联合脏器切除治疗结直肠癌：附32例报道

目的探讨联合脏器切除在晚期结直肠癌发生肿瘤组织浸润周围脏器或肝脏转移中的应用价值和可行性。方法回顾分析近年来32例晚期结直肠癌施行联合脏器切除患者的术后并发症发生情况和5年生存率。结果确诊时即发现有肝转移或浸润者9例,术中另发现合并有不同脏器受侵23例。行联合肝切除的9例中1例失访,获随访的8例中3例生存5年;行联合周围多脏器切除的23例中11例生存5年。5年生存率分别为37.5%(3/8)和47.83(11/23)。行联合切除者均无致死性并发症发生。结论联合脏器切除可提高晚期结直肠癌患者的生活质量和5年生存率,临床上对此类患者的治疗应持积极的态度。     

对局部晚期结直肠癌患者行联合脏器切除术的临床价值

目的探讨对局部晚期结直肠癌患者行联合受累脏器整块切除的临床价值。方法回顾分析182例局部晚期结直肠癌患者的临床资料。将97例行联合脏器切除治疗患者的疗效与同期85例未行联合脏器切除治疗者进行对比分析。结果97例患者切除的相关脏器为165个,经病理组织学证实51例(52.6%)的50个相关脏器(30.3%)有癌浸润,另外46例(47.4%)的115个(69.7%)相关脏器为炎性浸润,受累脏器以小肠最为常见,占28.9%(28/97)。经联合脏器切除后,97例患者1、3、5年生存率分别为83.5%、67.1%和49.4%;而同期85例仅行肿瘤局部切除或姑息切除治疗者1、3、5年生存率分别为81.1%,58.8%和10.5%。结论对于局部晚期的结直肠癌患者,积极施行周围联合脏器切除术,是提高5年生存率的一项重要措施。     

局部进展期大肠癌的联合脏器切除术

目的　研究局部进展期大肠癌扩大切除术的安全性，评价疗效和适用范围。方法　回顾性研究了１９７８ ～１９９３ 年行联合脏器切除的局部进展期（ Ⅳ期－ 中国改良法分类） 大肠癌６５ 例，选择同时期非联合脏器切除的６５ 例Ⅲ期病例作配对研究，比较两组手术并发症、手术死亡率、肿瘤复发率、术后生存率。并分析联合脏器切除组内疗效与年龄、性别、病变位置、病理特征、淋巴结转移范围、是否放化疗的关系。结果　两组病例在手术并发症和死亡率方面差异无显著性，５ 年生存率Ⅳ期病例与Ⅲ期相比差异无显著性意义。联合脏器切除术疗效与肿瘤病理特征、淋巴结转移范围关系密切。结论　对局部进展期大肠癌行联合脏器切除术是安全可行的，对提高病人生存率有肯定作用。对分化高的病例行此手术确保肿瘤完整切除尤为必要。     

联合脏器切除治疗局部进展期结肠癌

目的探讨对局部进展期结肠癌患者行联合脏器切除的疗效及影响预后的因素。方法回顾性分析1988～1998年对47例结肠癌患者进行联合脏器切除治疗的临床资料,对其肿瘤复发模式及患者生存率进行统计分析。结果本组患者有7例(14.9%)术后出现并发症,无死亡病例。病理证实周围组织器官有肿瘤侵犯30例(63.8%);局部复发8例(17.0%),远处转移16例(34.0%);5年生存率为40.4%。多因素分析,肿瘤UICC分期及淋巴结转移是影响预后的重要因素(P<0.05)。结论对于局部进展期结肠癌累及周围组织脏器的患者,应力争联合脏器切除治疗。     

晚期胃癌姑息性胃切除120例分析

目的　探讨姑息性胃切除治疗不能根治的晚期胃癌的临床效果。方法　回顾性分析1 983～ 2 0 0 1年 1 2 0例晚期胃癌行姑息性胃切除术 (切除组 ) ,与同期随机选择 1 2 0例晚期胃癌行非切除术 (非切除组 )进行比较。结果　两组病人在年龄、性别构成比、术后并发症和死亡率方面均无显著性差异 (P >0 .0 5 )。切除组术后 1、2、3年生存率分别为 5 7.1 %、2 8.6 %、1 1 .4 % ,非切除组 1、2、3年生存率分别为 35 .3%、1 1 .8%和 0 (P <0 .0 1 )。结论　对于有腹膜播散、远处淋巴结转移、周围脏器侵犯、H1 和H2 肝转移的晚期胃癌病人 ,姑息性胃切除可以改善其预后     

联合切除治疗晚期大肠癌有关问题探讨

目的：探讨浸润其它器官及局部复发大肠癌联合切除的意义及手术治疗的要点。方法：回顾分析1975年7月至2001年7月收治的浸润其它器官及忆部复发大肠癌的局部浸润情况及合并切除的疗效，直接法统计生存率。结果：①联合切除作1317例结肠癌中属Dukes D期者139例，占10.5%，行联合切除者47例，占全部病例的3.6%，Dukes D期病例的33.8%；2611例直肠癌中属Dukes D期者321例占12.3％，行联合切除者127例，占全部病例的4.8%，Dukes D期病例的39.1%。②47例结肠癌患者联合切除后的5年生存率为48.9%。③直肠癌患者中行全盆腔器切除者（TPE）27例，5年生存率为40.9%，100例联合一部分器官切除一患者的5年生存率为44.0%。结论：对浸润其它器官及忆部复发大肠癌患者，不论是初发还是复发，只要患者全身条件具备，应积极采用手术治疗的方法，对延长患者的生存期有重要意义。     

肝切除和腹腔灌洗化疗治疗大肠癌肝转移

目的　总结联合肝叶切除并温热低渗腹腔灌洗化疗治疗大肠癌的经验。方法　对1 993年～ 1 997年间施行联合肝叶切除并温热低渗腹腔灌洗化疗的 2 4例大肠癌的临床资料进行回顾性分析。结果　本组 2 4例术后无严重并发症发生 ,手术死亡率为 0。随访 1、3、5年生存率分别为79 .2 %、4 1 .7%、2 9.2 %。结论　掌握联合脏器切除的指征、关注腹腔内脱落癌细胞的处理、提高手术技巧、注重围手术期的营养支持是降低并发症发生率 ,提高手术成功率和远期生存率的重要因素     

层面优先入路在盆腔脏器联合切除术中的应用

局部进展期恶性肿瘤侵犯周围脏器是盆腔恶性肿瘤中常见情况。新发的直肠癌病例中约10%伴有周围组织器官侵犯, 通过联合脏器切除获得满意切缘, 可达到与无周围组织侵犯患者相似的5年生存率。局部复发的盆腔恶性肿瘤若仅行放化疗, 其5年生存率几乎为零, 通过盆腔脏器联合切除术获得满意的切缘是局部进展期及复发性盆腔恶性肿瘤患者获得长期生存的唯一机会。然而, 盆腔脏器联合切除手术复杂, 常常伴随更高的并发症发生率和病死率。膜解剖的发展使外科医生对盆腔筋膜层面有了更深的认识和全面的应用, 腔镜技术的进步为复杂盆腔手术提供了更为清晰的视野, 使得微创技术得以应用在复杂的盆腔脏器联合切除术中。层面优先入路是在盆腔筋膜解剖基础上, 通过盆腔无血管间隙优先分离, 为复杂的盆腔脏器联合切除术提供可重复性的手术入路。     

联合脏器切除治疗324例进展期胃癌的疗效分析

目的探讨联合脏器切除对伴有临近脏器侵犯或已有远处转移胃癌患者生存率的影响。方法对1998-2003年间收治324例伴有临近脏器侵犯或已有远处转移胃癌患者的临床资料进行回顾性分析。结果324例患者均经胃镜或术后病理证实为胃癌,其中91例（28．09％）行联合脏器切除扩大胃癌根治术;64例（19．75％）行姑息性手术;131例（40．43％）仅行化疗治疗;38例（11．73％）未行任何治疗。其1年的生存率分别为：76．92％（70例）、42．19％（27例）、46．56％（61例）和7．89％（3例）;其3年的生存率分别为：36．26％（33例）、21．88％（14例）、19．84％（26例）和0％（0例）;其5年的生存率分别为：20．88％（19例）、12．5％（8例）、14．50％（19例）和0％（0例）。联合脏器切除术后的并发症发生率为19．78％（18例）,围手术期死亡6例,姑息性手术术后并发症仅为3．13％（2例）。结论对有临近脏器侵犯或已有远处转移的晚期胃癌患者,进行联合脏器切除仅能提高患者1年的生存率,无助于延长手术患者远期的生存时间,同时术后并发症多,大大增加了围手术期的危险性,在手术中需谨慎对待。     

联合脏器切除治疗局部晚期贲门癌37例分析

目的探讨贲门癌侵及周围脏器的联合脏器切除术的适应证、手术技术及并发症的防治。方法回顾性分析1994年6月至2004年7月37例贲门癌直接侵及胃体、胃底、胰和脾施行联合脏器切除治疗局部晚期贲门癌病人的临床资料。结果手术死亡率为2·7%(1/37),主要并发症发生率为25·0%。1、3、5年总的存活率分别为:69·4%(25/36),44·4%(16/36),19·4%(7/36)。手术死亡率和并发症发生率与标准贲门癌切除术相比差异无显著性,预后与标准贲门癌切除术亦相近。结论局部晚期贲门癌的联合脏器切除术可提高贲门癌的切除率,改善生活质量,提高5年存活率,值得临床推广应用。     

Survival after hepatic resection for malignant tumours.

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.     

大肠癌伴肝转移的治疗及预后因素分析:附52例报告

目的:探讨大肠癌肝转移手术切除的疗效及影响术后生存率的因素，以改进提高远期疗效的措施。 方法:对52例手术治疗的大肠癌肝转移患者进行随访，比较11例生存5年以上与41例生存5年以内的患者的临床病理资料。结果:全组术后1，3，5年生存率分别为75%，30.8%和21.2%。影响患者愈后的因素主要有：原发癌病理类型、肝转移病灶数目、手术方式及时机选择，术后治疗（均P<0.05）。结论:根治切除以及加强术后综合治疗是提高远期疗效的关键。     

Long-term results of surgical resection of locally advanced colorectal carcinoma

This study was undertaken to review the long-term results of multivisceral resection of locally advanced colorectal carcinoma. Between 1964 and 1980, 1042 patients underwent exploratory surgery for colorectal cancer. Of these, 58 patients (5.5%) underwent curative multivisceral resection for suspected contiguous invasion by the primary tumor. Follow-up was complete for all patients. The primary tumors were located in the rectum (38 patients), sigmoid (9 patients), left colon (6 patients), and right colon (5 patients). En bloc resection of other viscera included uterus, adnexa, bladder, vagina, small intestine, abdominal wall, liver, stomach, kidney, and ureter. The operative morbidity and mortality rates were 31% and 1.7%, respectively. Resection margins were free of tumor in 54 patients. In the four patients with tumor-positive resection margins, recurrence of disease was evident between 8 and 22 weeks after surgery (mean survival time, 8.2 months). Carcinomatous invasion of the resected contiguous organ was confirmed in 49 patients (84%). The mean survival time for patients without lymph node metastases was 100.7 months, but it was only 16.2 months (p less than 0.01) for patients with lymph node metastases. Actuarial 5-year disease-free survival rate for patients without lymph node metastases was 76% (36 of 47 patients). None of the patients (0 of 11) with lymph node metastases survived for 5 years. Three of 36 of the 5-year survivors experienced recurrence of disease before the seventh postoperative year; no cancer-related deaths occurred between 7 and 25 years. These data suggest that survival in locally advanced colorectal carcinoma is more dependent on lymph node status than on the extent of local invasion. Effective disease control associated with survival in the long term can be achieved by multivisceral resection.     

Liver resection for metastatic colorectal cancer

From 1975 to 1985, 60 patients with isolated hepatic metastases from colorectal cancer were treated by 17 right trisegmentectomies, five left trisegmentectomies, 20 right lobectomies, seven left lobectomies, eight left lateral segmentectomies, and three nonanatomic wedge resections. The 1-month operative mortality rate was 0%. One- to 5-year actuarial survival rates of the 60 patients were 95%, 72%, 53%, 45%, and 45%, respectively. The survival rate after liver resection was the same when solitary lesions were compared with multiple lesions. However, none of the seven patients with four or more lesions survived 3 years. The interval after colorectal resection did not influence the survival rate after liver resection, and survival rates did not differ statistically when synchronous metastases were compared with metachronous tumors. A significant survival advantage of patients with Dukes' B primary lesions was noted when compared with Dukes' C and D lesions. The pattern of tumor recurrence after liver resection appeared to be systemic rather than hepatic. The patients who received systemic chemotherapy before clinical evidence of tumor recurrence after liver resection survived longer than those who did not.     

Surgical treatment for both pulmonary and hepatic metastases from colorectal cancer

OBJECTIVE: The role of surgery in the treatment of patients with pulmonary and hepatic metastases from colorectal cancer has not been delineated. METHODS: Of the 351 patients enrolled in the Metastatic Lung Tumor Study Group of Japan between June 1988 and June 1996 who underwent thoracotomy for pulmonary metastases from colorectal cancer, 47 also underwent hepatic resection for metastatic tumors. The records of these patients were studied. RESULTS: The 47 patients who underwent pulmonary and hepatic resection had a 3-year survival of 36% +/- 8%, a 5-year survival of 31% +/- 8%, and an 8-year survival of 23% +/- 9%. The longest survival was 98 months. This patient was alive without recurrence. There was a significant difference in the cumulative survival of the patients with a solitary pulmonary metastasis and the patients with multiple pulmonary metastases (P =.04). Neither age, sex, location of the primary tumor, maximum diameter of the pulmonary metastases, method of pulmonary resection, number of hepatic metastases, nor method of hepatic resection was correlated with survival. However, 9 of 10 patients who survived 3 years or more after the initial thoracotomy had only one or two hepatic metastases. CONCLUSION: Surgical treatment of a solitary pulmonary metastasis concurrent with or after resection of hepatic metastases from colorectal cancer may be appropriate if the hepatic metastases are resectable for cure. Patients with a solitary pulmonary metastasis and a small number of hepatic metastases are good candidates for resection. Long-term survival can be expected.     

Analysis of preoperative prognostic factors for long-term survival after hepatic resection of liver metastasis of colorectal carcinoma

Hepatic resection is the most effective therapy for liver metastasis of colorectal carcinoma. To clarify indications for this therapy, the clinicopathologic and follow-up data of 103 consecutive patients who underwent hepatic resection for metastases of colorectal carcinoma were analyzed. Factors influencing overall survival rate were investigated by multivariate analysis. Thereafter, patients who underwent resection were stratified according to the number of independent risk factors present, and their outcomes were compared with those of 14 nonresection patients with fewer than six liver tumors and without extrahepatic metastasis. The overall survival rate of the 103 resection patients was 43.1%. The clinicopathologic factors shown to affect on long-term survival after hepatic resection were the interval between colorectal and hepatic surgery (<12 months), preoperative carcinoembryonic antigen level (>-10 ng/ml), and number of hepatic metastases (four or more). The 5-year overall survival rates were 75.0% with no risk factors (n = 16), 53.6% with one risk factor (n = 46), 23.0% with two risk factors (n = 36), and0%with three risk factors (n = 5). Survival rates did not differ between resection patients with three risk factors and nonresection patients. Therefore, hepatic resection may be appropriate for patients with fewer than three risk factors.     

Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma

OBJECTIVE: To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS: A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS: The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS: Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.     

Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET)

OBJECTIVE: To report the first 5-year overall survival results in patients with colorectal carcinoma metastatic to the liver who have undergone hepatic resection after staging with [18F] fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET). SUMMARY BACKGROUND DATA: The 5-year overall survival after hepatic resection for colorectal cancer metastases without preoperative FDG-PET has been established in 19 studies (6070 patients). The median 5-year overall survival rate in these studies is 30% and has not improved over time. FDG-PET detects unsuspected tumor in 25% of patients considered to have resectable hepatic metastasis by conventional staging. METHODS: From March 1995 to June 2002, all patients having hepatic resection for colorectal cancer metastases had preoperative FDG-PET. A prospective database was maintained. RESULTS: One hundred patients (56 men, 44 women) were studied. Metastases were synchronous in 52, single in 63, unilateral in 78, and <5 cm in diameter in 60. Resections were major (>3 segments) in 75 and resection margins were > or = 1 cm in 52. Median follow up was 31 months, with 12 actual greater than 5-year survivors. There was 1 postoperative death. The actuarial 5-year overall survival was 58% (95% confidence interval, 46-72%). Primary tumor grade was the only prognostic variable significantly correlated with overall survival. CONCLUSIONS: Screening by FDG-PET is associated with excellent postresection 5-year overall survival for patients undergoing resection of hepatic metastases from colorectal cancer. FDG-PET appears to define a new cohort of patients in whom tumor grade is a very important prognostic variable.