直肠癌Hartmann手术中引流技术的改进

我院于 1998～ 2 0 0 0年 ,行Ｈａｒｔｍａｎｎ手术中有 30例改用经直肠残端肛门引流术。报告如下。30例均为直肠癌病人。男 12例 ,女 18例。年龄 43～78岁 ,平均 6 5岁。　　操作方法 :(1)直肠远端切除范围需超过肿瘤 3ｃｍ以上 ,近端自左侧腹壁作结肠造瘘术。 (2 )直肠残端缝合 ,中间只留一针孔 ,自残端放Ｔ管 ,通过直肠从肛门引出固定。(3)缝合盆腹膜。 (4 )冲洗盆腔后缝合腹腔 ,腹腔内不放引流管。 (5 )肛门处引流管可用生理盐水加抗生素冲洗。 (6 )当引流液很少或无时取下 ,大约在术后 10天。　　术后病人体温 36 5～ 37 5℃ ,ＷＢＣ(…     

经骶部途径的直肠手术30例临床分析

目的探讨经骶部径路的直肠手术在直肠外科中的应用。方法回顾分析1996—2004年30例中下段直肠疾病病人施行经骶部径路的直肠手术经验。结果本组中直肠绒毛状腺瘤17例，直肠平滑肌瘤1例。早期直肠癌9例，进展期直肠癌2例，直肠类癌1例。30例直肠肿瘤中行直肠部分切除术19例，直肠节段切除术11例。术后伤口感染1例，肿瘤局部复发1例。直肠癌组术后3年存活率100％，5年存活率91．7％。结论经骶部途径的直肠手术具有手术径路直达、术野表浅和显露良好，适用于可行局部切除治疗的中下段直肠良恶性疾病。     

腹腔镜下直肠癌根治术

目的：通过技术改进和经验积累，在不降低安全性、有效性和微创性的基础上，探讨扩大腹腔镜直肠癌根治手术的适用范围。方法：4—5孔法实施手术，术中根据肿瘤位置和大小，确定系膜保留位置，为术后盆壁腹膜化重建做好准备，按照标准的直肠全系膜切除手术要求，循解剖间隙实施手术。系膜血管采用解剖性游离然后结扎切断和提出腹腔处理两种方法。为了解决手术范围狭小的问题，充分显露腹膜返折及以下盆腔空间，腹腔镜下使用五叶拉钩，较好的解决了空间不利于显露的缺点。消化道的重建采用完全腹腔镜手术、腹腔镜辅助手术、肛门拖出吻合器吻合以及人工吻合等方法。盆底腹膜主要用连续缝合关闭，部分采用腹膜整形大部分关闭，少量采用完全不关闭等方法。结果：全组62例，57例手术成功，1例直肠中动脉出血，4例晚期肿瘤侵犯周围脏器中转开腹。手术时间平均175min，术中出血量平均70mL，术后住院时间平均9d，无严重并发症。全组患者随访3～36个月，平均15个月，失访率5％，1年生存率91％，3年生存率76％，6例拖出式吻合患者大便次数较多，6～9个月后好转。结论：经过技术改进，腹腔镜直肠癌切除手术可以被更广泛的应用。     

中国腹腔镜直肠癌根治术式选择原则与规范化

近年来,随着腹腔镜直肠癌手术技术的不断成熟,在经典的腹腔镜直肠前切除术式基础上,腹腔镜下的括约肌间切除（ISR）,经肛全直肠系膜切除（TaTME）等技术又有不断的发展,使得腹腔镜直肠癌根治手术的手术方式不断拓展,本文就我国腹腔镜直肠癌根治术式的选择原则与规范化作一探讨。     

套迭拉出式直肠癌根治术的临床应用

作自1991—1994年有选择地应用套迭拉出式直肠癌根治术(Welch手术)治疗低位直肠癌20例，效果满意。     

微创手术平台与微创手术方式的未来走向

近30年来,随着能量平台、器械平台、显像平台三大手术平台的发展,微创外科有了突飞猛进的提升。以结直肠癌手术为例,手术方式的五要素都有着不同程度的发展：手术入路经历了"从大到小"的过程;切除范围从单纯肠段切除到根治术或扩大根治术,再到注重保留器官功能的手术;随着对正常淋巴引流方向和肿瘤淋巴转移特点的认知,淋巴结清扫愈趋规...     

经肛门内窥镜微创手术在直肠肿瘤切除术中的应用

直肠低位肿瘤可以经肛门直肠镜或其他一些仪器将其切除，部分直肠中位肿瘤可经骶尾入路或肛门括约肌切开后将其切除。对于直肠中高位肿瘤难以经上述手术方法切除，主要由于肿瘤暴露不充分，手术器械不易经肛门直肠镜达到病变部位，切除过程中有进入腹腔的危险。经肛门内窥镜微创手术（transanal endoscopic microsurgery，TEM）是一种将直肠肿瘤和直肠全层一起切除的手术方法，手术损伤较小，能切除距肛门4～24cm的肿瘤。TEM技术是1984年德国Buess教授首先提出。     

直肠癌外科治疗进展

近二十年来直肠癌的外科治疗取得较大进展,直肠癌的外科治疗有了新的根治概念和原则[1].直肠癌根治术后5年生存率有了显著提高,达到50%～70%,早期直肠癌5年生存率＞90%.以下就直肠癌外科治疗进展作一简要综述.     

Advances in surgical treatment of rectal cancer

Increased understanding of the natural history of the disease, standardization of surgery and new procedures have led to significant advances in the treatment of rectal cancer. Anatomical dissection of the mesorectum permits optimal local control and volume cases may further improve oncological RESULTS: Autonomic pelvic nerves are preserved by the technique of total mesorectal excision (TME) and adapted anterior dissection plans improve preservation of genito-urinary functions. Sphincter preservation can be achieved by a conventional anterior resection for high and mid-rectal tumours, and by the technique of intersphincteric resection for low tumours. A J-pouch or a recently-designed coloplasty pouch must be associated with coloanal anastomoses in order to improve functional results and loop ileostomy is recommended to decrease early postoperative morbidity. Local excision constitutes an alternative to major surgery in patients with a low-risk early rectal cancer. Neoadjuvant treatments have a role in local control of the disease after TME surgery and in new strategies of sphincter-saving procedures. The place of anorectal reconstruction and that of laparoscopy are also discussed.     

The results of surgical treatment of rectal cancer

The results of treatment of 948 patients radically operated for cancer recti during 1989-1998 period was studied up. The postoperative complications frequency had lowered as well as mortality from 8.05 down to 1.32% due to application of the improved surgical tactics and an adequate correcting therapy also. Simultaneously there was not noted the trustworthy enhancement of the local recurrencies occurrence frequency and lowering of the average life span of patients after performance of rectal abdomino-anal resection.     

International trends in surgical treatment of rectal cancer

Background

Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described.

Methods

We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers.

Results

Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as “15 cm from the verge.” Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001).

Conclusions

Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.     

直肠癌外科治疗的热点问题

近10余年来,直肠癌的外科治疗有了显著的进步,直肠系膜环周切缘癌残留被确定为直肠癌术后局部复发的最主要因素,沿胚胎发育的筋膜间隙精细游离直肠系膜并完整切除,能显著降低环周切缘的癌残留机会,术前辅助性放化疗可降低直肠癌术后局部复发及降低术后泌尿性功能障碍的发生.本文就直肠癌外科治疗当前研究的热点问题作一评述.     

直肠癌外科治疗的热点问题

近10余年来,直肠癌的外科治疗有了显著的进步,直肠系膜环周切缘癌残留被确定为直肠癌术后局部复发的最主要因素,沿胚胎发育的筋膜间隙精细游离直肠系膜并完整切除,能显著降低环周切缘的癌残留机会,术前辅助性放化疗可降低直肠癌术后局部复发及降低术后泌尿性功能障碍的发生.本文就直肠癌外科治疗当前研究的热点问题作一评述.     

直肠癌外科治疗的热点问题

近10余年来．直肠癌的外科治疗有了显著的进步。直肠系膜环周切缘癌残留被确定为直肠癌术后局部复发的最主要因素．沿胚胎发育的筋膜间隙精细游离直肠系膜并完整切除．能显著降低环周切缘的癌残留机会。术前辅助性放化疗可降低直肠癌术后局部复发及降低术后泌尿性功能障碍的发生。本文就直肠癌外科治疗当前研究的热点问题作一评述。