直肠癌手术后的局部复发：完整切除直肠系膜的重要性

本介绍了直肠系膜完整切除术与传统的直肠癌切除术的不同处，并建议推广直肠系膜完整切除术。     

直肠癌手术后的局部复发:完整切除直肠系膜的重要性

本文介绍了直肠系膜完整切除术与传统的直肠癌切除术的不同处,并建议推广直肠系膜完整切除术。     

TME术治疗直肠癌15例疗效分析

近年来-直肠癌的手术治疗虽然取得较成熟的经验．但患者生存率无明显提高,其主要原因是直肠癌根治性切除后局部复发率较高。2002～2004年,我院采用全直肠系膜切除、保留肛门低位吻合(TME)手术治疗直肠癌患者15例,并与既往采用传统术式的患者进行对比分析。现报告如下。     

直肠癌直肠系膜中CK20的表达及临床意义

目的:通过对直肠癌直肠系膜中CK20表达的检测,探讨直肠癌区域转移及微转移的规律,为临床直肠癌术式的选择及实施提供依据.方法:应用RT-PCR方法对直肠癌TME术后50例患者的肿瘤组织、直肠系膜及盆筋膜壁层中CK20的表达进行检测,同时分析CK20的表达与病理特征的关系.结果:正常对照组织中无阳性表达,直肠癌组织中CK20高表达(78%),肿瘤平面和直肠系膜近端可表达,直肠系膜远端(20%)和盆筋膜壁层表达(6.38%)程度较低.CK20表达与肿瘤形态、TNM分期、浸润深度有关,而与肿瘤直径、肿瘤分化程度、原发部位无关.结论:直肠癌患者外科治疗时常规行TME是必要的.     

Twist1,MMP-2和MMP-9在结直肠癌组织中的表达及意义

目的:研究Twist1、MMP-2和MMP-9蛋白在结直肠癌组织中的表达及其相互关系.方法:建立组织微阵列平台,应用免疫组织化学方法检测92例结直肠癌组织Twist1、MMP-2和MMP-9蛋白的表达情况.结果:结直肠癌中Twist1的表达率为64.1%,MMP-2和MMP-9阳性率分别为66.3%和67.4%;Twi...     

全直肠系膜切除术治疗老年中低位直肠癌的疗效

目的探讨腹腔镜与开腹直肠系膜切除术治疗老年中低位直肠癌患者的临床疗效和安全性。方法选取2010年1月至2012年12月来该院就诊的120例60岁以上中低位直肠癌患者作为研究对象,根据入院顺序随机分为观察组和对照组,对照组按照传统操作方法进行开腹全直肠系膜切除术;观察组接受腹腔镜全直肠系膜切除术。结果观察组术中出血量〔(85.8±27.3)ml〕少于对照组〔(120.2±32.4)ml〕(U=6.3,P<0.01);观察组术后镇痛时间、术后排气时间、留置导尿管时间及术后住院时间分别为(2.2±0.7)d、(47.2±13.2)h、(4.5±1.3)d和(9.7±3.4)d,均短于对照组的(4.0±1.1)d、(96.7±26.5)h、(7.0±2.9)d和(13.9±5.8)d(U=10.7、13.0、6.1、4.8,P<0.01)。观察组标本长度、肿瘤距下切缘距离和淋巴结清扫数目分别为(18.3±4.2)cm、(3.7±1.8)cm和(20.4±5.3)个,对照组分别为(19.8±5.2)cm、(3.4±1.6)cm和(21.7±6.2)个,两组间差异无统计学意义(U=1.7、1.0、1.2,P>0.05)。结论腹腔镜与开腹直肠系膜切除术治疗老年中低位直肠癌患者的临床疗效相当,具有创伤小、住院时间短、出血量少、减少疼痛等优势。     

MMP-7在大肠上皮不同病变中的表达及意义

目的 探讨MMP-7(基质溶解素)在结直肠上皮病变的恶性转变中的表达及意义。方法用免疫组化方法检测37例结直肠癌，23例结直肠腺瘤、10例非肿瘤性息肉及10例正常结直肠组织手术标本的石蜡切片中MMP-7的表达。结果 37例结直肠癌切片中25例MMP-7为阳性表达(阳性表达率67．6％)；23例腺瘤切片中，15例表达阳性，阳性表达率65．2％；10例非肿瘤性息肉中，1例阳性表达，阳性率10％；10例正常结直肠上皮对照均未见表达。结论MMP-7在结直肠上皮病变的恶性变中逐渐增强，在结直肠癌的发生发展中起重要作用。     

直肠癌NRP-1、VEGF-C的表达与直肠系膜淋巴结转移的关系

目的探讨观察神经纤毛蛋白-1(NRP-1)、血管内皮生长因子-C(VEGF-C)在直肠癌组织中的表达与直肠系膜淋巴结转移的关系。方法采用免疫组织化学S-P法检测40例直肠癌组织中NRP-1、VEGF-C的表达,结合其肿瘤生物学特性及直肠系膜淋巴结转移情况进行分析。结果 (1)直肠癌组织中NRP-1、VEGF-C的高表达率分别为67.5%、62.5%;(2)NRP-1、VEGF-C在直肠癌组织中的表达与直肠系膜淋巴结转移及肿瘤的分期相关,与性别、年龄、肿瘤大小、术前CEA水平、侵犯肠管周径、浸润深度、分化程度不相关;(3)NRP-1表达与VEGF-C表达呈正相关(r=0.345,P0.05),表达一致率为70.0%,两者均为高表达的患者直肠系膜淋巴结转移阳性率(70.0%)远高于两者均为低表达者(12.5%)(P0.05)。结论 NRP-1、VEGF-C在人直肠癌中共同表达,其过度表达与淋巴管增生和扩张、促进癌细胞的淋巴转移有关。     

全直肠系膜切除术直肠系膜CD44v6检测47例

目的:通过检测CD44v6在的直肠癌及直肠系膜内的表达,从分子水平证明全直肠系膜切除术治疗直肠癌的科学性.方法:行全直肠系膜切除术的直肠癌患者47例于直肠癌组织、直肠系膜(距肿瘤下缘2cm)、直肠系膜远端切缘(距肿瘤下缘5cm)取病理标本,采用免疫组化SP法对标本进行CD44v6检测.结果:直肠癌组织中CD44v6高度表达,正常直肠系膜组织中CD44v6的阳性表达率(0/20)与直肠系膜(距肿瘤下缘2cm)的CD44v6的阳性表达率(15/47)存在显著差异(P<0.01),而与直肠系膜远端切缘(4/47)无差异(P>0.05).同时发现直肠癌中CD44v6的阳性表达率与肿瘤的淋巴转移(有vs无:88.5%vs61.9%,P<0.05)和临床分期(DukesC-DvsA-B:88.5%vs61.9%,P<0.05)有关.结论:对直肠癌组织进行CD44v6蛋白的检测,有助于评估直肠系膜局部病变程度;肿瘤远端直肠系膜切除长度至少比肿瘤平面多5cm.     

Functional results after radiochemotherapy and total mesorectal excision for rectal cancer

Background and purpose The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year after surgery. Materials and methods We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan–Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis. Results Median evacuation score was 16.12 ± 5.12 (range 0–28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 ± 4.79 (range 0–20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan–Kettering score. Conclusions The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.     

经腹腔镜全直肠系膜切除术治疗低位直肠癌

目的探讨经腹腔镜全直肠系膜切除术(TME)治疗低位直肠癌的可行性。方法经腹腔镜对14例低位直肠癌患者实施TME。结果14例患者手术顺利。手术时间120～240分钟，平均180分钟；术中出血30～180ml，平均50ml；术后1～2天恢复胃肠功能并下床活动；住院5～14天，平均6天。术后6例应用镇痛剂，无死亡者，无并发症发生。结论经腹腔镜TME治疗低位直肠癌安全可行，且创伤小、术后疼痛轻、恢复快。     

腹腔镜直肠全系膜切除术治疗中、低位直肠癌的临床研究

目的探讨腹腔镜直肠全系膜切除术(TME)治疗中、低位直肠癌的临床疗效。方法选择中、低位直肠癌患者96例,随机分为观察组与对照组各48例,观察组在腹腔镜下行TEM术,对照组则行开腹TME术,对比两组患者临床疗效。结果观察组术后肛门排气时间、住院时间及手术切口长度、术中出血量、术后VAS疼痛评分、围术期并发症发生率、术后性功能及泌尿功能障碍发生率等方面均显著优于对照组(P0.05),而手术时间、保肛率、肿瘤转移及复发率差异均无统计学意义(P0.05)。结论腹腔镜直肠全系膜切除术治疗中、低位直肠癌疗效确切且安全可靠,可在达到传统开腹手术疗效基础上降低并发症发生率。     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumors of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank,P=0.01 andP=0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank,P=0.38). CONCLUSIONS: When a mesorectal excision is performed, circumferential margin involvement is more an indicator of advanced disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.Research was performed at the General Infirmary at Leeds, Leeds, United Kingdom.     

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

AIM： To investigate the feasibility and safety of monopolar electrocautery shovel （ES） in laparoscopic total mesorectal excision （TME） with anal sphincter preservation for rectal cancer in order to reduce the cost of the laparoscopic operation, and to compare ES with the ultrasonically activated scalpel （US）.
METHODS： Forty patients with rectal cancer, who underwent laparoscopic TME with anal sphincter preservation from June 2005 to June 2007, were randomly divided into ultrasonic scalpel group and monopolar ES group, prospectively. White blood cells （WBC） were measured before and after operation, operative time, blood loss, pelvic volume of drainage, time of anal exhaust, visual analogue scales （VAS） and surgery-related complications were recorded. RESULTS： All the operations were successful; no one was converted to open procedure. No significant differences were observed in terms of preoperative and postoperative d I and d 3 WBC counts （P = 0.493, P = 0.375, P = 0.559）, operation time （P = 0.235）, blood loss （P = 0.296）, anal exhaust time （P = 0.431）, pelvic drainage volume and VAS in postoperative d 1 （P = 0.431, P = 0.426） and d 3 （P = 0.844, P = 0.617） between ES group and US group. The occurrence of surgery-related complications such as anastomotic leakage and wound infection was the same in the two groups.
CONCLUSION： ES is a safe and feasible tool as same as US used in laparoscopic TME with anal sphincter preservation for rectal cancer on the basis of the skillful laparoscopic technique and the complete understanding of laparoscopic pelvic anatomy. Application of ES can not only reduce the operation costs but also benefit the popularization of laparoscopic operation for rectal cancer patients.     

Laparoscopic anterior resection and total mesorectal excision for rectal cancer: a prospective nonrandomized study

Background The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis. Materials and methods Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity. Results A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12–90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis. Conclusion In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.     

Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer

BackgroundAn altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer.AimThe aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry.MethodsThirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2).ResultsResting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p = 0.007). Surgery determined a significantly decrease of the resting pressure (p = 0.001), of the maximum squeeze pressure (p = 0.001) and of the volume threshold for urgency (p = 0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively.ConclusionsCRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.     

Prospective randomised trial comparing ileocaecal interposition and colon-J-pouch as rectal replacement after total mesorectal excision

Background Ileocaecal interposition (ICI) is a technique of rectal replacement after total mesorectal excision (TME), but the method has never been evaluated in a randomised fashion. We performed a randomised, controlled trial to compare ICI and colon-J-pouch (CJP) for rectal replacements after TME for rectal cancer. Materials and methods Fifteen patients were enrolled into each treatment group of the trial according to the protocol. Follow-up evaluations were performed 3 months and 1 year after ileostomy closure and at a mean of 5 years after initial surgery. Results Similar results between the groups were found for incontinence, urgency, constipation and quality of life at all follow-ups. The frequency of defecation was slightly lower in the CJP group at 3 months [3 (2–6) vs 5 (2–11) (p=0.043)] and at 1 year [3 (2–5) vs 5 (2–8) (p=0.034)]. However, this difference lost significance if patients who had postoperative radiotherapy were excluded from the analysis. Four out of the 15 patients treated with ICI experienced bowel obstruction, which required open surgery in two, endoscopic dilatation in one or maintenance of the ileostomy in one patient. None of the patients treated with CJP had similar complications. Conclusions ICI and CJP reconstruction result in a similar functional outcome and quality of life. As ICI did not show any benefit over CJP and tended to result in a higher frequency of defecation, it should not be used as a first choice treatment. In addition, ICI was associated with significant complications after radiotherapy. Therefore, it must not be used if postoperative radiochemotheray is intended.     

直肠癌周围黏膜下注射微粒子碳在TME术中的应用

目的:探讨微粒子碳在直肠癌全直肠系膜切除术(TME)中的应用价值.方法:对45例直肠癌患者术前3d在直肠镜癌周黏膜下注射微粒子碳,行全直肠系膜切除术.并与常规TME手术组进行比较.所有切除淋巴结行RT-PCR法检测MMP-7mRNA的表达以确定此淋巴结有无转移.结果:实验组共清除淋巴结1056枚,平均23.5枚.对照组清除淋巴结723枚,平均16.1枚,两组比较有统计学意义(t=7.3733,P<0.05).实验组清除转移淋巴结403枚,平均9.0枚.对照组281枚,平均6.2枚,差别具有统计学意义(t=5.4235,P<0.05).实验组黑染淋巴结共680枚,其中转移淋巴结322枚,两者具有线性相关关系(r=0.3468,P<0.05).结论:黏膜下注射微粒子碳应用于直肠癌TME术可增加术中转移淋巴结的清除.直肠癌淋巴结墨染与转移有关.