直肠癌低位保肛术后局部复发的临床分析

目的探讨直肠癌低位保肛术后局部复发的原因及治疗。方法回顾性分析17例直肠癌低位保肛术后局部复发的临床病理资料。结果直肠癌低位保肛局部复发病例17例,以吻合口及周围组织复发为主,复发原因有未能保证全系膜切除、肠管切除不足、侧方淋巴结清扫不足等。复发病例中再行Miles术6例,术后1年生存率为75．0％（4例）,3年生存率为33．3％（2例）。结论对低位保肛患者术前肿瘤病理类型、临床分期的判断,是减少局部复发的关键。     

国外低位直肠癌侧方转移淋巴结的清扫

目前国外对腹膜反折下低位进展期直肠癌的外科治疗研究集中在手术方式的合理选择、切除肿瘤远端肠管范围和保留肛门括约肌手术。有关清扫区域淋巴结转移范围 ,特别是侧方（平行）淋巴结转移的清扫不断增加。为了深入了解对局部复发率高的低位直肠癌术后复发的控制程度及提高５年生存率 ,本文对国外的有关进展作一概述。１直肠癌侧方淋巴结的转移率腹膜反折下（Ｒｂ）直肠的淋巴引流 ,虽主要向上方但也向下方和两侧髂内血管淋巴结输出 ,因而直肠癌发生部位的划分 ,应以腹膜反折为界（距肛缘约７ｃｍ左右）较为合理、实用。从局部解剖学角度而…     

腹腔镜低位直肠癌保肛手术新进展

低位直肠癌在我国发病率逐年上升,严重威胁着人民的健康。外科手术是低位直肠癌最有效的治疗方法,随着对直肠解剖生理和低位直肠癌生物学特点研究的不断深入,低位直肠癌保肛手术得到越来越广泛的应用,尤其腹腔镜技术的应用已成为当前关注的热点问题之一。腹腔镜低位直肠前切除术、腹腔镜低位直肠前切除术联合经肛门括约肌间切除或经肛门直肠脱出外翻等术式是腹腔镜下低位直肠癌切除保肛手术可选的手术方法。消化道重建可选择双吻合器法、手工经肛结肠肛管吻合以及结肠J型储袋成形吻合等方式。各种术式有其特有的适应范围和优缺点,应以优先保证手术根治同时兼顾生活质量为原则合理选择术式。      

如何应对直肠癌保肛手术后局部复发——临床医师面对的挑战

直肠癌治愈性手术后局部复发是十分严重的临床问题。保肛手术后复发的原因主要有：肿瘤远端肠管切除长度不足、直肠系膜切除不足、环周切缘不足、淋巴结清扫不足以及手术者的技术水平高低。复发后各种治疗手段均属于挽救性的措施，疗效不十分理想，所以防治策略应该以防为主，尽量减少复发的机会。     

低位直肠癌行保肛手术的体会

目的为提高低位直肠癌保肛手术的治疗效果,减少术后局部复发,免除因人工肛门给病人造成的痛苦。方法对５７例肿瘤位于盆底腹膜返折处或以下的低位直肠癌保肛手术进行回顾性分析。其中行Ｄｉｘｏｎ前切除术４７例,Ｂａｃｏｎ拖出术２例,Ｐａｒｋｓ结肠肛管吻合术２例,经腹骶直肠癌切除术２例,经肛门局部切除术４例。结果术后局部复发者１４例占２４．７％,局部复发中盆腔内复发９例,吻合口复发２例,腹股沟淋巴结转移１例,会阴部及坐骨直肠窝内复发２例。术后肝转移６例,肺转移２例,骨转移１例。五年无瘤生存率为６４．９％。结论对于低位直肠癌只要满足根治性手术切除的条件应尽可能争取行保肛手术。距肿瘤边缘２－３ｃｍ切断直肠是安全可靠的。强调适当扩大盆腔内切除范围是减少术后局部复发的关键。     

腹膜返折以下直肠癌保肛手术有关问题探讨

本文对我院建院以来施行腹膜返折以下直肠癌保肛手术分析结果表明,病灶位于腹膜反折以下直肠癌患者的生存率及复发率并没有因为保肛而受到影响。结合我院的其它研究提出肿瘤远端切除的充分与否是选择保肛手术的前题,其下切端长度应综合肿瘤的病理类型,浸润周径及Dukos分期考虑。本组病例Duke C期病人的5年与10年生存率分别为32.1％、7.7％,证明进行淋巴清扫及侧方清扫,可使一部分Dudes C期病人获得5年甚至10年的生存,从而强调了扩大根治在保肛手术中的重要性,提出保肛手术的原则及适应症:保肛手术必须清除足够的淋巴结;切除足够的远端肠管;切除足够的侧方组织;注意保护肠管的血运,建立通畅的双腔引流,在此基础上根据肿瘤的部位选择不同的保肛手术:肿瘤下界距肛缘7cm行前切除术6cm行Turbull—Catoif手术,5cm行Block Bacon或改良Poiks手术。改良Parks手术远端肠管切除充分,肛门功能良好,为腹膜返折以下直肠癌拉出术中较好的手术。     

癌的诊治第二十二讲：我国直肠癌外科治疗的现状与进展

大肠癌是我国常见的恶性肿瘤之一，按其发病的部位分布，约56％－70％发生在直肠。临床上将直肠分为上、中、下三段。上段直肠癌外科治疗的原则是切除乙状结肠和上段直肠并清扫区域淋巴结（Dixon术），病变肠段切除后行手术吻合术或管状吻合器吻合（EEA）。对此，临床医师的观点是大体一致的。直肠癌的2／3发生在腹膜反折处的中、下段，由于其解剖位置特殊，国内学者对直肠中、下段癌的保肛手术问题一直有争论。直肠中、下段癌外科治疗的主要目的应达到尽量切除原发病灶，清扫肠系膜和盆腔引流淋巴结，提高生存率，并有较好的生存质量。多…     

低位直肠癌根治性局部切除体会

随着直肠外科的发展，直肠癌各种根治性保肛术式日见增多。在各种保肛术式中，局部切除是最简便的一种，正确掌握和运用好局部切除的适应证，不仅可以根治肿瘤，而且可以提高患者的生存质量。我们于１９９０年—１９９６年间，对２０例低位直肠癌行局部切除，现报道如下。...     

编者的话

近年来涌现出许多新技术，新药物和肿瘤治疗新理念，消化道肿瘤的诊断方法和治疗手段也在不断更新，使过去普遍被认为最难治的消化道肿瘤的治疗有了不小的进步，特别是大肠癌的治疗，其进展可谓迅猛；本期主要介绍消化道肿瘤的治疗，包括手术、化疗及靶向治疗等进展，可供肿瘤临床和基础研究者参考。万德森教授介绍直肠癌外科治疗的进展，保肛手术是受到重视的术式，然而保肛手术需掌握指证，以往远端的安全切除距离是有争议的，但越来越多的学者建议必须距肿瘤有1-2cm的安全距离，同时推行全肠系膜切除及侧方淋巴结切除以减少局部复发。应…     

低位直肠癌不同切除范围的疗效分析

目的:探讨低位直肠癌全直肠系膜切除与侧方淋巴结清扫对局部复发率、生存率和术后生存质量的影响.方法:对426例低位直肠癌行根治性切除,其中241例行全直肠系膜切除,185例全直肠系膜切除+侧方淋巴结清扫.结果:无手术死亡病例,两组在性别、年龄、肿瘤肠壁的浸润深度、组织学类型等方面差异无显著意义.全直肠系膜切除组排尿功能障碍占5.8%,性功能障碍占13.2%;而侧方淋巴结清扫组分别是51.9%和51.9%(P＜0.05).局部复发率,全直肠系膜切除组DukesC期为23.5%,而侧方淋巴结清扫组为12.0%(P＜0.05),5年生存率两组差异无显著性(P＞0.05).结论:低位直肠癌行侧方淋巴结清扫能降低术后局部复发率,但对术后生存质量有影响.     

腹腔镜中低位直肠癌根治术保留盆自主神经的疗效分析

目的:探讨腹腔镜中低位直肠癌根治术经"Holy plane"间隙保留盆自主神经的疗效.方法:把实施了经"Holy plane"间隙保留盆自主神经中低位直肠癌根治术的69例老年男性患者分为两组.观察组采用腹腔镜手术,对照组采用常规开腹手术.两组均采用全直肠系膜切除术(total mesorectal excision,TME).对两组患者的手术时间,术中出血量、术后排尿功能、性功能,局部复发率及5年生存率进行回顾性总结和比较.结果:观察组手术时间明显延长,术中出血量明显少于对照组,两组患者术后排尿功能及性功能障碍的比较均无显著性差异,术后3年患者局部复发率及5年生存率比较无显著性差异.结论:腹腔镜经"Holy plane"间隙保留盆自主神经的中低位直肠癌根治术具有微创优势.在神经保护方面,可以达到与开腹手术相近的手术效果.二者在局部复发率及5年生存率上无明显差异.     

40例中下段直肠癌行直肠全系膜切除术（TME）的临床观察

目的：回顾性分析比较传统术式与TME在直肠癌术后对局部复发、排尿功能和性功能的影响。方法：2005-2009年我院40例行TME治疗中下段直肠癌,其中男性16例,女性24例,同期观察40例行传统术式治疗中下段直肠癌,跟踪随访3年,局部复发以CT和肠镜结果为准,排尿功能以拔尿管时间和尿残留为指标,性功能以问卷形式进行调查。结果：病人术后随诊3年,局部复发率为5.0%,3年生存率92.5%,排尿障碍17.5%,勃起障碍25%。结论：TME治疗中下段直肠癌对降低局部复发,减少对排尿功能和性功能影响明显优于传统术式。     

40例中下段直肠癌行直肠全系膜切除术(TME)的临床观察

目的:回顾性分析比较传统术式与TME在直肠癌术后对局部复发、排尿功能和性功能的影响。方法:2005-2009年我院40例行TME治疗中下段直肠癌,其中男性16例,女性24例,同期观察40例行传统术式治疗中下段直肠癌,跟踪随访3年,局部复发以CT和肠镜结果为准,排尿功能以拔尿管时间和尿残留为指标,性功能以问卷形式进行调查。结果:病人术后随诊3年,局部复发率为5.0%,3年生存率92.5%,排尿障碍17.5%,勃起障碍25%。结论:TME治疗中下段直肠癌对降低局部复发,减少对排尿功能和性功能影响明显优于传统术式。     

A prospective study on radical and nerve-preserving surgery for rectal cancer in The Netherlands

INTRODUCTION: Preservation of the pelvic autonomic nerves is thought to lower bladder and sexual dysfunction after rectal cancer surgery. A prospective study was undertaken in a Dutch population to evaluate functional outcome, local recurrence and survival of a Japanese operative technique combining nerve preservation with radical tumour resection. METHODS: Forty-seven patients were operated upon by a Japanese surgeon. Voiding and sexual function were prospectively analysed using questionnaires. Two-year follow-up on urinary function was complete in 73%, and 2-year follow-up of male sexual function was complete in 77%. Median follow-up for survival and recurrence was 42 months and was complete in all patients. RESULTS: Five patients (19%) developed minor urinary incontinence in the period between 1 and 2 years of follow-up. Six patients (22%) had a persistently elevated frequency of voiding. There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunctions. None of the patients reported major incontinence of urine. Impotence was related to sacrifice of the inferior hypogastric plexus and ejaculatory dysfunction was related to sacrifice of the superior hypogastric plexus. Sexual function did not change during follow-up. Of 42 curatively-operated patients, three (7.1%) developed local recurrence. Sixty-seven per cent were overall free of recurrence. Disease-free survival was 57%. CONCLUSIONS: Preservation of the pelvic autonomic nerves minimizes bladder dysfunction after rectal cancer surgery. The preservation of the total autonomic nerve system is essential for normal sexual function in male patients. Nerve preservation does not compromise radicality in mesorectal excision. Mesorectal excision should involve identification and preservation of the pelvic autonomic nerves.     

低位直肠癌保肛手术的质量控制

 随着对盆腔解剖和直肠癌生物学特性认识的加深,越来越多的低位直肠癌患者能够保留肛门,保肛手术已成为目前临床上治疗直肠癌最常用的术式。高质量的手术需要同时在肿瘤学和功能学方面使患者受益,因而低位直肠癌保肛手术需兼顾肿瘤根治和肛门功能。全直肠系膜切除（total mesorectal excision,TME）原则、安全的远切缘和环周切缘是保证肿瘤学效果的关键,能够有效降低直肠癌局部复发率和远处转移率。而保留更多的肛门括约肌以及术中对盆腔植物神经的保护则是改善术后肛门功能,提高患者生活质量的重要因素。       

直肠癌保留盆腔自主神经手术辅助术后放疗对提高患者生活质量的评估

Objective:Preservation of the pelvic autonomic nerves in order to lower bladder and sexual dysfunction after radical rectal cancer surgery & to evaluate functional outcome,local recurrence.Methods:A prospective study was undertaken on Egyptian patients.Forty one patients participated in the study in the period from December 2002 till June 2004 where they underwent radical surgery but with preservation of the pelvic autonomic nerves this was followed by adjuvant pelvic radiotherapy.Results:Six months,1-year and 2-year follow-up of urinary function was complete in 32 out of 41(78%),30 out of 41 (73%) and 27 out of 41 patients (65%) respectively There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunction.None of the patients reported major incontinence.Six months,1-year and 2-year follow-up of sexual function revealed that 22 out of 41 patients (53%) were sexually active.Three out of 41 patients (7.3%) developed local recurrence.38 (92.7%) patients were free of local recurrence,regarding patients who received adjuvant radiotherapy 3 out of the 34 (8.8%) patients developed local pelvic recurrence while 9 patients (26.5%) developed distant metastases (3 of them did not receive adjuvant chemotherapy),while patients who received adjuvant chemotherapy,2 out of 20 patients (10%) developed local recurrence while distant metastases developed in 6 patients (30%).Conclusion:Preservation of the pelvic autonomic nerves minimizes bladder and sexual dysfunction especially in male patients after rectal cancer surgery.     

应用全直肠系膜切除和保留植物神经的三腔清扫技术治疗中晚期直肠癌247例

 【摘要】　目的　分析应用全直肠系膜切除（TME）、保留植物神经（PANP）的三腔清扫（TSD）技术治疗中晚期直肠癌的效果。方法　247例中晚期直肠癌患者采用TME和（或）TSD技术行根治性切除。其中,185例（74.9 %）进行了PANP（P组）的直肠癌根治术治疗,其余患者由于怀疑侵犯植物神经丛而行植物神经非保留式（P-组）切除术,P组中行TME者139例（Pm组）,行TSD者46例（Ps组）。结果　247例患者中无手术死亡病例。Pm组在手术时间、手术操作难度等方面优于Ps组（P ＜0.05）。P组在术后泌尿和性功能上明显好于P-组（P <0.05）。P组与P-组、Pm组与Ps组在肛门直肠功能、2年生存率及远期复发率、转移率及生存期等方面差异均无统计学意义（均P >0.05）。结论　TME技术PANP对绝大多数中晚期直肠癌均是应该优先选择的术式,应争取行"三明治"疗法。TSD手术操作相对复杂。TME、TSD的术后生存率差异无统计学意义,术后生存期主要取决于癌肿的早期发现与干预。     

Function preservation in rectal cancer surgery

When total mesorectal excision (TME) is accurately performed, dysfunction, theoretically, does not occur. However, there are differences among individuals in the running patterns and the volumes of nerve fibers, and if obesity or a narrow pelvis is present, nerve identification is difficult. Currently, the rate of urinary dysfunction after rectal surgery ranges from 33% to 70%. Many factors other than nerve preservation play a role in minor incontinence. Male sexual function shows impotence rates ranging from 20% to 46%, while 20%–60% of potent patients are unable to ejaculate. In women, information on sexual function is not easily obtained, and there are more unknown aspects than in men. As urinary, sexual, and defecation dysfunction due to adjuvant radiotherapy have been reported to occur at a high frequency, the creation of a protocol that enables analysis of long-term functional outcome will be essential for future clinical trials. In the treatment of rectal cancer, surgeon-related factors are extremely important, not only in achieving local control but also in preserving function. This article reviews findings from recent studies investigating urinary, sexual, and defecation dysfunction after rectal cancer surgery and discusses questions to be studied in the future.     

Underlying anatomy for CTV contouring and lymphatic drainage in rectal cancer radiation therapy

Despite the low local recurrence rate that can be achieved by adequate surgery (total mesorectal excision--TME), radiation therapy was shown to play a significant role in reducing this risk. The widespread use of TME in many European Centers has introduced a new terminology and the need to identify the area at major risk for local failure using this surgical procedure. In the surgical series where extended extra-mesorectal surgery was performed, the role of lymphatic spread was evidenced, especially for low rectal cancer, through the pelvic parietal fascia and lateral pelvic spaces. The aim of this study was to better define some anatomic concepts and the main risk factors which impact on CTV contouring and field conformation in rectal cancer treatment. This information helps formulating guidelines for CTV contouring in daily radiotherapy practice, in order to define the best therapy, according to the tumor stage and location.     

根治性全盆脏器切除术治疗局部晚期／复发性直肠癌的临床研究

目的：探讨根治性全盆脏器切除术治疗局部晚期／复发性直肠癌的效果。方法：对44例局部晚期／复发性直肠癌的临床、病理资料进行回顾性分析。结果：根治性全盆腔脏器切除术30例、姑息性切除术14例。结肠造瘘术39例,回肠代膀胱术21例,输尿管腹壁造瘘术23例。盆底腔隙采用膀胱脏层腹膜修复39例、双侧腹膜修复3例、带蒂大网膜填充1例、回肠末段填充1例。围手术期死亡率23％,总体并发症发生率50.0％。根治性和姑息性全盆脏器切除术后5年生存率分别为53.3％和0％。结论：根治性全盆腔器官切除术是提高局部晚期／复发性直肠癌病灶整块切除率、降低局部复发率、延长生存期的理想术式。