28例低位直肠绒毛状腺瘤癌变局部切除治疗经验

目的：探讨合理选择治疗低位直肠绒毛状腺瘤癌变的手术方式。方法：回顾性分析我院28例经局部切除治疗的低位直肠绒毛状腺瘤癌变的临床资料，并加以讨论。结果：经肛局部切除(transanal excision，TE术)20例．经骶局部切除(Kraske术)8例。术后病理高、中分化腺癌27例，低分化腺癌1例；肿瘤浸润粘膜层13例，浸润粘膜下层12例，浸润肌层3例。术后复发4例，转移2例，5年生存率78.6％(22／28)。结论：直肠绒毛状腺瘤癌变恶性程度低，对于病变位于低位直肠的患者，只要符合适应证，则局部切除术既可以达到根治术的疗效，又能保留正常排便功能，提高患者生存质量。     

经括约肌低位直肠肿瘤切除的体会

采用经括约肌经路行低位直肠肿瘤切除３６例，其中腺瘤１６例，腺瘤癌变９例，直肠癌１０例，类癌１例，术后切口感染６例，吻合口瘘４例，无肛门失禁。作者简述了手术方法，认为此手术损伤小，显露好，操作简单，不损害肛门功能，并针对术后常见并发症和局部复发的预防进行讨论。     

经括约肌低位直肠肿瘤切除的体会(附36例报告)

采用经括约肌经路行低位直肠肿瘤切除36例，其中腺瘤16例，腺瘤癌变9例，直肠癌10例，类癌1例。术后切口感染6例，吻合口瘘4例，无肛门失禁。作者简述了手术方法，认为此手术损伤小，显露好，操作简便，不损害肛门功能，并针对术后常见并发症和局部复发的预防进行讨论。     

直肠腺瘤的手术治疗

本文报道我院近５年来手术治疗的１８例直肠腺瘤。经肛门手术８例；经腹直肠部分切除术８例；对２例位于肛缘上７ｃｍ的经肛门手术后复发性腺瘤分别采用经直肠前和经直肠后入路的局部切除术。全组随访１６例，平均２．３（１—４年）年无复发。强调了纤维结肠镜活检及全面了解结肠情况的重要性。认为应严格把握经肛门手术的指征。     

直肠肛管癌选择经括约肌间切除术的多因素分析

目的探讨影响超低位直肠/直肠肛管癌经括约肌间切除术（Intersphincteric resection, ISR）选择的临床病理因素。方法回顾性分析由同一组专业医师共同完成的超低位直肠癌（肿瘤距肛缘≤5cm 或距齿状线≤3cm）切除术患者156例。纳入指标包括：年龄、性别、肿瘤分化程度、肿瘤距肛缘距离、病理TNM分期、术前CS分期和新辅助治疗。 结果共有63例患者接受ISR,93例患者未接受此术式。单因素分析表明肿瘤病理T分期(P=0.038)、N分期(P=0.044)和术前CS分期(P<0.001)与ISR选择有关。多因素分期显示肿瘤病理T分期、N分期和CS分期是影响直肠肛管癌ISR选择的独立因素。 结论超低位直肠癌患者是否可行经括约肌间切除术与肿瘤局部浸润程度、淋巴结受累情况有关,而与肿瘤距肛缘距离、肿瘤分化程度及新辅助化疗无关。直肠指检仍是决定是否可行经括约肌间切除术的有效方法。     

低位直肠间质瘤腹腔镜辅助下的经内外括约肌间切除术*

目的：针对伊马替尼治疗下的低位直肠间质瘤,探讨腹腔镜辅助下经内外括约肌间切除术的安全性和可行性。方法：随访2007年1 月至2011年1 月9 例低位直肠间质瘤患者,在术前接受伊马替尼治疗后行腹腔镜辅助下的经内外括约肌间切除术。结果：伊马替尼治疗前肿瘤大小为5～9 cm（中位值7.0 cm）,治疗后肿瘤大小为2～4.5 cm（中位值3.5 cm）（P < 0.001）。 治疗3～24个月（中位值7 个月）行腹腔镜辅助下的经内外括约肌间切除术,住院时间5~ 9 天（中位值7 天）,所有患者均行保护性造口,术后3 个月行造口还纳术。Wexner评分在伊马替尼治疗前为1～4 分（中位值2 分）,治疗后为1～5 分（中位值2 分）（P = 0.397）;造口还纳术后Wexner评分4～9 分（中位值7 分）,较术前明显增加（P < 0.001）,术后1 年为1～5 分（中位值2 分）,与术前比较差异无统计学意义（P = 0.842）。 术后有6 例继续服用伊马替尼24～30个月。1 例未继续服用伊马替尼,患者在30个月时出现盆底复发。结论：腹腔镜辅助下的经内外括约肌间切除术对于低位直肠间质瘤的治疗是安全可行的。     

极限保肛之低位直肠癌经括约肌间切除术(ISR)

结直肠外科医生从未停止对保肛手术的探索,只有在"保命、保功能"的基础上才能探讨保肛问题.直肠肿瘤患者对保留肛门有着强烈而广泛的需求.仅仅出于肿瘤学安全的考虑,不加区别地拿掉患者的肛门也是不人道的.保肛手术有很多种,但只有经内、外括约肌间切除的ISR(Intersphinc-teric resection)手术可以被称为...     

经骶尾途径切除直肠中段良性肿瘤六例报告

１９９２年５月～１９９８年１０月我院经骶尾途径行直肠中段良性肿瘤切除术６例,报道如下。１　临床资料１．１　一般资料　本组男４例,女２例,年龄３９～８０岁,中位年龄６０岁。病程最长２年,最短１５天。病变部位距肛缘８～１０ｃｍ。术前乙状结肠镜活检病理诊断为管状乳头状腺瘤２例,直肠腺瘤２例,直肠绒毛状腺瘤１例,乳头状腺瘤１例,术后病理诊断同术前。１．２　手术方法　硬膜外麻醉,俯卧位,作骶尾部纵形切口,切除尾骨及第３～５骶骨［１］。切开骶前筋膜,显露和切开直肠后壁,距肿块０．５～１ｃｍ切除肿瘤及全层肠壁…     

切除括约肌的低位直肠癌保肛术

目的：探讨全切除内括约肌和部分外括约肌仍保留肛门控制能力的低位直肠癌根治术，方法：自１９９１年７月至１９９４年１２月对１２例拒绝做壁人工肛门的低位直肠癌患者行直肠癌切除结肠管吻合术，９例肿瘤位于极靠近齿线的齿线上方，３例肿瘤达齿线，把直肠段翻转拖出肛门，在肛门外施行肛管及肛周组织的横断切作和结肠肛管的吻合，结果：肠管远端的切缘在齿线上０．２ｃｍ至齿线下１ｃｍ的范围，标本的远端切缘均为阴性，术后无并     

Flat Serrated Adenomas of the Colorectal Mucosa

A total of 47 flat serrated neoplasias of the colorectal mucosa are presented: 44 were flat serrated adenomas and the remaining 3 flat serrated adenocarcinomas arising in flat serrated adenomas. These lesions were found among 600 flat mucosal lesions removed at colonoscopy during a 3-year period (1992 and 1994) at the Karolinska Hospital. Thirty-five of the 47 patients (74%) were males and the remaining 12 (26%), females. Depending upon the degree of cellular dysplasia within the epithelium, serrated adenomas were divided into those with low-grade dysplasia (LGD), when the dysplastic nuclei were present in the deeper half of the epithelium, and those with high-grade dysplasia (HGD), when the dysplastic nuclei were found even in the upper half of the epithelium. LGD was present in 37 (84.1%) of the 44 serrated adenomas and HGD in the remaining 7 (15.9%). Depending upon the topographic distribution of the dysplastic epithelium within the crypts, flat serrated adenomas were divided into type I, when the dysplastic epithelium was limited to the lower half of the serrated crypts, and type II, when the dysplastic epithelium was even present in the superficial half of the serrated crypts. Of the 44 serrated adenomas, 38 (86.1%) were type I and the remaining 6 (13.9%) type II. The dysplastic epithelium seemed to originate at the base of the crypts and to progress upwards, replacing the scalloped, serrated epithelium of the sides of the crypts. Invasive adenocarcinomas (i.e., with submucosal extension) were seen to arise from flat serrated adenomas with LGD type I (n=2) or with HGD type II ( n = 1). This preliminary survey suggests that flat serrated adenomas of the colorectal mucosa may be lesions with a propensity to evolve into invasive adenocarcinoma, irrespective of the degree of the epithelial dysplasia or of their extension along the crypts.     

垂体瘤的立体定向放射治疗进展

垂体瘤是常见的颅内肿瘤,分为功能性和无功能性两种。控制肿瘤体积及激素水平为其治疗的两大目标。立体定向放射治疗作为垂体瘤二线治疗方案,获得了良好的肿瘤控制率及激素缓解率。但仍不可避免地存在一些治疗后并发症,最主要的为放疗相关垂体功能减退。本文总结近几年关于立体定向放疗治疗垂体瘤的文献,将国内外学者的共识及争议点加以综述。     

伽玛刀治疗垂体瘤的经验

报道１９９３年１０月～１９９４年４月经伽玛刀治疗的垂体瘤１００例，７８例随访了６～１２个月，其中４９例随访了ＭＲ，１２例复查了血ＰＲＬ水平，１０例复查了血ＧＨ水平。结果表明，病人的症状控制率及肿瘤大小控制率均为１００％，治疗前后血ＰＲＬ、ＧＨ差别均有显著性，故认为伽玛刀治疗垂体瘤近期效果良好。对治疗剂量、适应证及相关问题进行了探讨。     

Ki-67单抗标记指数与侵袭性垂体腺癌复发相关性研究

〔目的〕研究ki－67单抗标记指数（LabellingIndexLI）在评估侵袭性垂体腺瘤术后复发的作用。［方法］将16例侵袭性垂体腺瘤术后肿瘤标本用ABC法检测ki-67LIl,根据术后随访的复发资料,分复发组（6例）和未复发组（10例）两组,再分析和比较两组的Ki-67LI.[结果]在复发组中的Ki－67LI(63．8土4．5)％显著高于未复发组（21．7土2．3）%,P＜0．01;在所有激素类型中,多激素型的ki－67LI为最高。[结论]你一67LI与侵袭性垂体脉瘤术后复发相关,可作为预测垂体脉瘤术后潜在复发的一项指标。     

垂体腺瘤细胞增殖活性和肿瘤生长方式的相关性研究

目的　探讨垂体腺瘤细胞增殖活性和其侵袭性生长方式之间的相关性。方法　采用单克隆抗体MIB -1免疫组织化学染色 ,确定 110例垂体瘤的Ki -67标记指数。结果　平均标记指数是 2 65 %。患者年龄、肿瘤大小对标记指数无影响。非侵袭组是2 0 1% ,侵袭组是 3 71% ,P =0 0 2 7,有显著性差异。侵袭蝶窦组是 5 5 8%。功能性腺瘤是 3 0 9% ,非功能性腺瘤是 1 98% ,P =0 14 ,两者之间无显著性差异。ACTH腺瘤的标记指数是 5 47% ,其他功能性腺瘤是 2 3 3 % ,P =0 0 1,有显著性差异。患者年龄、肿瘤大小对标记指数无影响。结论　肿瘤细胞的增殖活性与垂体瘤的侵袭性生长有关 ,但不是肿瘤发生侵袭的唯一因素     

肌上皮细胞的表型分化在涎腺发育及多形性腺瘤中的意义

背景与目的探讨肌上皮细胞与涎腺发生、涎腺多形性腺瘤发生的关系以及肌上皮细胞的分化状态与肿瘤生物学行为的关系。材料与方法采用组织学、免疫组化方法对不同发育阶段(胚7~8周、胚9~10周、胚11~14周、胚15~20周)的涎腺胚胎组织及涎腺多形性腺瘤中肌上皮细胞的表型分化及功能状态进行比较分析。结果在涎腺发育过程中,导管腔面及基底层细胞表达CK19,偶可表达CK14,而不表达肌上皮细胞的标记物α-SMA,为非肌上皮来源;而原始腺泡和闰管中肌上皮细胞的标记物阳性表达,为肌上皮前体细胞分化而来。在多形性腺瘤中,非管腔的肿瘤实质中,梭形细胞、上皮样细胞表达肌上皮细胞标记物CK14、P63、α-SMA,为肌上皮来源,软骨样成分和粘液样成分偶可表达肌上皮细胞标记物CK14和α-SMA,可能亦为肌上皮来源。管腔样结构、浆细胞样细胞、透明细胞不表达肌上皮细胞标记物,可能来自管腔细胞系。结论在涎腺发育过程中,腺泡和闰管来自肌上皮细胞系;导管系统来自管腔细胞系。以肌上皮分化较好的肿瘤预后较好,其中可能的原因为肌上皮细胞分化异常,失去其自身的表型特征,从而失去抑制肿瘤生长和侵袭的作用。     

A Very Large Villous Adenoma with an Adjacent Cancer of the Rectum: An Informative Case for Testing the Proposed Molecular Basis of Colorectal Tumorigenesis

It is currently accepted that colorectal tumorigenesis resultsfrom accumulation of multiple mutations in certain genes. Thisconcept prompted us to search for possible mutations in theAPC, k-ras, and p53 genes in an advanced cancer coexisting witha large villous adenoma of the rectum in a 54-year-old patientwith no family history of colorectal cancer. Genomic DNA extractedfrom multiple subregions of the tumor and surrounding normalmucosa was studied by polymerase chain reaction (PCR) followedby single-strand conformation polymorphism (SSCP) analysis anddirect sequencing. Both the adenoma and carcinoma had abnormalPCR-SSCP for APC (exon 11) and k-ras, irrespective of the locationwithin the tumors. However, p53 abnormality (exon 7) was detectedonly in samples taken from the carcinoma. Subsequent sequencingrevealed a TTC to TAG mutation at codon 479 of APC, a GGT toGAT mutation at codon 12 of k-ras in both the adenoma and carcinoma,and a CGG to TGG mutation at codon 248 of p53 (exon 7) in thecarcinoma. These findings were in accord with the current conceptof colorectal tumor progression whereby genetic alteration ofAPC and k-ras occurs relatively early while that of p53 is ratherlate and is possibly a decisive event in relation to malignancy.     

Obesity, Weight Gain and Risk of Colon Adenomas in Japanese Men

Obesity has been related to increased risk of colon cancer or adenomas, but the epidemiologic findings are not entirely consistent. We examined the relation of not only body mass index (BMI) but also waist-to-hip ratio (WHR) and weight gain to colon adenoma risk in men who received a preretirement health examination at the Japan Self Defense Forces (SDF) Fukuoka and Kumamoto Hospitals during the period from 995 to 1996. In the series of 803 men at age 47–55 years, 189 cases of colon adenomas and 226 controls with normal total colonoscopy were identified. Weight at 10 years before was ascertained by referring to the recorded data. After allowance for hospital, rank in the SDF, smoking and alcohol use, weight gain over the past 10 years was significantly associated with increased risk of colon adenomas (odds ratio for ≥ 6 kg versus ≤−2 kg = 2.2; 95% confidence interval 1.0–4.8). High BMI and high WHR were each associated with increased risk, but only WHR was related to the risk independently of weight gain. In particular, weight gain accompanied with a high WHR was associated with a significant increase in the risk. Men with high physical activity tended to have lower risk. Associations with obesity-related variables and physical activity were not materially differential as regards the location and size of adenoma. The findings indicate that weight gain in middle age leading to abdominal obesity increases the risk of colon adenomas, and consequently of colon cancer.     

保留括约肌手术在直肠癌治疗中的价值

实践证明,低位前切除术(LAR)的5年生存率与Miles＇术式无明显差别。我院1981年～1990年,10年间共行前切除吻合术(AR)179例。其中满5年的50例。年龄22岁～77岁,平均49.9岁。40岁以上占70％。上、中、下段癌分别占16％(8/50)、52％(26/50)、32％(16/50)。高位前切除占7.9％(6/50)、低位42％(21/50)、超低位 46％(23/50)。全部手法吻合,无手术死亡。生存率3年为70.4％,5年为56％。术后吻合口漏发生率18％。肛门功能满意。