低位直肠癌治疗进展

自1986年英国Heald医生提出并推广直肠全系膜切除手术(total mesentery excision,TME)以来,该手术方式的价值已经被广泛的实践所证实,但肛肠外科医生仍然面对着诸多挑战,特别是对于低位直肠癌的治疗.例如:如何进一步提高患者的保肛率;如何进一步降低局部和系统的复发与转移率;如何改善患者术后肛门功能,提高生活质量等.通过多年不遗余力的探索和追求,人们取得了很大的进步.     

低位直肠癌的外科治疗

本文报道1980年12月～1988年12月收治直肠癌205例,肿块距肛门齿线7cm以下者占78.5%。保留肛门者84例,占41%;会阴部肛门再造30例,占14.6%;Miles手术75例,占36.6%;仅探查和单纯造瘘16例,占7.8%,手术切除率为92.2%。再造的方法有股薄肌移植19例,带蒂幽门代替肛门9例,结肠套叠加股薄肌移植2例。文中对各种手术方法作了介绍,强调会阴部造瘘优于腹壁造瘘。但病情较晚,恶性呈度高,年龄在60岁以上或有严重器质性病变和肥胖者,不适宜此种术式。     

低位直肠癌的外科治疗

手术治疗低位直肠癌１２３０例，切除率７９．９２％，根治性切除率６３．９８％，手术死亡率１．４２％。如果病例选择适当，保肛手术在低位直肠癌中无论生存率或生活质量均明显优于腹会阴切除术。     

低位直肠癌外科治疗进展

目前,我国结直肠癌的发病率为(3.1～10.7)/10万,其中直肠癌占56%～70%,而低位直肠癌的比例高达70%～80%[1],由于我国直肠癌的主要特点是低位直肠癌多,肿瘤位于距肛缘5 cm以下,这给结直肠外科医生带来许多挑战.近20年,随着人们对直肠癌生物学特性的深入研究,先进医学仪器的应用及患者对术后生活质量要求的提高,使直肠癌外科治疗模式发生了根本性的变化,手术方式已发生了变革,从传统的单纯追求根治术挽救生命的观点转变为在根治性切除肿瘤的同时,力求保留肛门功能以提高术后生活质量.本文就低位直肠癌外科治疗相关进展进行综述.     

低位直肠癌外科治疗进展

目前,我国结直肠癌的发病率为（3.1～10.7）/10万,其中直肠癌占56%～70%,而低位直肠癌的比例高达70%～80%[1],由于我国直肠癌的主要特点是低位直肠癌多,肿瘤位于距肛缘5 cm以下,这给结直肠外科医生带来许多挑战.近20年,随着人们对直肠癌生物学特性的深入研究,先进医学仪器的应用及患者对术后生活质量要求的提高,使直肠癌外科治疗模式发生了根本性的变化,手术方式已发生了变革,从传统的单纯追求根治术挽救生命的观点转变为在根治性切除肿瘤的同时,力求保留肛门功能以提高术后生活质量.本文就低位直肠癌外科治疗相关进展进行综述.     

低位直肠癌外科治疗新进展

直肠癌是我国常见的恶性肿瘤之一,发病率逐年上升.其中,低位直肠癌的治疗方式主要为以外科手术为主的综合治疗.治疗的理念也发展为不仅要根治肿瘤,还要尽量保留肛门和泌尿生殖功能,提高生活质量.通过提高低位直肠癌术前分期准确度、新辅助治疗,并遵循全直肠系膜切除原则,能够提高手术切除率,降低手术并发症发病率,提高保肛率,降低术后局部复发率,延长生存时间.随着医学技术的发展,低位直肠癌的微创治疗得到迅速发展.本文就低位直肠癌外科治疗新进展进行综述.     

局部切除术治疗低位直肠癌

探讨局部切除术在低位直肠癌的治疗中的作用。方法以经肛门途径和经骶尾部经肛门丘约肌途径对１９例低位直肠癌患者行局部切除术。结果无手术死亡。术后发生切口感染２例,无肛门失禁和直肠瘘。结论局部切除术对早期直肠癌的治疗具有良好的效果,对于患者有多种老年病而不能耐受根治术的老年患者,可作为较好的姑息手术方法。     

双吻合器低位前切除术治疗低位直肠癌

1993年1月至1996年12月，笔采用双吻合器低位前切除术治疗直肠癌183例，占同期全部直肠癌242的75．62％，其中属低位主肠癌124例，占同期低位直肺癌174例的71．26％。内有61例属超低位吻合音(吻合距肛缘≤3cm)，占低位主肠癌的35．06％和低位前切除术49.19％。本组无手术死亡。在此124例低位直肠癌行双吻合器低位前切除术患中，术后发生吻合口漏5例，占4．03％；吻合口狭窄14例，占11．29％；术后出现局部复发8例，直发率为6.45％，其中属吻合口复发3例，盆腔复发5例。本组资料充分显示低位直肠癌时应用双吻合器低位前切除术行保肛手术，不但显提高了肛门保留的成功率，也保证了最佳的性便功能，是一个安全、有效的首选保肛术式。     

双吻合器低位前切除术治疗低位直肠癌

1993年1月至1996年12月,笔者采用双吻合器低位前切除术治疗直肠癌183例,占同期全部直肠癌242的75.62％,其中属低位直肠癌者124例,占同期低位直肠癌174例的71.26％。内有61例属超低位吻合(吻合距肛缘≤3cm),占低位直肠癌的35.06％和低位前切除术49.19％。全组无手术死亡。在此124例低位直肠癌行双吻合器低位前切除术患者中,术后发生吻合口漏者5例,占4.03％;吻合口狭窄14例,占11.29％;术后出现局部复发者8例,复发率为6.45％,其中属吻合口复发3例,盆腔复发5例。本组资料充分显示低位直肠癌时应用双吻合器低位前切除术行保肛手术,不但显著提高了肛门保留的成功率,也保证了最佳的控便功能,是一个安全,有效的首选保肛术式。     

中低位直肠癌的综合治疗

随机临床研究已证实辅助放化疗的作用,德国研究证实术前新辅助放化疗较术后化疗的优势。荷兰的TEM研究中显示肿瘤位置是影响治疗疗效的预后因素。但在具体化疗的实施和与化疗的联合应用,目前没有统一的共识。术前放疗的分割剂量,同期化疗应用和病人的选择存有差异。在治疗选择时需注意综合分析,多学科治疗模式。     

Treatment of rectal cancer by low anterior resection with coloanal anastomosis.

OBJECTIVE: Our institution's experience with low anterior resection in combination with coloanal anastomosis (LAR/CAA) for primary rectal cancer was reviewed (1) to determine cancer treatment results, 2) to identify risk factors for pelvic recurrence, and 3) to assess the long-term success of sphincter preservation. SUMMARY BACKGROUND DATA: Use of sphincter-preserving resection for mid-rectal and selected distal-rectal cancers continues to increase. As surgical techniques and adjuvant therapy evolve, treatment results must be carefully assessed. METHODS: One hundred thirty-four patients treated for primary rectal cancer by LAR/CAA between 1977 and 1990 were studied retrospectively. All pathologic slides were reviewed. Median follow-up was 4 years. RESULTS: Actuarial 5-year survival for all patients was 73%. Among 36 patients who relapsed, distant metastatic disease had developed at the time of first clinical relapse in most (86%). Pelvic recurrence was detected in 13 patients, an actuarial rate of 11% at 5 years. Mesenteric implants, positive microscopic resection margin, T3 tumor, perineural invasion, blood vessel invasion, and high tumor grade were associated with increased risk for pelvic recurrence. Eleven patients ultimately required permanent colostomy, and in eight instances the cause was pelvic recurrence. CONCLUSIONS: Low anterior resection combined with coloanal anastomosis provides good treatment for mid-rectal cancers and for some distal rectal cancers. Pelvic recurrence is not associated with short distal resection margins but is correlated with the presence of histopathologic markers of aggressive disease in the primary tumor. Long-term preservation of anal sphincter function depends primarily on control of pelvic tumor and can be achieved in more than 90% of patients.     

低位直肠癌保肛手术中直肠冲洗治疗对预后的影响

目的研究低位直肠癌保肛术中应用直肠冲洗对预后的影响。方法随机选择98例低位直肠癌患者分为冲洗组（A组）和单纯手术组（B组）,各49例。在经腹低位直肠前切除中,A组进行远端直肠冲洗并将冲洗液进行细胞学检查。将两组2年局部复发率和1、3、5年生存率进行比较。结果A组有27例找到癌细胞,术后局部复发率为1413％,B组为30．6％,两组比较差异有统计学意义（P〈0．05）;A组术后1、3、5年生存率分别为96．8％、72．3％、52．3％,B组分别为95．7％、65．4％、43．0％,两组术后3、5年生存率比较,差异有统计学意义（P〈0．05）。结论低位直肠癌保肛术中远端直肠冲洗是必要的,可以提高低位直肠癌的治疗效果。     

Sphincter-saving resection for low rectal cancer

R0 resection, preservation of the anal sphincter, and local control are considered to be the most important target criteria in rectal cancer surgery. Many efforts have been made in recent years to increase the rate of sphincter preservation by performing pull-through operations, ultra-low anterior resection (U-LAR), and intersphincteric resection (ISR). U-LAR is the standard surgery for patients with lower rectal cancer to preserve anal function. Reconstruction in U-LAR is mainly performed using stapled anastomosis. Although conventional coloanal anastomosis makes it possible to preserve the anal sphincter, the mechanical methods are difficult. In that case, almost all the internal sphincter is preserved. The final options for preserving the sphincter are ISR and external sphincter resection (ESR). Although the internal sphincter is sacrificed partially, subtotally, or totally in ISR, and the external sphincter is resected partially or extensively in ESR, complete or incomplete anal function is maintained. However, the literature is not clear regarding long-term oncologic outcome and anal function after these procedures. The application of these surgical techniques can reduce the rate of abdominoperineal resection in very low rectal cancer. The indications for these procedures must be carefully determined based on tumor site and stage as well as the patient's own preference.     

新辅助放疗在低位直肠癌中的应用

目的探讨新辅助放疗在低位局部进展期直肠癌中的疗效及其对保肛手术的意义。方法回顾性分析2000~2005年39例行新辅助放疗低位直肠癌病人的临床资料。结果肿瘤距肛缘3~7 cm,平均4.9 cm。放疗后21例(53.8%)排便困难、便血等症状得以改善。腹会阴联合切除14例,低位前切除术13例,Parks术8例,Hartm ann术4例。术后病理显示肿瘤完全消退(CR)3例,肿瘤部分缓解(PR)22例,无效(NR)14例,总有效率为64.1%(25/39)。保肛率为53.8%(21/39),其中放疗有效者(CR PR)保肛率为64%(16/25),无效者为35.7%%(5/14),两者间差异有显著性意义(P<0.01)。结论新辅助放疗对多数直肠癌病人有效,可以使肿瘤缩小、降低分期,并可提高低位直肠癌的保肛率。     

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类癌源于肠黏膜的Kulchitsky细胞，其胞浆含有能沉积银盐的颗粒，故又称为嗜银细胞，为此，类癌也称为嗜银细胞癌。其细胞形态似癌，但发展缓慢，表现为良性肿瘤，与癌不同，因此称之为“类癌”。首先由Oberndorfer(1907)命名，以区别一般的腺癌和腺瘤。由于部分类癌分泌5-羟色胺，并引起类癌综合征(皮肤潮红、哮喘、腹泻、瓣膜性心脏病等系列症候群)，故有学者将其归入胺前体摄取及脱羧酶细胞瘤(APUD瘤)一类，     

局部进展期中低位直肠癌新辅助放化疗后的治疗选择

直肠癌放化疗出现临床完全缓解或显著缓解后密切观察及局部切除已成为中低位直肠癌治疗的新治疗策略.但由于放化疗后分期准确性低、临床与病理缓解的低符合率以及淋巴结转移状态的不确定性等因素,保留直肠治疗策略的确切适应证尚存争议,应结合放化疗疗效及放化疗前肿瘤分期确定具体治疗方式,对分期较早（如：cT0-2）放化疗显著缓解（如：ypT0-1）的中低位直肠癌患者可选择密切观察或局部切除,局切后根据病理结果决定后续治疗策略,反之仍宜直接施行根治性手术.根治性手术方式可根据放化疗后分期重新评估,宜在放化疗后6～12周内进行。     

Sphincter-saving surgery in low rectal cancer

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.     

腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术。术中首先经中间入路打开乙状结肠系膜内侧浆膜,循Toldt’s间隙向头侧游离至肠系膜下动脉根部,夹闭离断肠系膜下动脉,并清扫253组淋巴结;继续向外侧、尾侧游离左侧Toldt’s间隙,并向下延续至直肠后间隙,分离过程中注意保护左侧输尿管、左侧生殖血管。沿左结肠旁沟打开结肠系膜与侧腹壁的融合筋膜,向上游离左侧结肠至脾曲。向下继续沿直肠后间隙分离,并向两侧拓展;前方在腹膜返折略上水平打开腹膜,在邓氏筋膜前间隙向下游离,从前、后及两侧交替游离并完整切除直肠系膜;双吻合器法切除直肠肿瘤及重建肠道。