108例Tis~1N0M0期中低位直肠癌经肛门局部切除的临床评价

[目的]探讨Tis~1N0M0期中低位直肠癌经肛门局部切除的合理性。[方法]回顾性分析经肛门局部切除治疗的108例Tis~1N0M0期中低位直肠癌患者的资料。其中TisN0M063例,T1N0M045例。8例T1期患者接受了术后辅助放疗。[结果]所有患者术后恢复顺利,中位住院时间5d(3~8d)。无吻合口漏、直肠狭窄、肛瘘及其他手术并发症。术后肛门括约肌功能良好。5年总生存率为99.07%,Tis、T1期5年生存率分别为100%和97.78%。5年总复发率为1.85%,Tis、T1期5年复发率分别为0、4.44%。[结论]对Tis~1N0M0期中低位直肠癌患者,经肛门局部切除术既保证了生存率,又兼顾了患者的生存质量,为一种较为理想的术式选择。     

早期中低位直肠癌经肛门切除的疗效分析

目的:探讨早期中低位直肠癌经肛门局部切除术的临床应用价值。方法:回顾性分析2012年至2015年期间我院收治的112例早期中低位直肠癌患者,分为经肛门局部切除组（n=52）和根治性切除组（n=60）。术后标本行常规免疫组化病理检测,同时对比两组患者的各种临床病理特征。结果:两组患者肿瘤大小、肿瘤距肛缘距离比较差异无统计学意义（P＞0.05）;术后住院天数、术中出血量、术后并发症发生率及手术时间比较差异有统计学意义（P＜0.05）。结论:早期中低位直肠癌经肛门切除与根治性手术比较治疗效果相当,但操作更简便易行,创伤小,恢复快、并发症少、术后生活质量高,具有一定优势,特别是内镜切割吻合器的联合应用,使得该术式更简便易行,在具有适应征患者中可以推广。     

局部晚期中低位直肠癌新辅助同步放化疗58例分析

[目的]探讨局部晚期中低位直肠癌新辅助同步放化疗的疗效及其影响因素。[方法]58例局部晚期（T3-4N0-1M0）中低位直肠癌术前接受同步放化疗,放疗剂量50Gy,化疗包括奥沙利铂＋卡培他滨的联合化疗组及不含铂类药物的单药化疗组。共55例患者同步放化疗结束后2～10周内完成根治性手术,依据术后病理结果进行疗效评价。[结果]全组55例患者手术顺利,无严重手术并发症;术后病理示肿瘤完全消退8例（14．5％）,重度消退11例（20．0％）,中度消退20例（36．4％）,轻度及无消退16例（29．1％）;治疗前肿瘤（T）及淋巴结（N）临床分期与放化疗后肿瘤消退程度无关：奥沙利铂联合卡培他滨化疗组肿瘤完全消退与重度消退率为41．2％,不含铂类药物组为23．8％（P〉0．05）;与术前临床分期相比,同步放化疗后原发肿瘤（T）降期率为41．8％,淋巴结（N）降期率为58．8％。[结论]新辅助同步放化疗用于局部晚期中低位直肠癌的术前治疗可使大部分肿瘤获得不同程度消退：有关直肠癌同步放化疗疗效的预测指标以及高效的化疗方案有待进一步深入研究。     

新辅助同步放化疗联合全系膜切除对局部进展期中低位直肠癌的治疗价值

目的探讨新辅助同步放化疗联合直肠全系膜切除术(total mesorectal excision,TME)用于局部进展期中低位直肠癌治疗的可行性与临床价值。方法111例局部进展期(T3～4 N0～2 M0)中低位直肠癌术前接受同步放化疗,放疗剂量50 Gy,化疗包括奥沙利铂+卡培他滨的联合化疗方案及不含铂类药物的单药化疗方案。共105例患者同步放化疗结束后2～10周内完成了肿瘤根治性(R0)手术,可进行疗效的病理学评价。结果105例患者获得根治性切除,切缘均阴性,42例(37.8%,42/111)患者成功实施保肛手术;18例临床-影像分期为T4期患者中,15例(83.3%)新辅助放化疗后获得根治性切除(R0)。所有患者手术及术后恢复顺利,无严重手术并发症;术后病理示肿瘤完全消退15例(14.3%),重度消退26例(24.8%),中度消退40例(38.1%),轻度及无消退24 例(22.8%)。结论新辅助同步放化疗联合TME手术安全可行,可提高局部进展期中低位直肠癌的根治性切除率与保肛率,不增加手术并发症,是局部进展期中低位直肠癌的优选治疗模式。     

新辅助同步放化疗联合TME及术后辅助化疗对中低位局部进展期直肠癌的疗效研究

目的探讨新辅助同步放化疗联合全直肠系膜切除（TME）加术后辅助化疗三联疗法治疗中低位局部进展期直肠癌的疗效及安全性.方法选择局部进展期中低位直肠癌Ⅱ、Ⅲ期（T2N＋M0,T3-4N0-2M0期）65例,术前放疗总剂量50～54Gy,术前采用Xelox方案化疗3个疗程,放化疗结束后6～8周根据TME原则行直肠癌根治术.术后采用Forfox4方案辅助化疗6个疗程.结果65例均完成新辅助同步放化疗、手术治疗及术后辅助化疗.其中48例行Dix-on’s手术,17例行mile’s手术,保肛率73.85%,术后并发症发生率23.08%,其中伤口感染延期愈合6例,吻合口瘘4例,吻合口狭窄5例,手术后病理完全缓解（pCR）11例,占16.92%.结论新辅助放化疗＋TME手术治疗＋术后辅助化疗三联疗法治疗中低位进展期直肠癌安全有效,可以降低肿瘤分期,减少局部复发及远处转移,中远期疗效好.     

早期低位直肠癌局部切除术的辅助与新辅助放射治疗

正早期低位直肠癌是指肿瘤位于距离肛门7～10cm以内的T1～2N0M0的病变。传统的治疗方法为根治性手术,包括腹会阴联合切除术(APR)或者低位前切除术(LAR)。直肠癌局部切除术是一种保留肛门的手术方法,分为经肛门肿物切除(transanal resection,TAR,即Parks法)、内镜下显     

早期直肠癌经肛门局部切除的临床观察

目的:探讨Tis-1N0M0期低位直肠癌经肛门局部切除的合理性.方法: 回顾性分析1996-01-01-2002-12-30经肛门局部切除治疗的53例Tis-1N0M0期直肠癌患者的资料.其中TisN0M0 18例,T1N0M0 35例.6例T1患者接受了术后放疗.结果:所有患者术后恢复良好,住院时间7 d(5～8 d).无吻合口漏、直肠狭窄、肛瘘及其他手术并发症.术后肛门括约肌功能良好.总5年生存率为98.11%(52/53),Tis、T1期5年生存率分别为100%(18/18) 和97.14%(34/35).总5年复发率为3.78%(2/53),Tis、T1期5年复发率分别为0(0/18)、5.71%(2/35).结论:对Tis-1N0M0期低风险低位直肠癌患者,经肛门局部切除术既保证了生存率,又兼顾了患者的生存质量,是一种较为理想的术式选择.     

TME联合ISR不同术式治疗T1和T2期超低位直肠癌的临床疗效观察

目的：探讨全直肠系膜切除术（TME）联合经肛门括约肌间切除术（ISR）不同术式治疗T1和T2期超低位直肠癌的肿瘤根治效果及术后肛门功能观察。方法回顾性分析68例实施TME联合ISR手术的T1和T2期超低位直肠癌患者的临床资料,其中实施切除全部内括约肌的ISR者22例作为完全ISR组,切除部分内括约肌的ISR者26例作为部分ISR组,保留部分齿状线的ISR者20例作为保齿ISR组。比较三组患者的手术情况及术后肛门功能恢复情况。结果①三组的手术时间、术中出血量、切除肠管长度、远切缘距离、清扫淋巴结数目、切缘阴性情况及术后并发症发生情况比较差异无统计学意义（P>0.05）;②术后3、6、12个月时,部分ISR组和保齿ISR组的肛门功能良好率优于完全ISR组（χ2分别为4.384、4.227、4.654,P分别为0.026、0.018、0.015）。结论 TME联合ISR治疗T1和T2期超低位直肠癌安全有效,在保证根治性的前提下尽可能地保留部分内括约肌和齿状线对改善术后肛门功能具有重要的临床意义。     

术前同步放化疗联合全直肠系膜切除术治疗中低位局部晚期直肠癌的疗效

目的探讨术前同步放化疗联合全直肠系膜切除术(TME)治疗中低位局部晚期直肠癌的疗效。方法给予75例中低位局部晚期直肠癌患者(T3~4N0M0期或T1~2N1~2M0期)进行新辅助同步放化疗,放化疗结束后行全直肠系膜切除术(TME),观察治疗效果。结果 75例患者均完成术前同步放化疗,其中完全缓解(CR)13例,部分缓解(PR)50例,疾病稳定(SD)12例,84.0%(63/75)的患者临床分期下降。75例患者均接受了手术治疗,总保肛率为66.7%(50/75),无一例发生围手术期死亡,术后并发症发生率为20.0%(15/75)。结论术前同步放化疗联合TME治疗中低位局部晚期直肠癌安全、有效,可以降低肿瘤分期,提高保肛率,提高患者生活质量。     

新辅助放化疗联合局部切除对比全直肠系膜切除术治疗T2～3abN0M0期直肠癌：TAUTEM研究及短期疗效解读

摘 要：TAUTEM研究是一项随机、对照、前瞻性、多中心的Ⅲ期非劣效性研究，该研究旨在比较新辅助放化疗联合经肛门内镜显微手术（chemoradiotherapy and transanal endoscopic microsurgery，CRT-TEM）与全直肠系膜切除术（total mesorectal excision，TME）在T2～3abN0M0期直肠癌患者中的局部复发与术后并发症发生情况。该项研究的主要研究终点为2年局部复发率；次要研究终点为CRT的耐受性及其副反应发生率；CRT后的临床缓解率（clinical complete response，cCR）及病理缓解率（pathological complete response，pCR）；术后并发症发生率及死亡率；生活质量；患者的3年总生存期等。在接受CRT-TEM的患者中，新辅助放化疗后副反应发生率为29.6%（24/81），pCR率为44.3% (35/79)，器官保留率为82.7% (67/81)；CRT-TEM组术后并发症发生率为20.7%(17/ 82)，而TME组术后并发症发生率为50.6%(41/81)。TAUTEM研究结果提示新辅助放化疗联合局部切除将为早期浅表直肠癌患者实现器官保留奠定基础。     

腔镜直线切割吻合器用于T1期中低位直肠癌经肛门局部切除术的疗效及安全性

目的:探讨应用腔镜直线切割吻合器（endoscopic linear cutters,ENDOPATH）行经肛门局部切除术治疗T1期中低位直肠癌的疗效和安全性。方法:回顾性分析2011年01月至2017年12月我院收治的92例T1期中低位直肠癌患者的临床资料。根据手术方式分为经肛门局部切除术组（TAE组）与直肠癌传统根治术组（根治术组）。TAE组使用腔镜直线切割吻合器行经肛门全层局部切除术,共39例;根治术组按全直肠系膜切除原则行传统根治术,共53例(包括16例Miles手术和37例Dixon手术)。对两组患者的一般资料、术中及术后相关指标及预后情况进行比较。结果:TAE组和根治术组患者在性别、年龄、肿瘤病理分型、肿瘤大小、距肛缘距离方面对比分析,无显著性差异（P＞0.05）,两组资料有可比性。两组患者在手术时间［（TAE组:(37.74±10.66)min,根治术组:(117.66±41.78)min］、术后住院时间［TAE组:(6.85±1.06)天,根治术组:(10.70±1.72)天］、术中出血量［TAE组:(30.21±2.97)mL,根治术组:(78.96±12.65)mL］、术后并发症发生率（TAE组:2.56%,根治术组:43.39%）方面差异均有统计学意义（P＜0.01)。两组患者的3年无病生存率均为100.00%,两组患者3年内均无复发,相比较无统计学差异（P＞0.05）。两组患者的生存质量评分［TAE组:(90.31±3.82)分,根治术组:（71.59±6.33）分］差异有统计学意义（P＜0.01)。结论:与传统根治术相比,应用腔镜直线切割吻合器对T1期中低位直肠癌行经肛门局部切除术同样安全有效。应用腔镜直线切割吻合器行经肛门局部切除术创伤小、并发症少、恢复快,患者术后生活质量等方面明显优于根治术。应用腔镜直线切割吻合器行经肛门局部切除术可作为早期无淋巴转移的中低位直肠癌患者优先选择的一种术式。     

腹腔镜中低位直肠癌根治术经肛吻合口加固预防吻合口瘘

目的:探讨腹腔镜中低位直肠癌根治术(Dixon)经肛加固吻合口对预防直肠癌术后吻合口瘘的可行性。方法:收集2019年08月至2022年05月我院普外科行腹腔镜中低位直肠癌根治手术(Dixon)患者共127例。根据指南,中低位直肠癌为肿瘤下缘距离肛门10 cm以内,根据吻合口加固方式不同分为三组:经肛连续缝合组(n=43);经肛间断缝合组(n=42);对照组（未经肛门缝合组）(n=42)。对患者一般资料、手术时间、术中出血量、肛门首次排气时间、进流食时间、术后住院时间、吻合口瘘、吻合口出血、切口感染、肛周疼痛进行比较。结果:三组患者一般资料比较无统计学差异(P>0.05),与对照组比较,经肛连续缝合组和经肛间断缝合组在手术时间、术中出血量、进流食时间、术后肛门排气时间、切口感染、肛周疼痛无统计学差异(P>0.05),而吻合口瘘方面,连续缝合组为4.65%,间断缝合组为4.76%,对照组为16.67%,三组间比较虽无统计学差异（P=0.079）,但提示经肛缝合可降低吻合口瘘的发病,术后住院时间,间断缝合组为(8.17±1.52)d,连续缝合组为(8.15±1.69)d,对照组为(12.13±1.57)d,有统计学差异(P=0.035),经肛连续缝合组和经肛间断缝合组间比较术后住院时间无统计学差异(P>0.05)。C级吻合口瘘对照组例数为3例,多于经肛缝合组1例。结论:腹腔镜中低位直肠癌根治手术经肛连续吻合口加固和经肛间断吻合口加固能降低术后吻合口瘘,技术操作简单,并缩短住院时间,可以临床推广应用。     

Local excision of rectal carcinoma: a safe alternative for more advanced tumors?

BACKGROUND AND OBJECTIVES: Local excision of rectal carcinoma has primarily been limited to patients with small (< or =3 cm), early rectal carcinoma. We wanted to determine whether local excision (transanal or transacral), when combined with selective chemoradiation therapy, would be adequate treatment for patients with larger (>3 cm) and more advanced T3 and N1 tumors. METHODS: A prospective study of 20 patients with clinical T1-T3, N0-N1 rectal carcinoma was initiated in 1990. Local excision (transanal or transacral) was performed on all patients. Sixteen patients were treated with postoperative 5-fluorouracil (5-FU) and leucovorin (LV) combined with radiation therapy; six high-risk patients (T3 or N1) received an additional 6 months of 5-FU and LV. All patients were followed for a minimum of 4 years. RESULTS: Tumor size ranged from 2 to 5.5 cm (mean, 3.6 cm). Histology revealed well or moderate differentiation (19/20), gross or microscopic ulceration (14/20), and vessel invasion (5/20). Mucosal margins were 3-12 mm (mean, 8.3 mm); radial margins were clear in all patients except one (microscopically positive). Five patients had T3 tumors; two had node positive tumors (N1). With a median follow-up of 56 months (48-71), there have been no local or regional failures and two patients have died from metastatic disease. CONCLUSIONS: Local excision, when combined with selective chemoradiation therapy, can be safely applied to patients with large (>3 cm) and more advanced T3 and N1 rectal carcinomas.     

YpT1-2N0 rectal cancer after neoadjuvant chemoradiation has lower survival compared with pT1-2N0 rectal cancer

Pathologic T1-2N0 rectal cancer shows an excellent prognosis without preoperative or postoperative chemoradiation. However, oncologic outcome of ypT1-2N0 remains unclear and undetermined. Thus, the aim of this study was to compare the survival of ypT1-2 and pT1-2 rectal cancer patients after radical resection and identify risk factors of ypT1-2 rectal cancer in Surveillance, Epidemiology, and End Results Program (SEER)-registered rectal cancer patients. The results showed that ypT1-2N0 rectal cancer after neoadjuvant chemoradiation has lower survival compared with pT1-2N0 rectal cancer and mucinous/signet-ring cancer and less than 12 lymph nodes retrieval were two risk factors in ypT1-2 patients. These results suggest that ypT1-2 patients with one or two risk factors may benefit from postoperative adjuvant chemotherapy.     

预后营养指数对腹腔镜直肠癌根治术后并发症的预测价值

目的:探讨预后营养指数(PNI)对腹腔镜直肠癌根治术后并发症的预测价值。方法:回顾性分析2016年1月至2020年5月在我院普外科行腹腔镜直肠癌根治术的220例直肠癌患者的临床资料。根据术后有无发生并发症分为并发症组(n=63例)和无并发症组(n=157例)。比较两组临床病理特征;采用多因素Logistic回归分析影响腹腔镜直肠癌根治术后并发症的危险因素。结果:220例接受腹腔镜直肠癌根治术患者中63例(28.64％)术后发生了并发症;两组年龄、性别、BMI、术前有合并疾病、肿瘤位置、TNM分期、肿瘤直径、手术时间、PNI组间比较差异有统计学意义(P＜0.05);多因素Logistic回归分析显示,年龄、性别、术前合并疾病、肿瘤位置、手术时间和PNI是腹腔镜直肠癌根治术后并发症发生的独立危险因素(P＜0.05)。结论:术前低PNI是腹腔镜直肠癌根治术后并发症的独立危险因素,临床上可通过PNI评估患者术前营养状况,必要时术前予以营养支持治疗。     

Local therapy for rectal cancer.

In selected patients with early rectal cancer, local therapy is an effective alternative to radical resection and offers minimal morbidity and the avoidance of a colostomy. Several techniques are described: transanal excision, dorsal approaches (York-Mason or Kraske procedures), transanal endoscopic microsurgery, endocavitary radiation, and transanal fulguration. Among these, transanal excision is favored for the low rate of complications, promising outcomes, and ability to secure tissue for pathology. Patients with T1 lesions with favorable histologic features may undergo local excision alone, while those with T2 lesions require adjuvant chemoradiation. The data currently available do not support the use of local therapy with curative intent for tumors that are advanced (T3 or T4), poorly differentiated, or have other negative pathologic characteristics. In carefully selected patients for local excision, local recurrence and survival rates are similar to traditional radical resection. Following local excision, patients require close observation for recurrence. Most patients with local recurrence can be salvaged by radical resection, though the long-term outcome is unknown.     

Outcomes of Local Excision for Early Rectal Cancer: a 6-year Experience from the Largest University Hospital in Thailand

Background: This study aimed to determine clinical outcomes of local excision for early rectal cancer from aUniversity Hospital in Thailand. Materials and Methods: We performed a retrospective review of 22 consecutivepatients undergoing local excision for early rectal cancer (clinical and radiological T1/T2) from 2005-2010 at theFaculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok. Data were collected from patients’ medicalrecords, including demographic and clinical characteristics, pathological report and surgical outcomes. Results:This study included 10 males and 12 females, with average age of 68 years. Nineteen patients (86%) underwenttransanal excision and the others had trans-sacral excision. Median operative time was 45 minutes. Postoperativecomplications occurred in 2 patients (9%); 1 fecal fistula and 1 wound infection following trans-sacral excision.There was no 30-day postoperative mortality. Median hospital stay was 5 days. Pathological reports revealedT1 lesion in 12 cases (55%), T2 lesion in 8 cases (36%) and T3 lesion in 2 cases (9%). Eight patients receivedadditional treatment; one re-do transanal excision, two proctectomies, and five adjuvant chemoradiation. Duringthe median follow-up period of 25 months, local recurrence was detected in 4 patients (18%); two cases of T2lesions with close or positive margins, and two cases of T3 lesions. Three patients with local recurrence underwentsalvage abdominoperineal resection. No local recurrence was found in T1/T2 lesions with free surgical margins.Conclusions: Local excision is a feasible and acceptable alternative to radical resection only in early rectal cancerwith free resection margins and favorable histopathology.     

腹腔镜辅助经肛全直肠系膜切除术治疗直肠癌的临床疗效分析

目的:评价腹腔镜辅助经肛全直肠系膜切除术（transanal total mesorectal excision,TaTME）治疗直肠癌的可行性、安全性、根治性和近期临床疗效。方法:回顾性分析2018年12月至2019年12月我院收治的58例中低位直肠癌患者（肿瘤下缘距肛缘的距离≤10 cm）的临床资料。其中28例行腹腔镜辅助经肛全直肠系膜切除术（TaTME组）,30例行腹腔镜全直肠系膜切除术（LaTME组）。比较两组的相关临床指标。结果:两组患者在年龄、性别、肿瘤下缘距肛缘的距离、肿瘤浸润深度等一般资料差异无统计学意义,具有可比性（P＞0.05）。TaTME组手术时间为(187.82±38.99)min,LaTME手术时间为(113.00±21.84)min,两组差异有显著意义（P＜0.001）;两组术中出血量［(75.00±18.40)mL vs (73.16±17.88)mL］、术后镇痛时间［（1.93±0.71)d vs(1.83±0.64)d］、肠功能恢复时间［(1.76±0.58)d vs (1.75±0.58)d］及住院时间［(8.43±3.51)d vs (8.07±3.29)d］相比较,差异无统计学意义（P＞0.05）;术后并发症TaTME组和LaTME组两者无显著差异（P＞0.05）。两组在标本切除长度,肠管远切缘距离方面比较无差异;两组远处切缘所在病理学检查为阴性。两组随访时间到至今,所选入组为T3期以下,患者复查无瘤生存。结论:TaTME在游离低位直肠以及系膜更有优势,改善“困难骨盆”的低位直肠癌病人的手术切除和标本质量;同时手术安全可行,在手术并发症、手术死亡率等近期疗效方面与腹腔镜TME手术相当。     

腹腔镜下系统保留盆腔自主神经的宫颈癌根治术效果评价

目的:评价腹腔镜下系统保留盆腔自主神经的宫颈癌根治术效果。方法:宫颈癌手术患者60例,随机分为两组,对照组应用传统宫颈癌根治术治疗,研究组应用保留盆腔自主神经的宫颈癌根治术治疗。结果:在手术指标对比方面,两组患者手术时间、术中出血量比较有明显差异(P<0.05),术中中转开腹例数和术中/术后并发症发生率等对比无明显差异(P>0.05)。在膀胱功能以及直肠功能对比方面,研究组患者的术后残余尿时间以及排气、排便时间均显著短于对照组(P<0.05);尿流动力学指标对比方面,两组患者术前膀胱灌注阶段以及排尿阶段的各项指标对比无明显差异（P>0.05）,术后研究组各项指标显著优于对照组(P<0.05);两组患者术前生活质量以及性生活质量对比无明显差异（P>0.05）,术后研究组各项指标显著优于对照组(P<0.05)。结论:宫颈癌根治术患者通过系统保留盆腔自主神经,能够改善患者的膀胱功能、直肠功能以及尿动力学指标。