回眸2019——聚焦中国结直肠外科的发展与研究

虽然结直肠疾病的手术治疗进展较慢,但借助于近年来微创外科技术、围手术期综合治疗策略和临床研究的进步,中国结直肠外科亦得以快速发展。经肛全直肠系膜切除、盆腔侧方淋巴结清扫、直肠癌新辅助治疗临床完全缓解的“等待与观察”策略、机器人结直肠外科手术等仍然是近年来结直肠外科的热点议题。笔者结合全国性结直肠癌手术病例登记数据库建设以及临床研究等展开论述,以期为同道们梳理结直肠外科的发展脉络,共谋中国结直肠外科的发展。     

我国腹腔镜结直肠外科的发展

1990年Jacobs在美国成功完成第一例腹腔镜右半结肠切除术,随后短短数年内所有类型的结直肠手术均在腹腔镜下得以成功施行。1993年郑民华等完成了国内第一例腹腔镜乙状结肠癌根治术,随后国内腹腔镜结直肠手术逐步得到开展,近年更是发展迅猛,国内各家医院纷纷成立了微创胃肠外科中心,     

腹腔镜结直肠外科的现状与展望

1　现状自 1 990年美国的 Jacobs进行了世界上首例腹腔镜右半结肠切除术后 ,同年 Folwer进行了腹腔镜乙状结肠切除术。从此腹腔镜技术逐渐运用于传统的结直肠手术 ,但发展速度远不如其他腹腔镜手术 ,主要原因首先是它的手术难度较高 ,需行肠段的切除及重建 ,其次是人们对于肿瘤的根治性有疑虑。经过十余年的不断发展 ,腹腔镜结直肠手术已日臻成熟与完善 ,其良好的近期及远期疗效亦已逐渐得到证实 [1]。我院从 1 993年开始至 1 999年仅完成 5 0例 ,手术时间平均为 1 80 min,以后几年已完成近 80例 ,平均时间降至 1 2 0 min,接近开腹手术所需…     

对结直肠外科技术一些新概念的理解

本文简述了当前结直肠外科的一些新理念和新技术,比如微创外科、不输血技术、无接触肿瘤外科理念、胃肠吻合新技术。同时．介绍我们自己在临床工作中实践的无出血技术和闭合式切除技术。这些新理念和新技术的广泛应用．明显提高了结直肠外科疾病的治疗效果。     

结直肠肛门外科的几个重要理念

进入21世纪以来,随着基础医学的迅速发展以及各种新技术、新方法的应用,结直肠肛门外科也在发生着显著的变化,与此同时,该领域的一些新的观点和理念也逐步形成并得以逐渐完善,比如微创技术、精细解剖操作、无出血技术以及快速康复外科等理念的应用及实践,为结直肠肛门外科带来了深刻、甚至是革命性的变化,本文就这些相关问题分析介绍如下.     

结直肠外科的专科化发展及问题思考

随着中国经济的发展，需要有与之相适应的医疗体系及专业医师培训、准入制度。结直肠外科在欧美是一专科性极强的专业，在我国与结直肠外科相应的是肛肠外科，其主要分布于中医院，而一些大中型医院常常对结直肠肛门疾病不够重视。随着结直肠肿瘤、炎性肠病、便秘等结直肠外科疾病发病率的明显增加以及人们对生存质量的更高要求，     

美国结直肠外科医师学会2007年年会纪要

美国结直肠外科医师学会2007年年会于2007年6月2-6日在密苏里州圣路易斯市举行。会议邀请了约150位著名结直肠外科专家及来自45个国家的近2100位代表与会。会议针对结直肠外科新技术和新理论进行了深入探讨。     

围手术期外科之家理念在结直肠外科的应用

结直肠外科疾病由于其生物行为学复杂性,病人高龄倾向、常伴发营养不良、肠梗阻和心理障碍,以及手术后肠道功能障碍、抗肿瘤治疗后的相关并发症、肿瘤转移至其他脏器及手术后的康复等复杂问题往往难以在一个亚专科得到全程解决.因此,对于结直肠外科病人的围手术期管理提出更高要求,但这些复杂多学科问题如何能系统性地得以解决是当前临床的难...     

结直肠息肉病的外科治疗

结直肠息肉病与结直肠息肉的区别在于息肉数目的多少。根据Morson等[1]的标准:结直肠息肉数目100个以上属息肉病范畴。结直肠息肉病又分为错构瘤型与腺瘤     

基于临床数据挖掘技术的腹腔镜结直肠癌手术评估体系的构建及应用

目的 整合优势科研资源,搭建良好的科研平台,开展单（多）中心临床试验,以中国人的临床数据科学地评价腹腔镜结直肠癌手术目前仍存在争议的问题.方法 以南方医院2008年10月自主开发的一款专门以腹腔镜结直肠癌手术为数据架构,同时适合于回顾性和前瞻性临床研究,既能科学管理和深度分析临床数据,又能满足多单位合作需要的数据挖掘系统软件为数据平台,构建腹腔镜结直肠癌手术评估体系,开展单（多）中心腹腔镜结直肠癌手术研究.结果 历时1年多的开发和完善,南方医院已经使用该软件系统按照标准回顾性录入1200余例临床资料,构建了单中心腹腔镜结直肠癌手术评估体系.同时该软件系统作为＂中国南方腹腔镜结直肠外科研究组（SCLCSG）＂的数据平台,已在第1期临床研究项目＂腹腔镜与开腹结直肠癌手术的回顾性多中心对比研究＂中成功运行,迄今已录入8200余例病例数据.以南方医院数据完成＂腹腔镜与同期开腹直肠癌根治术后肿瘤学结果对比研究（单中心）＂,结果显示,腹腔镜直肠癌根治术的远期复发和生存并不劣于开腹手术,甚至优于开腹手术的肿瘤学结果.结论 该手术评估体系和临床数据挖掘软件设计达到预定目标,在腹腔镜结直肠癌手术领域具有广泛的应用前景和网络化升级扩展的潜能,值得推广.     

Current controversies in colorectal surgery: the way to resolve uncertainty and move forward

The are currently a number of unsolved clinical questions in colorectal surgery with new surgical principles being introduced without proper scientific high-level evidence. These include complete mesocolic excision with central ligation for colonic cancer, extralevator abdominoperineal excision for low rectal cancer, robotic surgery for various colorectal procedures, laparoscopic lavage without resection for Hinchey Stage III perforated sigmoid diverticulitis, and the use of the single port technique for laparoscopic surgery. Before general implementation the new modalities should ideally be evalueted in randomized studies and meta-analyses. Many randomized studies, however, cannot give the final answer to the research question because they are underpowered and it is therefore important to perform well-designed studies that are large enough to provide the final answer. A way forward could therefore be to form multicenter and even multinational research groups in order to ensure accrual of sufficient sample sizes.     

精准医学在结直肠外科中的内涵与临床实践

2015年,美国医生Francis S.Collins在著名的新英格兰医学杂志上撰文介绍了精准医学的概念。精准医学是近年来出现的新的医学概念。它是以分子基因为基础实现对疾病的诊断和治疗。我们已经进入了一个精准医学的时代。我们也经历了经验医学,循证医学,现在又进入了精准医学的时代。今天,在结直肠癌领域,我们已经看到:精准医学已经在结直肠癌的姑息治疗中发挥着重要作用,如:常用的爱必妥,安维汀和帕尼单抗等。因此,结直肠外科医生应该认真地学习精准医学的概念,了解精准医学在结直肠领域的独特作用。同时,我们也要应用精准医学的概念去认识和解决结直肠癌领域亟待解决的科学问题。而且,我们也要看到精准医学的局限性,客观公正地评价精准医学。     

疝和腹壁外科相关基础研究现状及未来方向

疝和腹壁外科在近20年迅速发展,疝和腹壁外科手术方式较20世纪已经有了明显的改善,尽管总体疗效满意,但术后仍存在复发和并发症等诸多问题.围绕膜解剖的深入探究并在优化现有补片的同时开发新型补片已经成为疝和腹壁外科乃至外科学领域的研究热点和焦点.更好的理解膜解剖,深入探索膜解剖,结合对理想补片材料的深入探索,并将最新的理念...     

A comparison of the colorectal surgical research across Europe, USA and Australasia

Aim The annual scientific meetings of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the American Society of Colon and Rectal Surgeons (ASCRS), the European Society of Coloproctology (ESCP) and the Royal Australasian College of Surgeons (RACS) are the major fora for presentation of colorectal surgical research. Thus, their content could be a proxy of the content and quality of colorectal surgical research worldwide. We aimed to critically appraise the quantity, quality and topics of colorectal surgical research over the previous 5 years for the above meetings. Method All published abstracts from the ACPGBI, ASCRS, ESCP and the colorectal‐specific component of the RACS from 2006 to 2010 were appraised. Abstracts were coded by predefined categories pertaining to study type and topic. Results Level 1 evidence (systematic reviews/meta‐analyses) and level 2 evidence (randomized controlled trials) comprised 3% (95% CI 1–9%) and 5% (95% CI 2–11%), respectively, of research presented at the meetings. There was a predominance of level 4 evidence (retrospective studies) across all years (mean 54%, 95% CI 44–68%). Operative management was most commonly studied (mean 43%, 95% CI 36–49%). There was minimal research in perioperative care (mean 6%, 95% CI 2–13%) and basic surgical science (mean 6%, 95% CI 2–11%). Research related to perioperative care was significantly higher at the ACPGBI and RACS meetings than the ASCRS and ESCP meetings (P < 0.01). Conclusion The research at these meetings consists largely of retrospective reviews exploring operative management with minimal high quality scientific content. Active steps need to be taken to increase the quantity of high level evidence especially in topics other than operative management.     

Need for simulation in laparoscopic colorectal surgery training

The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.     

结直肠癌外科临床研究进展及展望

进入21世纪以来，普通外科学发展迅速，理念不断更新，新技术不断涌现，这在结直肠癌治疗领域表现更加具有代表性和特色。尽管手术作为结直肠癌治疗的核心已经相当成熟，但外科领域开展随机对照研究难度很大，很多新的治疗方法和技术的优效性需要一个漫长的证明过程，而规范和科学的开展结直肠癌外科临床研究可能是解决这一问题的根本方法。总结目前结直肠外科的几个热点问题相关临床研究的新进展，结果可以看出，将最大限度地保留功能、获得更好的生活质量与延长生存时间更好的结合在一起是未来结直肠癌外科治疗的目标，而通过开展相应的临床研究，获得更多的循证医学证据，在此基础上让结直肠癌的外科治疗更加规范，是实现这一目标的必由之路。     

一间医院十年来结直肠癌的临床流行病学和病理特征变化回顾分析

目的探讨解放军总医院10年来收治结直肠癌的临床流行病学和病理特征变化趋势。方法回顾分析解放军总医院普通外科1993年1月1日至1998年3月31日和1998年4月1日至2003年6月30日两个时间段各63个月(5年3个月)连续收治的有完整记录的结直肠癌患者资料。对这两个时间段的肿瘤发病人数、发病年龄、性别、部位、病理类型、Dukes分期及组织学分级进行统计和比较分析。结果共有2379例有完整记录的结直肠癌患者资料,第一时间段有968例,第二时间段有1411例,平均患病年龄为56.8岁。第一时间段与第二时间段比较,平均发病年龄为55.1岁比58.4岁(P<0.001);近侧结肠癌所占比例为21.6%比26.4%(P<0.01),总的结肠癌患者所占比例为46.2%和50.3%;DukesA加B期和DukesC加D期比较分别为39.3%比49.6%和60.7%比50.4%(P<0.001);病理类型及组织分级未见明显变化。结论10年来结直肠癌发病率显著增加;发病年龄趋向老龄化;发病部位有向近段转移的趋势;病理类型及组织分级无明显变化;晚期病例明显减少。     

Clinical outcome of the laparoscopic surgery for stage II and III colorectal cancer

Background Laparoscopic colorectal cancer surgery has become widely accepted recently. However, the oncological validity of this surgery has not yet been well analyzed, especially for advanced cancer. The aim of this study is to assess the clinical outcome of laparoscopic surgery for stage II/III colorectal cancer in our hospital. Patients and methods Between June 1999 and August 2006, 321 patients underwent laparoscopic colorectal cancer surgery in our hospital; of those 121 cases whose pathological findings revealed stage II/III were included in this study. Among these cases, we assessed a short-term outcome and a medium-term outcome in terms of survival evaluation. Results The male:female ratio was 73:48, and mean age of patients was 62.4 years. Thirteen tumors were located in the cecum, 29 in the ascending colon, five in the transverse colon, one in the descending colon, 43 in the sigmoid colon, and 30 in the rectum. Average duration of operation was 184 minutes, and mean estimated blood loss was 53.5 ml. Five patients (4.1%) were converted to open procedures. No intraoperative complication was observed but eight complications (6.6%) occurred postoperatively. Forty-two cases were classified as stage II, 62 as stage IIIA /B, and 17 as stage IIIC. Five patients died of cancer relapse (4.1%), and 18 cases had recurrence of disease (14.9%), to date. No port-site recurrence was detected. Overall five-year survival was 95.7% in stage II, 84.1% in stage IIIA/B, 70.0% in stage IIIC. Meanwhile disease-free five-year survival was 75.6% in stage II, 80.1% in stage IIIA/B, and 66.8% in stage IIIC. No significant difference was observed between stages, in terms of either overall or disease-free survival. Conclusion Although further evaluation is required, laparoscopic surgery for stage II/III colorectal cancer is safe and would be an oncologically adequate procedure.