CO2气腹下早期宫颈癌的腹腔镜手术对癌细胞种植和转移的影响

目的:探讨早期宫颈癌的CO2气腹腹腔镜手术对肿瘤种植和转移的可能影响.方法:选取佛山市第一人民医院2005年9月至2006年9月行腹腔镜手术的宫颈癌20例和同期行开腹手术10例(FIGO临床分期Ⅰ a2～Ⅱ a).腹腔镜手术采用全自动气腹机形成CO2气腹,每充气流量设定4～6L/min,腹腔内CO2气腹压力均维持在13mmHg.收集20例腹腔镜手术开始和结束前的腹腔冲洗液、术中CO2气体滤过液和器械冲洗液行肿瘤细胞学检查.DAKOEnVision二步法检测手术开始前和结束后癌组织的E-cadherin、β-catenin、P-selectin、MMP-2、VEGF和CD44v6蛋白表达.结果:20例腹腔镜手术开始时和结束前的腹腔冲洗液、CO2气体滤过液和器械冲洗液的肿瘤细胞学检查均未见癌细胞.E-cadherin,β-catenin蛋白的异常表达在腹腔镜组和开腹组手术前、后比较无统计学差异(P>0.05);两组间两种指标的异常表达变化亦无统计学差异(P>0.05).分别比较两种术式手术前、后MMP-2、P-selectin、VEGF和CD44v6蛋白表达均无统计学差异(P>0.05);两组间四种指标的表达变化亦无统计学意义(P>0.05).腹腔镜组随访15～27个月(24.85±3.53).无复发;开腹组随访15～27个月(24.20±4.47),1例阴道残端复发.结论:20例早期宫颈癌腹腔镜手术未影响E-cadherin、β-catenin、P-selectin、MMP-2、VEGF和CD44v6的表达,未找到其促进宫颈癌组织种植和转移的依据.     

腹腔镜结直肠癌手术的应用现状与进展

腹腔镜手术应用于结直肠癌在技术上是安全可行的,且微创优点明显,然而对于其能否达到肿瘤根治以及是否增加腹腔及切口种植等仍存在争议。文章就腹腔镜应用于结直肠癌的手术适应证、禁忌证,根治效果、远期疗效及其是否促进手术戳口癌种植转移进行评价,认为腹腔镜结直肠癌手术在严格遵循肿瘤根治的原则下是安全有效的,也能达到与开腹手术相当的长期生存效果。     

胃癌术中腹腔冲洗液CK19检测临床意义的探讨

目的探讨胃癌根治术中腹腔冲洗液CK19的检测与胃腺癌分化程度、TNM分期的关系以及腹腔镜胃癌根治术后对肿瘤细胞腹膜微转移的影响。方法应用流式细胞术法检测50例胃癌患者(分开腹组及腹腔镜组)及同期10例胃良性病变患者腹腔冲洗液的CK19表达,比较腹腔镜辅助下胃癌根治术与传统开腹根治术患者腹腔灌洗液的CK19表达,分析腹腔冲洗液CK19的表达与肿瘤组织分化程度、TNM分期的关系。结果胃良性病变患者腹腔冲洗液CK19阳性表达率为0,低分化腺癌组CK19阳性表达率明显高于高中分化腺癌组(P0.05)。TNM分期Ⅲ期胃癌组腹腔冲洗液CK19阳性表达率显著高于Ⅰ+Ⅱ期患者(P0.05)。腹腔镜辅助下胃癌根治术患者CK19阳性表达率术后较术前检出率虽有所增加但差异无统计学意义,与开腹组相比较差异亦无统计学意义。结论胃癌患者腹腔冲洗液CK19表达水平与肿瘤分化程度、TNM分期有关,腹腔镜辅助下胃癌根治术与传统开腹手术一样,并不增加腹腔冲洗液的CK19阳性表达率和术后肿瘤腹膜微转移的危险性。     

腹腔镜胃癌手术腹腔冲洗液中sICAM-1、sCD44v6表达的影响及其意义

目的 探讨腔镜胃癌手术腹腔冲洗液中可溶性细胞间黏附分子(sICAM-1)、可溶性CD44变异体(sCD44v6)浓度的变化及意义,以此评价腔镜胃癌手术对腹膜种植转移的危险性.方法 92例胃癌患者,按照随机数字表法分为对照组和试验组,对照组采用传统开腹手术,试验组采用腹腔镜手术,采用酶联免疫吸附法检测两组患者腹腔冲洗液中sICAM-1、sCD44v6的浓度水平,并比较两组患者的肿瘤细胞阳性率.结果 手术前对照组与试验组sICAM-1、sCD44v6水平差异无统计学意义(t=0.198,P =0.543;t =0.897,P=0.429),手术后两者水平较手术前显著升高,但两组间比较差异无统计学意义(t =0.766,P=0.312;t=1.092,P=0.129).结论 腹腔镜胃癌根治术并不增加腹腔冲洗液中sICAM-1、sCD44v6的表达,没有增加胃癌腹膜种植转移的危险性,值得临床进一步推广研究.     

胃癌术中腹腔冲洗液CK20mRNA、COX-2 mRNA检测及与腹膜微转移的相关性

目的:运用细胞学及实时荧光定量RT-PCR方法对胃癌术中腹腔冲洗液进行检测,以探讨对预测胃癌腹膜微转移的意义.方法:胃癌50例和胃良性病变10例,收集患者术中腹腔冲洗液,用实时荧光定量RT-PCR方法测定腹腔冲洗液中游离细胞的CK20mRNA、COX-2 mRNA表达,同时作冲洗液细胞学检测(PLC).结果:50例胃癌患者腹腔冲洗液中CK20mRNA阳性表达为62.0%(31/50);COX-2 mRNA阳性表达率60.0%(30/50),CK20mRNA、COX-2 mRNA联合检测阳性率为68.0%(34/50),皆高于腹腔冲洗液细胞学28.2%(11/50),CK20mRNA、COX-2 mRNA的阳性率与肿瘤分期、浸润深度、淋巴结转移、浆膜侵犯程度呈正相关.结论:CK20mRNA、COX-2 mRNA实时荧光定量RT-PCR方法检测腹腔微量游离癌细胞较PLC有更高的灵敏度,是一种检测胃癌腹膜微转移的有效方法.     

CO2气腹对结直肠肿瘤细胞腹腔种植影响研究进展

以腹腔镜技术为代表的微创技术在肿瘤外科中的应用得到了飞速的发展,其中腹腔镜结直肠癌根治术被誉为仅次于腹腔镜胆囊切除术的“金标准”术式。在腹腔镜技术应用肿瘤外科传统治疗领域时,腹腔镜手术中CO2气腹对肿瘤细胞的影响一直是人们关注的焦点问题之一,亦是该领域基础研究的热点,现综述CO2气腹对结直肠肿瘤细胞腹腔种植影响的研究进展。     

腹腔冲洗液L3-PP和整合素α5β1检测对胃癌腹膜种植转移预测价值分析

目的:探讨检测腹腔冲洗液中L3-PP和整合素α5β1对于预测胃癌腹膜种植转移的意义。方法:收集96例胃癌患者腹腔冲洗液,用RT-PCR方法测定冲洗液中游离细胞L3-PP、整合素α5β1及CEA mRNA的表达情况,同时作冲洗液细胞学检查(PLC)。结果:腹腔冲洗液中的L3-PP、α5β1和CEA mRNA的阳性率分别为74.0%(71/96)、65.6%(63/96)和62.5%(60/96),均高于腹腔冲洗液细胞学21.9%(21/96),差异均有统计学意义,χ2值分别为52.174、37.333和32.480,P值均<0.01。L3-PP、α5β1及CEA mRNA的阳性率与肿瘤的浸润深度(χ2=7.898,P=0.046;χ2=10.692,P=0.014;χ2=7.897,P=0.048)、TNM分期(χ2=21.960,P<0.01;χ2=29.266,P<0.01;χ2=22.291,P<0.01)、腹膜转移(χ2=13.919,P<0.01;χ2=16.627,P<0.01;χ2=9.089,P<0.01)等密切相关。对CEA-组和CEA+组的生存分析发现差异均有统计学意义(Log-rank test=8.349,P=0.039;Log-rank test=10.864,P=0.012)。结论:用RT-PCR联合检测腹腔冲洗液中L3-PP和整合素α5β1mRNA可作为预测胃癌腹膜种植转移的方法,为临床医生选择合适的治疗方案提供依据。     

CO_2气腹对结直肠肿瘤细胞腹腔种植影响研究进展

以腹腔镜技术为代表的微创技术在肿瘤外科中的应用得到了飞速的发展,其中腹腔镜结直肠癌根治术被誉为仅次于腹腔镜胆囊切除术的“金标准”术式。在腹腔镜技术应用肿瘤外科传统治疗领域时,腹腔镜手术中CO2气腹对肿瘤细胞的影响一直是人们关注的焦点问题之一,亦是该领域基础研究的热点,现综述CO2气腹对结直肠肿瘤细胞腹腔种植影响的研究进展。     

蒸馏水与生理盐水对腹腔肿瘤脱落细胞清除效果的比较

目的观察比较无菌蒸馏水和生理盐水两种冲洗液对腹腔肿瘤脱落细胞的清除效果。方法选择胃癌手术患者200例,随机分成蒸馏水冲洗组(A组)和生理盐水冲洗组(B组),每组各100例,以3000mL蒸馏水或生理盐水冲洗腹腔。分别于手术打开腹腔探查前(手术前)、手术结束腹腔冲洗液冲洗前(冲洗前)和冲洗后收集、检查肿瘤脱落细胞阳性情况。结果手术前肿瘤脱落细胞检查阳性率为10%(20/200),手术结束后肿瘤脱落细胞阳性率为19%(38/200)。A组冲洗后肿瘤脱落细胞检查阳性率由20%(20/100)减少为9%(9/100),B组冲洗后肿瘤脱落细胞阳性率由18%(18/100)减为7%(7/100),均P<0.05,差异均有统计学意义。A、B两组冲洗有效率(转阴例数/阳性例数)分别为55%(11/20)和61%(11/18),差异无统计学意义(P>0.05)。结论手术可以引起肿瘤脱落细胞的增加,腹腔冲洗能够有效清除腹腔肿瘤脱落细胞。无菌生理盐水可以替代蒸馏水用于胃癌手术后腹腔冲洗。     

胃癌术中腹腔冲洗液CK20mRNA、COX-2 mRNA检测及与腹膜微转移的相关性

目的：运用细胞学及实时荧光定量RT-PCR方法对胃癌术中腹腔冲洗液进行检测,以探讨对预测胃癌腹膜微转移的意义。方法：胃癌50例和胃良性病变10例,收集患者术中腹腔冲洗液,用实时荧光定量RT-PCR方法测定腹腔冲洗液中游离细胞的CK20mRNA、COX-2 mRNA表达,同时作冲洗液细胞学检测（PLC）。结果：50例胃癌患者腹腔冲洗液中CK20mRNA阳性表达为62.0%（31/50）;COX-2 mRNA阳性表达率60.0%（30/50）,CK20mRNA、COX-2 mRNA联合检测阳性率为68.0%（34/50）,皆高于腹腔冲洗液细胞学28.2%（11/50）,CK20mRNA、COX-2 mRNA的阳性率与肿瘤分期、浸润深度、淋巴结转移、浆膜侵犯程度呈正相关。结论：CK20mRNA、COX-2 mRNA实时荧光定量RT-PCR方法检测腹腔微量游离癌细胞较PLC有更高的灵敏度,是一种检测胃癌腹膜微转移的有效方法。     

Prevention of peritoneal dissemination after colorectal surgery--significance of MMC administration in abdominal cavity

Peritoneal lavage cytology during surgery was done in 287 patients with colorectal cancer. Positive cytologic specimens were obtained from 21 patients. Of 13 patients who had free cancer cells in peritoneal cavity but no peritoneal dissemination macroscopically, 5 patients received intraperitoneal administration of 20 mg of MMC dissolved in 500 ml of saline. Peritoneal dissemination occurred in 0/5 (0%) of the MMC treated group and in 5/8 (63%) of the untreated group (p less than 0.05). Our results indicate that intraperitoneal administration of MMC (20 mg) is an effective method of preventing peritoneal dissemination after resection of colorectal cancer.     

腹腔镜行结直肠癌根治术14例

[目的]探讨腹腔镜结直肠癌根治术的可行性及临床疗效.[方法]自2004年3月～9月,共施行腹腔镜结直肠癌根治术14例,其中Dixon手术4例,Miles手术6例,右半结肠切除术3例,左半结肠切除术1例.[结果]其中13例手术成功,1例中转开腹.手术平均时间240min(180～480min),平均出血量100ml(20～500ml),术后平均住院时间9d(7～15d).无术后并发症,无腹壁戳口的癌种植及肿瘤复发.[结论]腹腔镜结直肠癌根治术具有创伤小,术后并发症少,肠功能恢复快及平均住院时间缩短等优点.     

CO2气腹促进胃肠肿瘤侵袭转移的研究进展

 【摘要】 目的：总结国内外关于CO2气腹与胃肠肿瘤侵袭转移的研究进展。 方法：应用Medline、PubMed、CNKI期刊全文数据库检索系统，以“CO2气腹、肿瘤转移、腹腔镜手术”等为关键词，检索1997-01—2010-02的相关文献。纳入标准：1）CO2气腹对腹腔微环境的影响；2）CO2气腹机械压力的影响；3）CO2气腹与细胞黏附分子表达的关系；4）CO2气腹与肿瘤细胞相关分子表达的关系。根据纳入标准，最后纳入分析24篇文献。 结果：C02气腹通过改变腹腔微环境、机体免疫力、气腹的机械压力和肿瘤细胞生物学行为等方面，促进了术后戳孔及腹腔内肿瘤种植转移。 结论：CO2气腹促进了胃肠肿瘤侵袭转移，所以要采取规范术前检查，严格掌握腹腔镜胃肠道恶性肿瘤手术的指征，手术时尽量减小气腹压力，缩短手术时间，用He气代替CO2气腹或使用免气腹的腹腔镜技术等有效措施来降低肿瘤种植转移的风险。     

Long-term prognostic value of conventional peritoneal cytology after curative resection for colorectal carcinoma

BACKGROUND: This study was undertaken to evaluate the long-term prognostic significance of conventional peritoneal cytology in patients with advanced colorectal carcinoma after curative resection. METHODS: A review was performed of 189 patients who underwent curative resection for pT3/T4 carcinoma of the colon and upper/middle rectum between March 1987 and December 1991. Patient outcomes were reviewed retrospectively. Peritoneal cytology was performed before manipulation of the tumor. Intraoperatively, 50 ml of saline were instilled and 20 ml were reaspirated for cytology. In all patients, Papanicolaou and Giemsa stainings were performed to detect intraperitoneal free tumor cells. RESULTS: The median follow-up was 103 months. Malignant cells were identified in peritoneal washings from 11 patients (5.8%). Of the 11 patients with positive cytology, six (54.5%) developed recurrence and peritoneal recurrence was observed in four (36.4%). In contrast, of the 178 patients with negative cytology, 46 (25.8%) developed recurrence and peritoneal recurrence was observed in four (2.2%). The peritoneal recurrence rate was significantly increased (P = 0.0004) in the patients with positive cytology. The cancer-specific 10-year survival rates for the patients with positive and negative cytology were 45.5 and 80.3%, respectively (P = 0.0051). Multivariate analysis (Cox proportional hazard model) revealed that peritoneal cytology (positive: P = 0.0256) and lymph node metastasis (pN2: P = 0.0004) were independent predictors of cancer-specific survival. CONCLUSION: Conventional peritoneal cytology serves as a new prognostic marker after curative resection in patients with advanced colorectal carcinoma. It appears to be a useful diagnostic procedure for predicting recurrence, especially peritoneal recurrence.     

Hyperthermic chemotherapy intra-abdominal laparoscopic approach: development of a laparoscopic model using CO2 recirculation system and clinical translation in peritoneal carcinomatosis

Introduction: Hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for peritoneal carcinomatosis (PC). Laparoscopic surgery is performed in the treatment of colorectal and appendiceal cancer, and PC from diverse origin in selected patients. HIPEC management by laparoscopic approach after cytoreductive surgery (CRS) completed locoregional treatment of PC, and may be feasible and safe after appropriate patient selection.

Objective: Development of an experimental model of HIPEC by laparoscopic approach, with CO₂ recirculation. Clinical translation in two patients with PC and low peritoneal cancer index.

Material and methods: We performed CRS in a porcine model of 5 pigs (35–38?kg) by laparoscopic approach. Laparoscopic HIPEC by CO₂ recirculation system was performed; laparoscopic access was used for catheter input and output placement (Paclitaxel 175?mg/m² for 60?min at 42?°C). The experimental variables were: blood gases, haemodynamic and intra-abdominal and central temperature. Clinical model application was performed in three cases with PC from colorectal origin.

Results: No statistically significant differences was found in blood gases, haemodynamic or temperature in the experimental study. In clinical study, there were no technical complications during laparoscopic-HIPEC approach, and we observed no changes in haemodynamic variables during the procedure.

Conclusions: CRS and HIPEC laparoscopic model by CO₂ recirculation system is safe and feasible technique in selected patients, that include low PC index, local and accessible tumour recurrences or high-risk of PC tumours.     

The prognostic value of positive peritoneal lavage cytology and the prevention of peritoneal dissemination after colorectal surgery

Peritoneal washing cytology during surgery was done in 745 patients with colorectal cancer. The positive washing cytology rate was 49/745 (6.6%). The peritoneal recurrence rates were 12/22 (54.5%) and 8/682 (1.3%) among patients with positive and negative peritoneal washing, respectively (p < 0.0001). The 5-year survival rate is 89.4% of the patients with positive cytology and 38.2% with negative cytology. The patients with positive cytology have a significantly lower survival rate than the negative one (p < 0.0001). Eleven patients of the positive cytology received intraperitoneal administration of MMC. Peritoneal dissemination occurred in 3/11 (27.3%) of the MMC treated group and 9/11 (81.8%) in the untreated group (p = 0.030). Our results indicated that intraperitoneal administration of MMC was an effective method of preventing peritoneal dissemination after resection of colorectal cancer.     

Recent advances in minimally invasive colorectal cancer surgery

Laparoscopy has improved surgical treatment of various diseases due to its limited surgical trauma and has developed as an interesting therapeutic alternative for the resection of colorectal cancer. Despite numerous clinical advantages (faster recovery, less pain, fewer wound and systemic complications, faster return to work) the laparoscopic approach to colorectal cancer therapy has also resulted in unusual complications, i.e. ureteral and bladder injury which are rarely observed with open laparotomy. Moreover, pneumothorax, cardiac arrhythmia, impaired venous return, venous thrombosis as well as peripheral nerve injury have been associated with the increased intraabdominal pressure as well as patient's positioning during surgery. Furthermore, undetected small bowel injury caused by the grasping or cauterizing instruments may occur with laparoscopic surgery. In contrast to procedures performed for nonmalignant conditions, the benefits of laparoscopic resection of colorectal cancer must be weighed against the potential for poorer long-term outcomes of cancer patients that still has not been completely ruled out. In laparoscopic colorectal cancer surgery, several important cancer control issues still are being evaluated, i.e. the extent of lymph node dissection, tumor implantation at port sites, adequacy of intraperitoneal staging as well as the distance between tumor site and resection margins. For the time being it can be assumed that there is no significant difference in lymph node harvest between laparoscopic and open colorectal cancer surgery if oncological principles of resection are followed. As far as the issue of port site recurrence is concerned, it appears to be less prevalent than first thought (range 0-2.5%), and the incidence apparently corresponds with wound recurrence rates observed after open procedures. Short-term (3-5 years) survival rates have been published by a number of investigators, and survival rates after laparoscopic surgery appears to compare well with data collected after conventional surgery for colorectal cancer. However, long-term results of prospective randomized trials are not available. The data published so far indicate that the oncological results of laparoscopic surgery compare well with the results of the conventional open approach. Nonetheless, the limited information available from prospective studies leads us to propose that minimally invasive surgery for colorectal cancer surgery should only be performed within prospective trials.     

Current status on laparoscopic surgery for colorectal cancer

The current status of laparoscopic surgery and its indications for colorectal cancer are described. According to multi-institutional registry by the Japanese Society of Endoscopic Surgeons, the number of laparoscopic surgeries for advanced colorectal cancer has been increasing during the last couple years. The short- and long-term results of laparoscopic surgery for pT1 or pT2 colon cancer are favourable, and laparoscopic surgery could be a standard procedure for such cases. However, the indications for pT3/T4 cancer remain controversial due to limited length of follow-up. A multi-centre randomised controlled trial (RCT) comparing open with laparoscopic surgery for advanced (T3/T4) cancer is to start in autumn this year. Laparoscopic surgery for such cases should be confined to trial cases. Laparoscopic surgery for rectal cancer is feasible; however, it is associated with higher anastomotic leak rates. Issues on education and medical costs need to be resolved.     

Modified approach for extraperitoneal laparoscopic staging for locally advanced cervical cancer

Describe a modified approach to the technique for staging laparoscopic extraperitoneal aortic and common iliac lymph node dissection for locally advanced cervical cancer.Retrospective, nonrandomized clinical study. (Canadian Task Force classification II-2), setting in an acute-care, teaching hospital. Thirty-six patients with locally advanced cervical cancer underwent laparoscopic surgical staging via extraperitoneal approach with the conventional or the modified technique from August 2001 through September 2004. Clinical outcomes in 23 patients who were operated on with the conventional technique using index finger for first trocar entrance; 12 patients with the modified technique using direct trocar entrance, were compared. One patient was excluded due to peritoneal carcinomatosis. Technique, baseline characteristics, histopathologic variables and surgical outcome were measured. There were no significant differences in patients basal characteristics on comparative analysis between conventional and modified technique. With our proposed modified technique, we obtained a reduced surgical procedure duration and blood loss. The proposed modified surgical technique offers some advantages, is an easier approach because the parietal pelvic peritoneum is elastic and this helps to avoid its disruption at time of trocar insertion, size of incision is shorter, we achieved no CO2 leak through the trocar orifice, and wound suture is fast and simple.