腹腔镜左半结肠癌根治术

位于降结肠的肿瘤,包括结肠脾曲肿瘤在内,约占所有结肠癌的5%~6%,因此左半结肠癌的发病数相对较少。此外,由于左半结肠癌较易引起梗阻,许多病人往往因梗阻症状而直接行急诊开腹手术。从技术角度而言,由于左半结肠癌根治术在淋巴清扫和游离脾曲的操作上存在一定难度,因此,腹腔镜辅助下的左半结肠癌根治手术病例较右半结肠、乙状结肠或直肠癌手术相对少。同样,因为上述原因,许多腹腔镜与开腹结肠癌根治术的前瞻性随机对照临床研究亦将左半结肠癌作为排除标准剔除,针对腹腔     

腹腔镜左半结肠癌根治术现状及进展

我国结直肠癌的发病率和死亡率均呈上升趋势。2015年中国癌症统计数据显示,结肠癌在全球范围内其发病率和死亡率均位于恶性肿瘤的第3位,结肠癌的临床表现与肿瘤的病理类型和部位相关,其中左侧结肠癌以肠梗阻、腹泻、便秘、便血等症状为主要表现,多数确诊时已属于中晚期。左半结肠癌占所有结肠癌总数的5%～6%,治疗原则是采取以手术切除为主的综合治疗。腹腔镜下左半结肠根治性切除的范围包括横结肠左侧、降结肠和乙状结肠大部。本文就腹腔镜左半结肠癌根治术的现状及相关进展作一综述。     

腹腔镜左半结肠癌根治术的技术要点探讨

Jacobs在1991年首次报道腹腔镜结肠切除术,其后多项研究证实腹腔镜结肠癌根治术与传统开放手术可获得同样肿瘤学效果~([1])。2009年,Hohenberger等~([2])提出完全结肠系膜切除(complete mesocolic excision,CME)理念,进一步规范结肠癌手术治疗。理论和实践的发展使得腹腔镜结肠癌根治术被越来越多的国内外学者接受并实施。但降结肠癌的发病率相对较低,约占所有结肠癌的5%~     

腹腔镜左半结肠癌根治性切除术的手术体会

目的:探讨腹腔镜左半结肠癌根治性切除术的临床疗效及操作体会。方法:回顾分析2015年9月至2016年7月11例患者行腹腔镜下标准左半结肠癌根治术的临床资料,采用五孔法中间入路,操作过程中严格遵循层面间隙内游离及结肠恶性肿瘤根治原则。结果:11例患者均顺利完成标准腹腔镜辅助左半结肠癌根治术,手术时间平均(142.25±35.26)min,术中出血量平均(21.53±8.76)ml,清扫淋巴结数量平均(18.45±4.28)枚,肛门排气时间平均(30.48±8.23)h,平均住院(10.23±5.26)d。术后无切口愈合不良表现,术后出现肺部感染1例,腹腔感染1例,吻合口瘘1例,经营养支持、消炎、引流等保守治疗后痊愈,术后肠梗阻1例,保守治疗成功,术后1例发生腹腔内出血,再次行腹腔镜探查,发现为胰腺尾部创面边缘出血,行止血治疗。无围手术期死亡病例,患者均获随访,未发现切口肿瘤种植。结论:只要熟悉各个解剖层次,术中保持层面间隙内游离,避免过度牵拉,腹腔镜辅助左半结肠癌根治术是安全、有效的。     

左半结肠癌根治术

手术指征：横结肠远侧1／3、结肠脾曲、降结肠及乙状结肠癌肿。     

4K全腹腔镜左半结肠癌根治术及腔内Overlap消化道重建

腹腔镜左半结肠癌根治术在淋巴结清扫、结肠脾曲游离和消化道重建等方面均有较大难度。4K腹腔镜系统的高清晰度辨识能力能够为左半结肠的完整系膜切除和神经保护提供帮助。笔者通过手术实例探讨4K全腹腔镜左半结肠癌根治术及腔内Overlap消化道重建技术要点。     

腹腔镜左半结肠癌根治手术的技巧与短期疗效

目的探讨腹腔镜左半结肠癌根治术的手术操作技巧与短期疗效。方法回顾性分析2001年8月至2006年7月上海微创外科临床医学中心28例行腹腔镜左半结肠癌根治术患者资料,并探讨其手术操作技巧、术后恢复情况及肿瘤根治性效果。结果Ⅰ期病例1例,Ⅱ期17例,Ⅲ期10例。所有病例无术中严重并发症和手术死亡,3例（10.7%）中转开腹。手术时间为155min,术中平均出血量为100ml,排气时间、进食流质、半流质时间和住院天数分别为3、4、5.5、12d。清扫淋巴结数为11枚,其中结肠上、旁淋巴结4枚,系膜间淋巴结4枚,血管根部淋巴结2枚,手术切除标本长度为14cm。术后吻合口漏2例,肠梗阻1例,肺部感染1例。所有患者均获随访6～55个月,中位随访时间17.5个月。2例发生肝转移,短期累计生存率为92.4%。结论腹腔镜左半结肠切除术治疗左半结肠癌是安全有效的,符合肿瘤根治原则。     

4K腹腔镜左半结肠癌根治术手术团队建设

随着腹腔镜技术的发展,外科医师对于精细解剖的要求逐渐提高。腹腔镜系统对于外科手术中解剖层面的选择、神经血管的保护具有较大优势。4K腹腔镜系统可提供高清手术视野,为术中精细解剖提供有利条件。笔者分享4K腹腔镜左半结肠癌根治术手术团队协作实践经验,旨在为外科同道提供参考。     

左半结肠癌并急性肠梗阻I期左半结肠癌根治术临床分析

目的探讨左侧结肠癌合并急性肠梗阻行I期左半结肠根治术的可行性。方法对30例合并急性肠梗阻的左侧结肠癌患者(A组),采取术中充分减压及肠道灌洗,急诊I期左半结肠癌根治术。对同期67例无急性梗阻的左侧结肠癌患者(B组)行限期左半结肠癌根治术。比较2组患者术后住院天数、排便时间、切口感染率、吻合口瘘发生率。结果所有患者手术过程顺利,未发生围手术期死亡病例。A组术后平均住院8.9 d,术后首次排气时间4.1 d,切口感染3例(10.0%),切口裂开1例(3.3%),吻合口瘘1例(3.3%),经对症治疗治愈。B组术后平均住院天数7.8 d,术后首次排气时间3.7 d,切口感染7例(10.4%),吻合口瘘2例(2.9%),经保守治疗治愈1例,1例经回肠造口愈合后行造口还纳。2组差异均无统计学意义(P>0.05)。结论对左侧结肠癌合并急性肠梗阻患者,在严格掌握手术适应证和术中充分肠道减压及灌洗的基础上,I期左半结肠癌根治术是安全可行的。     

The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy

The purpose of our study was to determine the lowest concentration of ropivacaine that offers pain relief for the initiation of labor epidural analgesia. Women in active labor were enrolled in this prospective, randomized, double-blinded study to receive either ropivacaine 0.20% (Group I), ropivacaine 0.15% (Group II), or ropivacaine 0.10% (Group III). After placement of the epidural catheter, 13 mL of the study medication was administered. Fifteen minutes later, the adequacy of analgesia was assessed. If the woman reported that her degree of analgesia was not adequate, an additional 5 mL of the study medication was given, the degree of pain relief was reassessed 15 min later, and the study was concluded. A sequential study design was used to assess the success rates. We found that 26 of 28 (93%) women in Group I had adequate analgesia, compared with only 18 of 28 (64%) in Group II (P = 0.014) and 4 of 12 (33%) in Group III (P = 0.003). We conclude that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%. IMPLICATIONS: The lowest effective concentration of ropivacaine for the initiation of labor epidural analgesia has not been determined. We found that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%.     

左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果

目的分析左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果。 方法回顾性分析2014年1月至2017年6月80例行左半结肠切除一期吻合术患者的临床资料,根据左半结肠切除一期吻合术后是否加行回肠末端造瘘手术分为研究组(加行回肠末端造瘘手术,39例)和对照组(未加行回肠末端造瘘手术,41例)。数据采用SPSS 20.0统计软件进行分析,患者术中术后各项指标以( ±s)表示,组间比较采用独立t检验。术后并发症的发生情况采用χ²检验。以P<0.05表示差异具有统计学意义。 结果两组患者术中出血量相比,差异无统计学意义(P>0.05);研究组患者手术时间较对照组显著延长(P<0.05);研究组患者术后首次排气时间、首次进食时间、引流管拔出时间以及住院时间分别为(2.5±0.9) d、 (2.5±0.7) d、 (5.7±1.5) d、 (14.3±1.8) d,较对照组均显著缩短,差异具有统计学意义(P<0.05)。研究组吻合口漏及总并发症发生率分别为2.6%、17.9%,显著低于对照组(17.1%、41.5%),差异具有统计学意义(P<0.05)。两组患者术后存活率分别为92.3%、 90.2%,差异无统计学意义(P>0.05)。 结论左半结肠切除一期吻合联合回肠末端造瘘,可促进梗阻性左半结肠癌患者进术后恢复,缩短住院时间,减少术后并发症,值得在临床推广使用。     

Robotics confers an advantage in right hemicolectomy with intracorporeal anastomosis when matched against conventional laparoscopy

Comparisons between robotic and laparoscopic right hemicolectomy have been confounded by variations in operative technique. This study evaluates the two procedures after standardizing the intraoperative steps and perioperative management. Patients who underwent robotic right hemicolectomy with intracorporeal bowel anastomosis between July 2015 and June 2017 were matched with a laparoscopic group. Perioperative management was in accordance to an enhanced recovery protocol. Outcomes and histopathological data were compared. Thirty-two patients were included. Amongst the patients who did not undergo complete mesocolic excision, the median operative time did not differ between the two groups (p = 0.413). The robotic group recorded a statistically shorter time for intracorporeal anastomosis (13 vs 19 min, p = 0.024). Postoperative recovery and complication rates were similar, except for a greater lymph node harvest in the robotic group (41 vs 31, p = 0.038). Robotic surgery achieves short-term results comparable to existing conventional laparoscopy, notwithstanding the advantages of enhanced ergonomics.     

胃上部癌行近端胃切除双通道吻合与全胃切除Roux-en-Y吻合临床疗效比较的meta分析

目的 采用meta分析方法比较胃上部癌患者行近端胃切除双通道吻合（PG-DT组）与全胃切除Roux-en-Y吻合术（TG-RY组）的临床疗效。方法 计算机检索Pubmed、Cochrane Library、Embase、中国知网,万方数据库、维普中文期刊网中关于胃上部癌行近端胃切除双通道吻合与全胃切除Roux-en-Y吻合研究报道。文献检索时限均从建库到2021年3月,由两名评价人员按照Cochrane系统评价手册5.1.0标准独立筛选文献,提取资料,分别应用Jadad量表及Newcastle-Ottawa Scale量表（NOS量表）对随机对照试验及观察性研究进行文献质量评价,使用RevMan 5.3软件分别对结局指标数据进行Meta分析,并对结果进行分析。结果 共纳入16项研究,均为病例对照试验,共纳入1346例患者,其中PG-DT组589例,TG-RY组757例。Meta分析结果显示：PG-DT组较TG-RY组围手术期并发症发生率更少（OR=0.56,95%CI:0.39～0.79,P<0.001）,但严重并发症（OR=0.47,95%CI:0.2～1.08,P=0.08）...     

依托咪酯靶控输注复合瑞芬太尼用于妇科腹腔镜手术病人麻醉的效果

目的 评价依托咪酯靶控输注(TCI)复合瑞芬太尼用于妇科腹腔镜手术病人麻醉的效果.方法 择期行妇科腹腔镜手术病人60例,年龄25 ～ 56岁,体重指数18 ～ 27 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其分为2组(n=30):TCI丙泊酚复合瑞芬太尼麻醉组(PR组)和TCI依托咪酯复合瑞芬太尼麻醉组(ER组).2组静脉注射咪达唑仑0.1 mg/kg、芬太尼4 μg/kg和顺阿曲库铵0.15 mg/kg麻醉诱导,PR组TCI丙泊酚,效应室靶浓度(Ce) 2.5 μg/ml,ER组TCI依托咪酯,Ce 0.8μg/ml,气管插管后行机械通气.麻醉维持:PR组TCI丙泊酚,Ce 2.0～ 2.5μg/ml,ER组TCI依托咪酯,Ce 0.5～0.7 μg/ml,2组静脉输注瑞芬太尼0.1～0.2μg·kg-1·min-1,间断静脉注射顺阿曲库铵5 mg,维持BIS值40 ～ 60.分别于术前(基础状态,T0)、术毕(T1)、术后24 h(T2)和术后48 h(T3)时采集静脉血样,测定血清皮质醇和醛固酮的浓度;记录苏醒时间、拔除气管导管时间和术中血管活性药物使用情况;记录麻醉诱导时注射痛和肌颤、术中知晓和术后躁动、恶心呕吐的发生情况.结果 与T0时比较,T1时ER组血清皮质醇浓度降低(P＜0.05),2组各时点血清醛固酮浓度差异无统计学意义(P＞0.05).与PR组比较,ER组血管活性药物使用率和注射痛发生率降低,肌颤发生率升高(P＜0.05),苏醒时间、拔除气管导管时间、躁动和恶心呕吐发生率差异无统计学意义(P＞0.05).结论 与TCI丙泊酚复合瑞芬太尼比较,TCI依托咪酯复合瑞芬太尼用于妇科腹腔镜手术时有助于维持血流动力学稳定,对肾上腺皮质功能的抑制作用是一过性的,注射痛发生较少.     

Roux-en-Y吻合方案对腹腔镜全胃切除术消化道重建患者疗效及安全性的影响

目的 探讨常规Roux-en-Y吻合方案与Uncut Roux-en-Y吻合方案对腹腔镜全胃切除术消化道重建患者疗效及安全性的影响。方法 回顾性分析济源市第二人民医院2013年1月至2017年12月收治的行腹腔镜全胃切除术消化道重建患者共154例的临床资料,其中102例采用常规Roux-en-Y吻合方案,设为对照组;52例采用Uncut Roux-en-Y吻合方案,设为观察组。比较两组围手术期临床指标水平、术后并发症发生率、营养指标水平及随访生存情况。结果 观察组手术出血量少于对照组（P＜0.05）;观察组术后肛门排气恢复时间少于对照组（P＜0.05）;观察组术后食物襻排空异常和RY滞留综合征发生率均低于对照组（P＜0.05）;两组手术前后体重指数（BMI）、血红蛋白（HGB）、白蛋白（ALB）及总蛋白（TP）比较,差异无统计学意义（P＞0.05）;两组随访生存情况比较,差异无统计学意义（P＞0.05）。结论 行腹腔镜全胃切除术消化道重建患者采用Uncut Roux-en-Y吻合方案可有效减少手术出血量,加快术后胃肠功能恢复,降低术后食物襻排空异常和RY滞留综合征发生风险,且未影响营养状态和生存情况,价值优于常规Roux-en-Y吻合方案。     

Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection

BACKGROUND: Use of laparoscopy in patients with gastrointestinal cancer has been associated with port-site and peritoneal tumour metastases. The effect of laparoscopy on tumour recurrence and long-term survival in patients undergoing resection of ruptured hepatocellular carcinoma (HCC) remains unknown. METHODS: Between June 1994 and December 2001, 59 patients with ruptured HCC underwent surgical exploration with a view to hepatic resection. Laparoscopy with laparoscopic ultrasonography was performed in 33 patients; the other 26 patients underwent exploratory laparotomy without laparoscopy. Perioperative and long-term outcomes were compared between the two groups. RESULTS: Exploratory laparotomy was avoided in 12 of 13 patients with irresectable HCC who had a laparoscopy. The hospital stay of these 12 patients was significantly shorter than that of eight patients found to have irresectable HCC at exploratory laparotomy (median 11 versus 15 days; P = 0.043). Twenty patients had a laparoscopy followed by open resection of HCC, whereas 18 patients underwent laparotomy and resection without laparoscopy. There were no significant differences in disease-free (16 versus 19 per cent; P = 0.525) and overall (32 versus 48 per cent; P = 0.176) survival at 3 years between the two groups. The tumour recurrence pattern was similar between the two groups, and there were no port-site or wound metastases. CONCLUSION: Use of diagnostic laparoscopy in patients with ruptured HCC helps avoid unnecessary exploratory laparotomy. The present data suggest that laparoscopy does not have an adverse effect on tumour recurrence or survival in patients who undergo resection.