Total mesorectal excision with ultrasonic coagulation knife ("UltraCision") in surgery of rectal cancer

The authors report a total of 62 middle and low third rectal cancer cases operated on by total mesorectal excision by the method of Heald. The oncological basis of this procedure is the horizontal regional metastatization of rectal cancer. The total mesorectal excision facilitates, the low anterior resections and preservation of sphincter with an ultra-low colorectal, or coloanal anastomosis using the double stapling technique. In the authors' experience, the "UltraCision" cutting-coagulating device permits an atraumatic, bloodless and oncologically correct dissection. Using the double stapling technique, we succeeded in 60% of our middle- and low-third rectal cancer patients to perform a sphincter preserving low anterior resection. In 9 (28%) of the low third rectal cancer patients, preservation of the sphincter was possible with oncologically correct anterior resection and an ultra-low colo-anal anastomosis. Three anastomotic insufficiencies occurred, two of them healed on lotion-suction drainage, and one on the application of transient protective ileostomy. The literature data suggest a lower local recurrency rate after radical rectal cancer surgery, if total mesorectal excision is performed.     

Local recurrences and primary surgery in rectal carcinoma

BACKGROUND: The authors analyze retrospectively a consecutive series of rectal carcinomas operated on with different surgical strategies at Third Surgical Department of "La Sapienza" University of Rome, between January 1985 and December 1997, by one expert surgeon (GDM), and report the incidence of the local recurrence correlated to the surgical technique development. METHODS: In most recent groups of patients treated for extraperitoneal neoplasm from January 1992 with curative (R0) total mesorectal excision (TME) and nerve sparing technique (NST) (Group C, n = 47) and with curative TME plus lateral pelvic lymphadenectomy (LPL) and NST (Group D, n = 7), sacrificing the pelvic autonomic nervous system only in case of neoplastic infiltration, the local recurrence was 8.5% (4 cases, with mean interval of 30.5 months) and 0 respectively at mean follow-up of 44.9 and 55 months. RESULTS: In none of the local recurrences of the Group C a re-resection (neither curative nor palliative) was possible and the survival was 50% at 14 months from the diagnosis of relapse. Instead, in local recurrences of rectal carcinoma in patients who underwent a first anterior resection with less extended dissection in other Department (Group E), a re-resection was possible for 3 cases out of 4 (R0, R1 and R2 operations); re-resected patients are now alive at mean follow-up of 33.6 months (82, 12 and 7 months, respectively). In Group A patients, treated between January 1985 and December 1988 with partial mesorectal excision (R0) also for extraperitoneal localization, the incidence of local relapses is 21.9% (9/41 cases) vs 11.2% (11/98 cases) in Group B patients, treated from January 1989 with curative TME for extraperitoneal tumors. CONCLUSIONS: The incidence of local recurrences of extraperitoneal rectal cancer can be reduced by total mesorectal excision. The total sparing of pelvic autonomic nervous system in advanced rectal carcinoma doesn't increase the incidence of local recurrences.     

直肠癌前切除术后局部复发的危险因素研究及其预防

目的分析直肠癌患者前切除术后局部复发的危险因素并探讨有效的预防措施。方法选择2007年10月-2010年1月湖北省肿瘤医院行直肠癌前切除术的98例患者,统计术后局部复发比例,分析复发的危险因素。结果本组98例患者的术后局部复发率为11.2%（11/98）,其发生与性别、年龄、肿瘤距肛缘距离、全系膜切除、辅助化疗、病理分型恶性程度及Duck’s分期相关（P〈0.05）。结论临床工作者应了解直肠癌前切除术后局部复发的危险因素,注意针对危险因素采取相应的预防措施,降低患者术后局部复发率,提高患者的生活质量。     

Total mesorectal excision and preoperative radiotherapy in patients with rectal carcinoma: good preliminary results]

The value of a short course of radiotherapy prior to total mesorectal excision was studied in patients with resectable rectal cancer. The new surgical technique of total mesorectal excision was introduced under appropriate supervision and gave favourable treatment results. The incidence of local recurrence was markedly reduced by preoperative radiotherapy. Long term results should give greater insight into potential improvements in survival rates and any late side effects which may arise as a result of the radiation schedule.     

直肠癌直肠系膜全切除术的临床病理依据及意义

目的 探讨直肠癌直肠系膜全切除术的临床病理依据.方法 对102例具有较完整临床病理资料行直肠癌直肠系膜全切除术直肠癌组织、癌旁组织、直肠系膜进行常规病理切片,分析直肠系膜与直肠癌的分化程度、临床分期、淋巴结转移的关系及治疗效果.结果 直肠系膜癌转移均与癌组织分化程度、临床分期、淋巴结转移有相关性(P<0.05).结论 直肠癌直肠系膜全切除术是治疗直肠癌的最佳途径,切除的直肠系膜的范围应根据Dukes分期、肿瘤的分化程度及肿瘤浸润肠壁的深度区别对待.     

直肠癌直肠系膜全切除术的临床病理依据及意义

目的探讨直肠癌直肠系膜全切除术的临床病理依据。方法对102例具有较完整临床病理资料行直肠癌直肠系膜全切除术直肠癌组织、癌旁组织、直肠系膜进行常规病理切片,分析直肠系膜与直肠癌的分化程度、临床分期、淋巴结转移的关系及治疗效果。结果直肠系膜癌转移均与癌组织分化程度、临床分期、淋巴结转移有相关性(P<0.05)。结论直肠癌直肠系膜全切除术是治疗直肠癌的最佳途径,切除的直肠系膜的范围应根据Dukes分期、肿瘤的分化程度及肿瘤浸润肠壁的深度区别对待。     

Clinical results and toxicity for short-course preoperative radiotherapy and total mesorectal excision in rectal cancer patients

Short-course preoperative radiotherapy (SCPRT) is an alternative method to chemoirradiation for patients with Stage II and III rectal cancer when no downsizing is needed, but there is still widespread reluctance to use this method because of fear of side effects from high-fraction doses. This paper reports on a single institution patient cohort of operated rectal cancer patients after SCPRT, evaluated for chronic adverse effects, local control, progression-free survival and overall survival. Altogether, 257 patients were treated with SCPRT and surgery including total mesorectal excision (92% total mesorectal excision = TME) between 2002 and 2009. Local control and survival were analyzed. Chronic adverse effects for 154 patients without local relapse were evaluated according to the NCI–CTCAE version 4.0 classification, with a median follow-up of 48 months. We found a 5-year disease-free survival (DFS) and overall survival (OS) of 71%. The 5-year estimated local control (LC) rate was 94%. A positive resection margin was found in 4% of the patients and was significantly correlated with decreased DFS, OS and LC. Chronic adverse effects were reported by 58% of the patients, of which 10% were Grade 3 toxicities. The most frequent Grade 2 toxicity was stool incontinence (13%). Sexual dysfunction was found in 36% of the patients (31% Grade 1 or 2, and only 5% Grade 3). SCPRT combined with TME produced excellent LC rates together with a low rate of high-grade chronic adverse effects.     

腹腔镜下全直肠系膜切除术治疗低位直肠癌临床疗效观察

目的 探究腹腔镜下全直肠系膜切除术对治疗低位直肠癌临床疗效及优越性.方法 将86例低位直肠癌患者随机分为观察组和对照组,观察组给予腹腔镜下全直肠系膜切除术,对照组给予开腹全直肠系膜切除术,观察2组患者术后复发率、死亡率及手术效果.结果 2组复发及死亡率比较无显著性差异(P＞0.05),2组手术时间、清除淋巴结数目比较无显著差异(P＞0.05);观察组术中出血量及肠功能恢复时间均明显低于对照组(P＜0.05).结论 腹腔镜下全直肠系膜切除术治疗低位直肠癌安全可行,具有创伤小、术中出血量少、胃肠功能恢复快等优点,可作为目前治疗低位直肠癌的一种较佳手术方案.     

新辅助化疗和放疗在局部晚期子宫颈癌治疗中的比较

目的:观察比较新辅助化疗和放疗治疗局部晚期宫颈癌的疗效及影响疗效的相关因素,以及对患者长期生存的影响。方法:收集1999年4月年3月在山东省日照市人民医院、日照市中医院、山东省淄博市周村区人民医院行新辅助化疗的局部晚期或巨块型宫颈癌患者73例,分析其临床病理资料和化疗后的疗效;并对同期行放疗的局部晚期或巨块型宫颈癌51例,分析其临床病理资料和化疗后的疗效。分析比较新辅助化疗和放疗治疗的效益。结果:新辅助化疗的总有效率为79.46%(58/73),放疗的总有效率为49.02%(25/51)。新辅助化疗患者的疗效与病理类型有关,鳞癌患者的有效率为81.36%(48/59)明显高于腺癌54.17%(13/24,P<0.05);而与其他因素无关(P<0.05);放疗患者的疗效也与病理类型有关,鳞癌患者的有效率为51.35%(19/37)明显高于腺癌42.86%(6/14)。新辅助化疗有效者手术后盆腔淋巴结阳性率为8.62%(5/58),宫旁血管癌栓阳性率为3.45%(2/58),均明显低于新辅助化疗无效者(分别为6/15,5/15;P<0.05)。放疗有效者手术后盆腔淋巴结阳性率为16%(4/25),宫旁血管癌栓阳性率为12%(3/25),均明显高于新辅助化疗有效者。结论:新辅助化疗和放疗局部晚期宫颈癌的疗效与病理类型有关,新辅助化疗优于放疗,对化疗和放疗有效者应选择手术,可提高长期生存率。     

术前放疗在直肠癌病人中的临床应用

目的:探讨术前放疗在进展期直肠癌中的疗效及其对保肛手术的意义.方法:分析12例直肠癌术前放疗病人的临床资料.结果:放疗后7例(58.3%)排便困难、便血等症状得以改善.腹会阴联合切除3例,Hartmann术1例,Dixon术8例.术后病理显示完全消退(CR)2例,肿瘤部分缓解6例,无效4例.结论:术前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.     

同步新辅助放化疗联合全根治性切除治疗中低位局部进展期直肠癌的探索研究

目的：探讨同步新辅助放化疗联合全直肠系膜切除术（TME）治疗中低位局部进展期直肠癌的可行性及安全性。方法：选取2013年6月-2014年6月本院23例中低位局部进展期直肠癌患者,Ⅱ期（T3-4No Mo）11例,Ⅲ期（T1-4N1-2Mo）12例,均接受术前同步新辅助放化疗（术前放疗总剂量全盆腔DT 40-46Gy/20-23 Fx,瘤床区加量至50-56 Gy/25-28 Fx;化疗采用含希罗达方案2个周期）。同步新辅助放化疗结束后4-8周行手术治疗,遵循TME原则,并尽可能保肛。结果：22例患者均完成同步新辅助放化疗,放化疗期间3级毒副反应总发生率为27.3%,无4级毒副反应者。放化疗后CR 2例、PR 14例、SD 4例;16例（80%）患者的临床TNM分期下降。同步新辅助放化疗结束后4-8周,20例患者行根治性手术治疗,其中12例行低位或超低位前切除术（Dixon术）,7例行腹会阴联合切除术（Miles术）,1例行Hartmann手术,保肛率为60.0%（12/20）。无一例发生围手术期死亡,术后并发症的总发生率为20%（4/20）。结论：同步新辅助放化疗联合TME治疗中低位局部进展期直肠癌安全而有效,可以降低肿瘤分期、提高肿瘤切除率和保肛率,改善患者的生活质量。     

低位直肠癌保肛手术适应症选择与评价

目的 探讨低位直肠癌保肛手术适应症选择标准，评价保存肛术后临床效果。方法 根据肛门指诊、直肠腔内超声、盆腔ＣＴ、ＭＲＩ、术前活检病理，９６例低位直肠癌用美国ＪＯＨＮＳＯＮ吻合器或／和闭合器行结肠直肠（肛管）吻合术。低位直肠保肛手术适应症选择标准：高中分化腺癌、隆起型、未浸透深肌层、环周度≤１／２周，无肠旁淋巴结肿大、距齿状线１ ｃｍ以上；高中分化腺癌、溃疡型≥１／２周，浸透肠壁深肌层、无盆腔淋巴结肿大、距齿状线３ ｃｍ以上；低分化腺癌、粘液腺癌未浸透深肌层，环周度≤１／２周，无肠旁淋巴结肿大，距齿状线４ ｃｍ以上，在完成全直肠系膜切除和淋巴结清扫的基础上保留肛门。结果 全组除发生１例直肠阴道瘘外无手术死亡及其它严重并发症。寿命表法计算３年生存率７８．１％，局部复发率５．２％。术后病人排便功能优者达８４．０％，１２～１８月排便次数和排便功能接近正常状态，无完全性排便失禁。结论 低位直肠高中分化腺癌隆起型，未浸透肠壁深肌层，环周度≤１／２周，无肠旁淋巴结肿大，距齿状线１ ｃｍ以上；高中分化腺癌溃疡型≥１／２周，浸透肠壁深肌层，无盆腔淋巴结肿大，距齿状线３ ｃｍ以上。低分化腺癌、粘液腺癌未浸透深肌层，环周度≤１／２周，无     

Ⅱ期直肠癌淋巴结微转移检测的临床意义

目的 探讨Ⅱ期直肠癌患者淋巴结微转移检测的临床意义.方法 对2000年1月至2001年8月行全直肠系膜切除术的42例Ⅱ期直肠癌标本的484枚淋巴结行间断病理切片结合细胞角蛋白20(CK20)免疫组化染色检测,根据随访资料结合文献分析Ⅱ期直肠癌患者系膜淋巴结微转移的临床意义.结果 42例患者中淋巴结微转移发生总例数为15例,发生率为35.7%(15/42),淋巴结微转移检出总数为33枚,检出率为6.8%(33/484).随访12～80个月,以60个月为界,31例存活,11例死亡.淋巴结微转移阳性患者5年生存率为40.0%,淋巴结微转移阴性患者5年生存率为92.6%.经Log-rank检验两者的生存率比较差异有统计学意义(P=0.000).Cox比例风险回归模型分析示淋巴结微转移的RR值为11.435,是惟一引入的危险因素.结论 淋巴结微转移是Ⅱ期直肠癌患者重要的预后指标,淋巴结微转移是直肠癌患者术后复发转移的独立预后指标,有淋巴结微转移的直肠癌术后患者可能从化疗中受益.     

全直肠系膜切除术治疗直肠癌52例临床分析

目的：探讨全直肠系膜切除术（TME）治疗直肠癌的临床疗效。方法：回顾性分析52例中低位直肠癌患者行TME术治疗的临床资料,均行Dixon术。结果：全组病例无手术死亡。术后吻合口漏3例,无吻合口狭窄。随访6个月～5年,52例病例中,性功能障碍4例,占7.7%（4/52）,局部复发占3.8%（2/52）。结论：直肠癌根治术中TME可明显降低直肠癌术后局部复发率,减少性功能障碍发生。     

研究分析磁共振3.0T高分辨T2WI成像技术在直肠癌术前TN分期中的诊断效果

目的:探究磁共振3.0T高分辨T2WI成像技术在直肠癌术前TN分期中的诊断效果.方法:选取2018年1月~2019年3月本院收治的50例直肠癌患者为研究对象,对其进行磁共振3.0T高分辨T2WI成像技术检查.结果:50例患者中癌症类型分为管状腺癌35例,黏液腺癌3例,高级别绒毛管状腺癌6例,中-低分化腺癌5例,印戒细胞癌1例;病灶形态分为环周浸润22例,环周菜花14例,局部肿块14例;分化程度为高分化6例,中-低分化5例;T分期为T1分期3例,T2分期13例,T3分期19例,T4分期15例;N分期为N0分期7例,N1分期10例,N2分期33例.患者T分期诊断中的灵敏度分别为76.36%、72.52%、96.25%和100.00%,特异度分别为99.99%、95.63%、92.25%和100.00%.N分期灵敏度为86.63%、88.52%和93.25%,特异度为99.63%、94.25%和100.00%.结论:对于直肠癌术前T N分期诊断而言,磁共振3.0T高分辨T2WI成像技术应用具有重要诊断价值,对于患者TN分期诊断和识别具有准确率高、可控性强等优势.     

Improving outcomes in rectal cancer

Concerted efforts are being made to improve the poor surgical outcomes in rectal carcinomas and this includes the use of total mesorectal excision by specially trained colorectal surgeons, in addition to the use of pre- or postoperative radiotherapy and chemotherapy. The role of each modality should be carefully evaluated, and benefits weighed against toxicity and added costs.     

Missing forms and dropout in the TME quality of life substudy

Objective Missing forms may pose problems in health related quality of life (QOL) studies, because the absence of a QOL measure may be related to the patients health and hence to the patients QOL itself. Studying patterns of missingness, dropout, and the possible impact of missing data on QOL measures is an important step in reporting outcomes of QOL studies. We study patterns of dropout and evaluate the impact of missing forms in the TME QOL substudy. Methods: Patients with rectal cancer, randomized to receive either radiotherapy plus total mesorectal excision (TME) or TME only were included in the TME trial. QOL was evaluated in 1302 Dutch patients, before treatment, and 3, 6, 12, 18 and 24 months after surgery. Here only the visual analogue score (VAS) was studied. Results: At baseline, differences between VAS scores were found with respect to whether the QOL forms were dated before or after radiotherapy and surgery. Differences were small between different statistical methods accounting for dropout; only a cross-sectional analysis gave biased results. Conclusion The results of the sensitivity analysis indicated that a linear mixed model analysis is a reliable and attractive approach for this study.     

血清VitD、FA水平与三阴乳腺癌患者新辅助化疗敏感性关系

目的 分析血清维生素D(VitD)、叶酸(FA)水平与三阴乳腺癌(TNBC)患者新辅助化疗敏感性的关系。 方法 以接受新辅助化疗后病理结果为残留癌(RD)的235例患者观察组,以接受新辅助化疗后达到病理完全缓解(pCR)的235例患者为对照组。回顾性收集患者一般特征、瘤体大小、TNM分期、淋巴结、组织Ki-67表达和基底标志情况等;采用酶联免疫吸附测定法(ELISA)检测血清VitD、FA水平;用logistic回归、受试者工作特征曲线(ROC)分析法等分析血清VitD、FA水平与三阴乳腺癌患者新辅助化疗敏感性的关系。 结果 单因素分析显示观察组VitD和FA水平低于对照组,差异有统计学意义(均P＜0.05);观察组中瘤体为T3/4、Ki-67为低表达、基底标志标记为阳性、VitD和FA具有显著降低趋势的人数比率显著高于对照组,差异有统计学意义(均P＜0.05);但两组年龄水平、TNM分期和淋巴结情况方面比较,差异无统计学意义(P＞0.05);logisitic回归分析显示瘤体为T3/4(OR=4.122,95%CI:2.768~7.502)、组织Ki-67低表达(OR=4.193,95%CI:1.967~8.880)、基底阳性(OR=3.459,95%CI:1.884~80.30)、VitD(OR=2.689,95%CI:1.656~4.306)和FA(OR=2.005,95%CI:1.470~3.436)有降低趋势与新辅助化疗效果不佳有关;ROC分析显示血清VitD预测TNBC患者新辅助化疗效果不佳的灵敏度0.782、特异度0.899;FA预测TNBC患者新辅助化疗效果不佳的灵敏度0.775、特异度0.862;两者联合预测敏感性为0.856,特异性0.908。 结论 血清VitD、FA水平降低可增加TNBC患者新辅助化疗效果不佳风险,二者水平降低可作为预测新辅助化疗敏感性有效的指标。     

直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症剖析及防治

目的探讨直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症的形成原因及防治方法。方法回顾性分析按TME原则手术的120例低位直肠癌行保肛手术的临床资料。结果术后发生吻合口漏7例,占5.8%,吻合口出血8例,占6.7%,吻合口狭窄5例,占4.2%。结论在低位直肠癌保肛手术中,严格掌握低位直肠癌行保肛手术的指征、充分的术前准备、保证吻合口的血供、正确选择和使用吻合器及引流管是降低吻合口并发症发生的关键,对术后吻合口漏视具体病情采用个体化治疗。     

直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症剖析及防治

目的探讨直肠全系膜切除术治疗低位直肠癌术后常见吻合口并发症的形成原因及防治方法。方法回顾性析按TME原则手术的120例低位直肠癌行保肛手术的临床资料。结果术后发生吻合口漏7例,占5．8％,吻合口出血8例,占6．7％,吻合口狭窄5例,占4.2％。结论在低位直肠癌保肛手术中,严格掌握低位直肠癌行保肛手术的指征、充分的术前准备、保证吻合口的血供、正确选择和使用吻合器及引流管是降低吻合口并发症发生的关键,对术后吻合口漏视具体病情采用个体化治疗。