,但术后吻合口瘘依然是结直肠癌患者最常见、最严重的并发症之一。笔者对国内外关于结直肠癌术后吻合口瘘的研究做相关综述,以期能降低吻合口瘘的发生率。     

Surveillance patterns after curative-intent colorectal cancer surgery in Ontario

BACKGROUND:

Postoperative surveillance following curative-intent resection of colorectal cancer (CRC) is variably performed due to existing guideline differences and to the limited data supporting different strategies.

OBJECTIVES:

To examine population-based rates of surveillance imaging and endoscopy in patients in Ontario following curative-intent resection of CRC with no evidence of recurrence, as well as patient or disease factors that may predispose certain groups to more frequent versus less frequent surveillance; to provide insight to the care patients receive in the presence of conflicting guidelines, in efforts to help improve care of CRC survivors by identifying any potential underuse or overuse of particular surveillance modalities, or inequalities in access to surveillance.

METHOD:

A retrospective cohort study was conducted using data from the Ontario Cancer Registry and several linked databases. Ontario patients undergoing curative-intent CRC resection from 2003 to 2007 were identified, excluding patients with probable disease relapse. In the five-year period following surgery, the number of imaging and endoscopic examinations was determined.

RESULTS:

There were 4960 patients included in the study. Over the five-year postoperative period, the highest proportion of patients who underwent postoperative surveillance received the following number of tests for each modality examined: one to three abdominopelvic computed tomography (CT) scans (n=2073 [41.8%]); one to three abdominal ultrasounds (n=2443 [49.3%]); no chest CTs, one to three chest x-rays (n=2385 [48.1%]); and two endoscopies (n=1845 [37.2%]). Odds of not receiving any abdominopelvic imaging (CT or abdominal ultrasound) were higher in those who did not receive adjuvant chemo-therapy (OR 6.99 [95% CI 5.26 to 9.35]) or those living in certain geographical areas, but were independent of age, sex and income. Nearly all patients (n=4473 [90.2%]) underwent ≥1 endoscopy at some point during the follow-up period.

CONCLUSION:

In contrast to findings from similar studies in other jurisdictions, most Ontario CRC survivors receive postoperative surveillance with imaging and endoscopy, and care is equitable across sociodemographic groups, although unexplained geographical variation in practice exists and warrants further investigation.     

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation.METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended.RESULTS: The recurrence patterns were: intramural local recurrence(five cases), regional lymph node recurrence(three cases), and associated with simultaneous distant metastasis(three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases(enteritis).CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.     

Value of postoperative surveillance after radical surgery for colorectal cancer

PURPOSE: Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow-up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative-intent surgery and rate of survival. METHODS: One hundred ninety-nine colorectal cancer patients who underwent radical primary surgery were followed according a well-defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow-up program. A multivariate regression model was constructed to predict survival. RESULTS: One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow-up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38vs. 41 percent;P=0.52), curative-intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P=0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63vs. 37 percent at 5 years;P<0.001) and cancer-related (69vs. 49 percent at 5 years;P<0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13–59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50–3.60) had an independent negative impact on survival. CONCLUSION: Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative-intent surgery and rate of survival.Supported in part by grants from the Agència d'Avaluació de Tecnologia Mèdica de la Generalitat de Catalunya (2/6/96), the Fondo de Investigaciones Sanitarias de la Seguridad Social (96/0240), and the Marató TV3-Càncer (95/3008).Presented in part at the meeting of the American Gastroenterological Association, Washington, D.C., May 11 to 14, 1997.     

腹腔镜联合快速康复结直肠外科手术在老年人结直肠癌治疗中的近期疗效分析

目的 评估70岁以上老年结直肠癌患者接受腹腔镜联合快速康复结直肠外科(FTCS)治疗的安全性、可行性. 方法 将123例老年结直肠癌患者,随机分为腹腔镜+ FTCS组(41例)、腹腔镜组(41例)和开腹组(41例).比较患者手术效果指标,康复指标以及术后并发症等. 结果 腹腔镜+FTCS组与单独腔镜组或开腹组比较,其失血量、手术时间、排便时间,淋巴结清扫个数等差异无统计学意义(P＞0.05);腹腔镜+FTCS组较腔镜组或开腹组能够显著缩短患者下床时间、排气时间、首次流质时间以及住院时间(P＜0.05).各组术后并发症发生率分别为腹腔镜+ FTCS组:12.2％(5/41);腹腔镜组:34.1％(14/41);开腹组:68.3％(28/41).腹腔镜+FTCS组患者并发症发生率低于腹腔镜组和开腹组(x2 =5.549,P=0.018;x2 =28.826,P＜0.01),腹腔镜组患者并发症发生率显著低于开腹组(x2 =9.567,P=0.002). 结论 腹腔镜联合FTCS治疗方法在老年结直肠癌治疗中安全有效,是老年结直肠癌患者的理想治疗方式.     

Systemic coagulation activation and anastomotic leakage after colorectal cancer surgery

PURPOSE: The aim of the present study was to study whether patients developing anastomotic leakage after colorectal resections for colorectal cancer have laboratory signs of an altered hemostatic balance in the systemic circulation, preoperatively and postoperatively, causing an impaired healing process. METHODS: Patients operated on for colorectal cancer were studied. Seventeen consecutive patients with anastomotic leakage and 17 patients without anastomotic leakage were matched according to age, gender, tumor stage, and localization of tumor. Hemostatic balance was estimated preoperatively and at one, two, and seven days and at three months after surgery by plasma levels of sensitive markers of coagulation activation and fibrinolysis,i.e., prothrombin fragment 1+2, thrombin-antithrombin complexes, soluble fibrin, tissue-type plasminogen activator activity, and plasminogen activator inhibitor Type 1. RESULTS: Preoperatively, the hemostatic balance was comparable in patients with and without anastomotic leakage. In the early postoperative period, patients developing anastomotic leakage exhibited signs of systemic coagulation activation,i.e., elevated plasma levels of prothrombin fragment 1+2, thrombin-antithrombin complexes, soluble fibrin, and plasminogen activator inhibitor Type 1. The observed coagulation activation appeared before the anastomotic leakage became clinically evident. More patients with anastomotic leakage received perioperative blood transfusions than patients without leakage, despite the fact that duration of surgery and intraoperative blood loss were comparable in the two groups. CONCLUSIONS: Enhanced coagulation activity was observed postoperatively in patients developing anastomotic leakage after colorectal resections for colorectal cancer. Such a hypercoagulable state may contribute to the development of anastomotic leakage by facilitating formation of microthromboses in the perianastomotic area.This study was supported in part by grants from the Danish Cancer Society and Aalborg Stifts Juleotteri.This study was presented in part at the scientific meeting of the Danish Society of Surgery, Herlev, Denmark, April 17, 1998. No reprints are available.     

Over-the-scope-clipping system for anastomotic leak after colorectal surgery:Report of two cases

An anastomotic leak is one of the major complications following colorectal surgery.Standard treatments for anastomotic leak are total parenteral nutrition or temporary ileostomy.The over-the-scope-clipping(OTSC)system was originally developed to treat intestinal perforation or to close the tissue after natural orifice transluminal endoscopic surgery.Two cases of successful management of an anastomotic leak after colorectal surgery using the OTSC system are reported.One patient avoided a temporary ileostomy.In the other,hospitalization was shortened by the use of the OTSC system.The OTSC system can be a potential option in the management of anastomotic leaks after colorectal surgery.     

ERAS理念在结直肠癌治疗中的应用

加速康复外科是近年来提出的一种崭新的围手术期管理模式,其具有术后恢复快、并发症少、住院时间短、住院费用低等特点,并已广泛应用于各个外科领域。本文主要概述了加速康复外科在手术治疗结直肠癌中的具体应用。