腹腔镜辅助根治性右半结肠切除术式及其评价

腹腔镜结肠切除术无论从根治性及安全性方面均已得到多项随机试验论证：而对腹腔镜辅助根治性右半结肠切除（LRRH）的认识经历了两个阶段。早年认为该术在腹腔镜结肠切除术中难度最低，适于掌握初级腹腔镜技能的外科医师操作;随着众多结肠直肠专科医师应用LRRH后认识到由于必须解剖及清扫肠系膜上静脉的外科干周围淋巴组织，才感到手术难度明显大于其他腹腔镜结肠直肠手术，使其发展相对滞后。目前，国内外有关LRRH的专题报道较少，且例数多在20-40例。本文就其术式及其相关的安全性、根治性及预后作一综述评价。     

结直肠癌腹腔微转移的检测

腹腔内脱落癌细胞或微小癌灶(又称腹腔微转移)是导致结直肠癌术后复发的重要原因。本研究联用癌胚抗原(CEA)、基质金属蛋白酶-7(MMP-7)和细胞角蛋白20(CK20)3种标志物检测腹腔内脱落癌细胞,以期提高腹腔微转移的检出率。1.材料与方法:采集协和医院2001年5月至2002年3月手术的52例结直肠癌患者(病灶位于腹膜反折以上)的腹水或腹腔灌洗液,其中男33例、女19例,中位年龄59岁。以结直肠癌细胞株(LS-174T)和10例新鲜结直肠癌组织作为阳性对照;以30例非肿瘤患者的腹水或腹腔灌洗液作为阴性对照。试剂:总RNA提取试剂盒、反转录试剂盒、PCR试…     

经腹腔镜行全直肠系膜切除的可行性研究

目的探讨经腹腔镜行全直肠系膜切除治疗直肠癌的可行性。方法比较经腹腔镜与开腹两组标本的直肠系膜完整性和肠旁 3站淋巴结清扫数目的差异。结果①两组各 2 0例直肠癌切除标本的直肠系膜均完整无破损。②腹腔镜组与开腹组N1的淋巴结数分别为 8 5± 3 6与10 6± 6 2 (P =0 334 ) ;N2 的淋巴结数分别为 3 7± 2 2与 2 4± 2 1(P =0 32 8) ;N3 的淋巴结数分别为2 4± 1 7与 2 0± 1 8(P =0 5 90 )。③直肠远切端均无癌细胞浸润。结论经腹腔镜行全直肠系膜切除是可行的     

腹腔镜经盆腔途径个体化的经肛提肌外腹会阴联合直肠切除术

<正>1908年,Miles[1]在Lancet杂志上撰文提出了腹会阴联合直肠切除术(abdominoperineal excision, APE),报道了12例接受该术式的直肠癌患者,其中5例死亡,存活的7例患者术后1年复查均无复发。这一术式革命性地降低了直肠癌的病死率和局部复发率,半个多世纪来它一直被看作是直肠癌手术的金标准。1982年,Heald等[2]提出了全直肠系膜切除术(total mesorectal excision,TME)     

腔镜直肠癌根治术侧方淋巴结清扫的关键技术与意义

中低位直肠癌的预防性侧方淋巴结清扫的意义目前国内外仍存在争议。但如影像学或术中发现盆侧方有可疑阳性淋巴结转移时，有必要选择性对盆侧方淋巴结进行清扫，该术式在直肠癌根治术中具有重要意义。传统侧方淋巴结清扫以开放手术为主，创伤大且术后并发症较多。随着腹腔镜技术的广泛应用，腔镜盆侧方淋巴结清扫术在我国逐步开展，利用其视野放大的优势，可对盆侧方进行按层次、按程序及更精细地解剖，并可降低盆侧方淋巴结清扫的难度、减少出血量及创伤。结合本中心手术经验，本文介绍腔镜盆侧方淋巴结清扫术的关键技术及相关研究进展，以供同道参考。     

局部晚期直肠癌术前同期放化疗临床及病理降期效果的探讨

目的:探讨局部晚期直肠癌术前同期放化疗后临床及病理降期情况及其相关影响因素.方法:回顾性分析30例行术前同期放化疗的局部晚期直肠癌患者的临床资料,放疗采取三维适形放疗技术,同期化疗为奥沙利铂与卡培他滨联合方案.评价其术前临床及术后病理降期效果并分析相关影响因素. 结果:术前临床评价T分期降期率达73.3%(22/30),17例N+患者10例淋巴结完全消退;术后病理发现,14例患者T分期下降,降期率为46.7%,其中5例患者达pCR,完全缓解率为16.7%(5/30).单因素分析显示,放疗后继续服用卡培他滨及放疗至手术间歇期长者肿瘤降期率高.除1例放疗期间出现膀胱瘘者,仅1例出现Ⅲ级造血系统毒副反应,未见Ⅳ级毒副反应.结论:局部晚期直肠癌术前同期放化疗耐受性良好,有效率高,更加合理的同期化疗需更进一步的临床试验证实.     

浆膜受侵的结直肠癌术后腹腔化疗联合静脉化疗的临床研究

Objective To compare the clinical efficacy of postoperative intraperitoneal chemotherapy combined with systemic chemotherapy to systemic chemotherapy alone for serosa-involved colorectal cancer. Methods According to the criteria of serosa-involving in colorectal cancer, 332 cases were divided into 2 groups prospectively without randomization. Study group (n=166) was treated with intraperitoneal chemotherapy combined with systemic chemotherapy, and control group (n=166) with systemic chemotherapy alone. Incidence of local recurrence, peritoneal metastasis, hepatic metastasis, other distant metastasis and 3-year, 5-year overall survival (OS) rate of two groups were compared. Results 3-year and 5-year OS rates of stage Ⅱ B in study group were similar to those in control group (χ2=0.612,P=0.434). The above rates of stage Ⅲ in study group were higher than those in control group (χ2=3.989,P=0.046). Either the study group or the control group, the 3-year and 5-year OS rates of patients undergone laparoscopic surgery or open surgery were similar (P=0.839, P=0.172). Incidences of local recurrence, peritoneal metastasis and hepatic metastasis in study group were 1.9%, 3.8% and 3.8% respetively, lower than those in control group (8.2%,9.5% and 10.1%,P<0.05). Distant metastasis rate in study group was similar to that in control group. In study group, intraperitoneal chemotherapy regimen with Oxaliplatin had lower rates of peritoneal metastasis and hepatic metastasis as compared to that with Cisplatin (0.9% vs 8.8% ,P=0.019), while the incidences of local recurrence and other distant metastasis were similar. Conclusions Postoperative intraperitoneal chemotherapy combined with systemic chemotherapy improves 3-year and 5-year overall survival rates in patients with stage Ⅲ serosa-involved colorectal cancer, and decreases local recurrence, peritoneal metastasis and liver metastasis rate, especially when intraperitoneal chemotherapy regimen contains Oxaliphtin. Comparing with open surgery, laparoscopic surgery dose not improve 3-year and S-year overall survival rates in patients receiving combined chemotherapy or systemic chemotherapy alone.     

盆部内脏神经血管的解剖特点及临床应用

目的:探讨经腹腔镜行全直肠系膜切除术中盆部内脏神经和血管的保护.方法:解剖32具成人躯干标本(女15、男17)和31侧成人男性骨盆矢状标本,结合腹腔镜手术,观测有关的盆腔血管神经的形态及定位.结果:(1)骶中静脉大多1支,61%偏左,骶外侧静脉53%为两支,骶前静脉丛在骶曲处密集粗大,骶椎椎前穿通静脉在第4、5骶椎前方形成静脉窦,且与骨膜结合紧密.(2)盆从位于距直肠外侧约1.1cm和距直肠膀胱陷凹上外测约4.7cm处的骨盆侧壁.左右腹下神经分别于骶骨岬上下1.0～2.0 cm的范围内分出,其夹角约95.9°.上腹下丛位于腹主动脉分叉周围至骶骨岬下2 cm之间.(3)腹腔镜下骶前间隙主要由少量的疏松结缔组织填允容易分离,解剖层面清晰.结论:手术中应找准解剖层面,根据血管神经的定位以神经为导向进行分离,可避免损伤盆部的内脏神经及骶前静脉丛.