新辅助化放疗对局部进展期直肠癌低位前切除后吻合口愈合的影响

目的 探讨新辅助化放疗对局部进展期直肠癌低位前切除术后吻合13愈合的影响.方法 收集2001年5月至2007年8月的低位直肠癌(距肛缘≤6 cm)患者192例.全部病例均经术前化放疗.放疗40～46 Gy/20～23次,每周5次,每次2 Gy.放疗结束后休息六周.放疗同时进行化疗,口服卡培他滨1250 mg/(m~2·d),每日2次口服,直至手术.手术遵循TME原则进行.分析低位直肠癌术后吻合口漏发生情况.结果 全部病例完成术前化放疗.17例术前复查肿瘤完全消失(8.9%),未再进行手术治疗.手术前复查无一例发现肿瘤有进一步发展或转移.24例术后病理提示肿瘤完全消失,故肿瘤完全消失者共41例(21.4%).175例患者均按TME原则进行直肠癌根治术.保肛手术166例,保肛率为95.3%.其中低位直肠癌前切除术(LAR,双吻合器)134例,Parks术32例.腹会阴切除术6例.Hartmann术3例.在所有保肛患者中,发生吻合口漏9例,发生率为5.1%.LAR(双吻合器)术后发生吻合口漏6例,发生率为4.4%,其中直肠阴道漏4例.Parks术后吻合口漏3例,发生率为9.4%,其中直肠阴道漏1例.两组保肛手术吻合口漏发生率无显著差异(P＞0.05).吻合口漏发生时间为术后2～10 d,均经相应处理后获得良好结果 .结论 合理运用新辅助化放疗不会明显增加低位直肠癌术后吻合口漏的发生.     

中低位直肠癌新辅助放化疗后安全手术切缘的临床病理研究

目的探究中低位直肠癌新辅助放化疗后肿瘤退缩规律,为直肠癌手术合理切除范围提供病理学依据。方法收集2009年1月至2012年6月间在陕西省人民医院接受术前新辅助放化疗加根治性手术的40例进展期中低位直肠癌患者的新鲜手术标本,纵行连续切片进行病理检测．判断肿瘤组织学反应情况。采用细胞角蛋白免疫组织化学方法于显微镜下测量残余肿瘤在直肠肛侧黏膜下浸润距离以及残余肿瘤细胞空间分布特征;采用Ki-67免疫组织化学染色方法评估残存肿瘤细胞增殖活性。结果40例患者新辅助放化疗后获完全反应者5例（12．5％）,中度反应19例（47．5％）,轻度反应9例（22．5％）,反应不良7例（17．5％）。新鲜直肠肠壁标本经病理学制片后,标本收缩率平均为18％。残存肿瘤细胞Ki-67增殖指数较放化疗前明显降低（P〈0．01）。以残余溃疡或瘢痕下缘为参照点,肠壁内癌逆向浸润平均距离为（6．1±4．7）mm;其中最远1例为11．0mm,根据病理制片收缩率换算,未受牵张的新鲜标本为13．0mm。残存肿瘤细胞散在分布于溃疡、纤维瘢痕组织周围,其空间分布呈向心性退缩。结论中低位直肠癌患者接受新辅助放化疗后,其肿瘤具有不同程度的退缩,残余溃疡或瘢痕组织内存在增殖活性肿瘤细胞。术中应在体切除肿瘤下方肠壁2em：环周切除范围应以完整切除肿瘤区域残余瘢痕组织为度。     

腹腔镜下经肛门拖出式前切术对低位直肠癌患者并发症及复发率的影响

目的分析腹腔镜下经肛门拖出式前切术对低位直肠癌患者并发症及复发率的影响,为临床治疗提供参考。 方法回顾性分析2014年4月至2017年10月期间接受腹腔镜下经肛门拖出式前切术治疗的低位直肠癌患者(观察组,n＝80)临床资料,同期腹腔镜下非肛门拖出式前切术治疗的低位直肠癌患者为对照组(对照组,n＝80)。数据统计采用SPSS21.0统计软件完成,术中术后计量资料用平均数±标准差表示,两组比较采用独立t检验;术后并发症和复发率比较采用χ²检验。P<0.05为差异具有统计学意义。 结果与对照组相比,观察组病理切缘距离明显增大[对照组(3.0±0.6) cm,观察组(3.9±1.1) cm, P<0.05]、局部复发率明显降低[对照组5.0% ,观察组1.3%, P<0.05],而并发症发生率、手术时间、术中出血量、淋巴结清扫数和阳性淋巴结数目之间差异无统计学意义(P>0.05)。 结论腹腔镜下经肛门拖出式前切术治疗低位直肠癌简便易行,复发率低。     

Prognostic significance of thymidylate synthase polymorphisms in rectal cancer patients treated with neoadjuvant chemoradiotherapy

Aim There is a lack of prognostic factors of preoperative chemoradiation for locally advanced rectal cancer. Thymidylate synthase (TS) is the most important target of 5‐fluorouracil; three main genetic polymorphisms of TS have been described. We analysed the prognostic value of these in patients with locally advanced rectal cancer treated with fluoropyrimidine‐based chemoradiation. Method Ninety‐nine patients treated between November 2001 and March 2009 were included. All were treated by radiotherapy (5040 cGy) and concomitant fluoropyrimidine‐based chemotherapy. Three polymorphisms were analysed: (i) a double (2R) or triple (3R) repeat of a 28 base pair (bp) tandem sequence upstream of the ATG codon initiation site in the 5′‐terminal regulatory region, (ii) a functional G > C single nucleotide polymorphism present in the second repeat of the 3R alleles and (iii) a 6 bp deletion at nucleotide 1494 in the 3′‐untranslated region. DNA was extracted from paraffin‐embedded core biopsies taken from the tumour and the genotype was analysed using polymerase chain reaction restriction fragment length polymorphism. Results The 6 bp polymorphism was significantly associated with disease‐free survival (+ 6 bp/+ 6 bp vs?6 bp/?6 bp, P = 0.032 logistic regression). No differences were found in disease‐free survival according to the other polymorphisms studied. No relationship was observed between the different TS genotypes and pathological regression. Conclusion The study suggests that the TS 6 bp polymorphism may be a predictor of disease‐free survival in patients with locally advanced rectal cancer treated with fluoropyrimidine‐based chemoradiation.     

Outcomes in patients treated by laparoscopic resection of rectal carcinoma after neoadjuvant therapy for rectal cancer.

OBJECTIVE: We analyzed the effect of neoadjuvant chemo radiation on feasibility and outcomes in rectal cancer patients undergoing laparoscopic resection of the rectum. METHODS: This was a retrospective analysis of a consecutive series of laparoscopic resections for rectal cancer from 1998 to 2004 (N=60). RESULTS: Eight patients received preoperative chemoradiation therapy (neoadjuvant group) for rectal cancer and 52 patients did not (primary surgical group). The conversion rate was higher in the neoadjuvant group, but this did not reach statistical significance (3/8, 37% in the neoadjuvant group vs. 7/52, 13% in the primary surgical group, P=0.12). Operative time was longer in the neoadjuvant group (170+/-60 vs 228+/-70 min, P=0.03). Complication rates (3/52, 5.7% in the primary surgical vs. 0% in the neoadjuvant group, P=1.0), and a median number of resected lymph nodes (14.5 in the primary surgical vs. 16.0 in the neoadjuvant group, P=0.81) were similar between groups. CONCLUSION: Laparoscopic resection of rectal cancer in patients after preoperative chemoradiation treatment seems to be associated with a higher conversion rate and a longer duration of surgery. No change in mortality and morbidity was detected. We encourage further investigation of laparoscopic rectal surgery for treatment of rectal cancer.     

Outcome of patients with rectal cancer treated by stapled anterior resection

The mortality, morbidity and long-term survival in stapled anterior resection for rectal carcinoma has been analysed in 74 patients. Twelve patients were Dukes' A, 26 B, 29 C, and 7 'D' (submitted to hepatic resection). Operative mortality rate was 3 per cent. Three patients (4 per cent) had clinical anastomotic leakage. Two patients (3 per cent) developed anastomotic stenosis. Local recurrence was present in three patients (4 per cent). The mean (+/- s.e.m.) overall survival rate at 5 years was 67 +/- 6 per cent. There was no significant difference in survival between Dukes' B and C (70 +/- 10 per cent versus 59 +/- 10 per cent, P = 0.209). Patients with absent local spread had a significantly better 5-year survival rate than those with positive local lymph nodes (80 +/- 7 per cent versus 54 +/- 9 per cent, P less than 0.01). The present results confirm the satisfactory use of the EEA stapler device for colorectal anastomoses in rectal cancer and in patients with resectable liver metastasis.     

腹腔镜下直肠低位前切除术与直肠经肛门拖出切除术治疗直肠癌的效果比较

目的比较直肠癌患者经腹腔镜下直肠低位前切除术与直肠经肛门拖出切除术后的治疗效果。 方法选取2014年7月至2016年12月进行腹腔镜下直肠低位前切除术与直肠经肛门拖出切除术的不同手术方式患者共120例,按照不同手术方式分为镜下组和拖出组两组,每组各60例,镜下组行腹腔镜下直肠低位前切除术,拖出组行直肠经肛门拖出切除术。采用SPSS 18.0软件对所有数据进行统计分析,术中术后指标以均数±标准差表示,组间比较采用t检验;术后并发症发生率采用χ²检验;P<0.05差异有统计学意义。 结果术中出血量、住院时间相比,直肠经肛门拖出切除术患者少于腹腔镜下直肠低位前切除术,P<0.05。术后肠功能恢复情况如术后1、3、6个月患者排便次数相比,拖出手术组明显恢复情况好于镜下组,P<0.05,差异具有明显统计学意义;术后并发症相比,中青年患者拖出手术组术后并发症发生率为6.7%(2/30),镜下手术组为30%(9/30),老年患者拖出手术组术后并发症发生率为6.7%(2/30),镜下手术组为26.7%(8/30),不同年龄段患者内部比较,P<0.05,差异具有明显统计学意义。 结论直肠经肛门拖出切除术的手术疗效和术后患者恢复情况均好于腹腔镜下直肠低位前切除术,治疗效果满意,手术操作安全,具有临床推广意义。     

新辅助放化疗联合手术治疗局部进展期低位直肠癌的疗效分析

目的 探讨新辅助放化疗联合手术治疗局部进展期(CtnmⅡ期和Ⅲ期)低位直肠癌的疗效.方法 回顾分析我院281例局部进展期低位直肠癌患者(肿瘤距离肛缘≤6cm)临床资料,所有患者全部进行术前联合放化疗,给予盆腔常规放疗,总剂量为45～50Gy,2Gy/d,每周5天,休息2d.同时给予口服卡培他滨1250mg/(m2·d),分2次口服,直至手术;放疗结束后休息4～6周,按TME原则行根治性切除术.结果 所有患者均完成新辅助放化疗,急性毒副反应较小,一般为Ⅰ～Ⅱ级反应.其中15例(5.3%)复查肿瘤完全消失,未行手术治疗并予以密切随访.266例按照TME原则行直肠癌根治性切除术.241例行保肛手术(保肛率90.6%).手术标本显示肿瘤已完全消失24例,肿瘤降期明显.局部复发率显著降低(3.9%).结论 新辅助放化疗对局部进展期低位直肠癌患者肿瘤降期作用明显,提高保肛成功率,降低局部复发率,是局部进展期低位直肠癌综合治疗的一种安全有效的治疗方案.     

直肠上动脉亚甲蓝灌注在新辅助放化疗后腹腔镜直肠癌手术中的应用

目的:探讨新辅助放化疗后腹腔镜直肠癌根治术中采用直肠上动脉亚甲蓝灌注对淋巴结检出数及男性直肠癌患者术后性功能、排尿功能改变的影响。方法:选择2013年3月—2017年4月期间湘潭市中心医院胃肠外科和中山市陈星海医院接受新辅助同步放化疗及腹腔镜根治性切除手术的96例男性直肠癌患者临床资料,随机分为试验组和对照组,每组48例,试验组根治术前经直肠上动脉内注射1%亚甲蓝8mL,对照组直接行根治术。比较两组患者淋巴结的清扫数目及术后性功能(包括射精功能和勃起功能)、排尿功能的变化。结果:两组间手术方式无统计学差异(P=0.408);试验组患者淋巴结清扫数目多于对照组[(15.04±4.063)枚vs.(12.23±2.991)枚,P0.05]。试验组与对照组患者术后1年Ⅰ、Ⅱ、Ⅲ级射精功能例数分别为41(85.4%)、7(14.6%)、0(0)与31(64.6%)、13(27.1%)、4(8.3%);术后1年Ⅰ、Ⅱ、Ⅲ级勃起功能例数分别为42(87.5%)、6(12.5%)、0(0)与32(66.7%)、15(31.3%)、1(2.1%);术后Ⅰ、Ⅱ、Ⅲ、Ⅳ级排尿功能例数分别为35(72.9%)、12(25.0%)、1(2.1%)、0(0)与26(54.2%)、13(27.1%)、5(10.4%)、4(8.3%)。统计分析结果显示,试验组术后1年的射精功能、勃起功能、排尿功能均明显优于对照组(均P0.05)。结论:新辅助放化疗后行腹腔镜直肠癌根治术,直肠上动脉灌注亚甲蓝能清晰区分手术界面,能增加淋巴结检出率,减少盆神经的损伤,降低男性患者术后性功能障碍及排尿功能障碍发生率。     

Colon perforation caused by transanal decompression tube after laparoscopic low anterior resection: A case report

IntroductionThe effectiveness of transanal decompression tube (TDT) to prevent anastomotic leakage after rectal surgery has been widely accepted in recent years. However, a rare complication of intestinal perforation due to TDT has been also reported.Presentation of caseA 88-year-old woman underwent laparoscopic low anterior resection for rectal cancer. An abdominal drainage tube adjacent to the colorectal anastomosis and a TDT were placed. The patient experienced abdominal pain, nausea and elevated inflammatory markers on postoperative day 6. Enema and computed tomography demonstrated colonic perforation due to the TDT, and emergency laparotomy was performed. Perforation of the anterior sigmoid colon located at the proximal side of the colorectal anastomosis was seen, and the TDT was exposed to the abdominal cavity. Therefore, primary closure of the perforation site, peritoneal lavage, drainage tube placement and transverse colostomy was performed.DiscussionIn our case, TDT seemed to compress the anterior wall of the colon and lead to perforation. The looseness of the remaining oral intestinal tract depressed in the pelvis was compressed by the TDT.ConclusionTDTs should be very carefully placed to avoid complication. The length and looseness of the oral intestine and the relationship between the TDT to be inserted might be important.     

经腹膜外双套管持续负压冲洗法对直肠癌低位前切除术后吻合口瘘的防治研究

目的：对比经腹膜外放置自制简易双套管并持续负压冲洗法与传统腹腔引流方法防治直肠癌低位前切除术后吻合口瘘的临床疗效。方法回顾性分析2007年1月至2012年3月南京军区福州总医院普通外科同一手术组实施的627例数据完整的开腹直肠癌低位前切除术患者的临床资料,其中370例采用自制简易双套管在术中放置于吻合口背侧,经左侧腹膜外穿出,并固定于腹壁皮肤进行引流（双套管组）,257例经腹腔放置常规引流管（常规引流组）。对比两组患者吻合口瘘发生率以及手术干预率、引流管放置时间、住院时间、住院费用、生活质量评分和半年随访时吻合口狭窄的发生率。结果全组患者术后吻合口瘘发生率为4．0％（25／627）,其中双套管组14例（3．8％,14／370）,常规引流组11例（4．3％,11／257）,差异无统计学意义（P＞0．05）。双套管组患者吻合口瘘发生后,经肛门在直肠内放置另一自制简易双套管进行持续低负压（50 mmHg）冲洗后治愈,无需再次手术干预。而常规引流组联合经直肠放置双套管冲洗,保守治疗半月无效后有5例进行了再次手术。双套管组和常规引流组引流管放置时间分别为（9．7±2．7） d和（16．4±3．6） d;住院时间分别为（15．7±4．3） d和（21．5±6．4） d;住院费用分别为（42470±3190）元和（53480±5630）元;两组比较,差异均有统计学意义（均P＜0．05）。生活质量调查结果显示,术后15 d双套管组总体生活质量明显优于常规引流组（P＜0．05）。结论尽管经腹膜外放置自制简易双套管并不能降低直肠癌低位前切除术后吻合口瘘发生率,但该方法联合经肛门在直肠内放置另一双套管持续负压冲洗可以提高吻合口瘘保守治疗成功率,降低吻合口瘘手术干预的比率,提高患者生活质量。     

High incidence of late anastomosis leakage in patients for rectal cancer after neoadjuvant chemoradiotherapy: A comparative study

PurposeThe purpose of this study was to investigate the clinical features and risk factors of late anastomotic leakage (AL) in a homogeneous cohort with elective sphincter-sparing surgery (SSS) with ileostomy after neoadjuvant chemoradiotherapy (nCRT) for rectal cancer.MethodsData from a total of 359 patients who underwent elective rectal cancer surgery between Jan 2017 and May 2020 were retrospectively reviewed. Patients were classified into early and late AL groups, referring to onset of AL occurring within or after 30 post-operative days, respectively. We analyzed clinical, pathological, and inflammatory features of both AL and risk factors of stoma reversal failure and late AL.ResultsA total of 85 patients with SSS with ileostomy after nCRT were classified into 8 (9.4%) patients of early AL and 16 (18.8%) of late AL. Unlike early AL patients, late AL group showed lower neutrophil-lymphocyte ratio (NLR) (P < 0.001) and did not need an invasive intervention at the time of diagnosis. 50% (5/10) patients needed reformation of ileostomy. (P = 0.048) Failure of stoma reversal is associated with advanced stages, high NLR ratio (≥3), and inflammatory lesions seen around anastomosis in radiologic findings, which was confirmed as the risk factor of late AL.ConclusionLate AL, with different clinical features, showed a higher incidence than early AL in patients who underwent surgery after nCRT and also had a higher stoma reformation rate. Careful evaluation using laboratory and radiological findings before an ileostomy closure is performed to prevent late AL.     

直肠癌新辅助治疗后手术并发症

术前同步放化疗（新辅助治疗）已经成为局部进展期直肠癌综合治疗的标准模式。从临床应用以来，它对外科手术并发症（伤口愈合、吻合口漏等）的影响一直就受到关注。许多随机临床试验的结果认为，新辅助治疗并不显著增加术后伤口愈合、吻合口漏方面的风险，但仍不时有些回顾性研究得出相反的结果。虽然保肛手术后的括约肌功能与外科手术之间存在必然联系，但是不同形式的术前放疗也可能对其产生影响。当我们决定患者是否接受新辅助治疗时，不但要考虑肿瘤的TNM分期，也应该考虑放疗方式、与手术的间隔时间、化疗周期数等。     

末端回肠置管造瘘术防治直肠癌同期放化疗后术后吻合口漏

目的探讨末端回肠置管造瘘术防治直肠癌同期放化疗术后吻合口漏临床效果。 方法选取2013年6月至2015年12月收治的中低位局部晚期直肠癌患者16例,均接受术前放化疗,治疗结束后5～8周行直肠癌全直肠系膜切除术(TME),在TME术中行末端回肠置管造瘘术,观察其术后吻合口漏的发生情况及恢复指标。 结果本组患者16例,术后发生吻合口漏2例,占12.5%,予生长抑素及保守治疗后吻合口漏愈合。未发生吻合口漏14例,占87.5%,吻合口愈合良好,术后第10～14天出院。 结论末端回肠置管造瘘术可有效减少及治疗直肠癌同期放化疗术后吻合口漏,具有安全性和可行性,可在临床推广应用。