直肠癌行TME术癌组织及周围组织CEA检测的意义

目的:对直肠癌及其周围组织进行CEA检测,证明全直肠系膜切除术(TME)治疗直肠癌的科学性.方法:行TME手术的直肠癌患者52例直肠癌组织、直肠系膜远端、环周切缘、盆筋膜壁层取病理标本采用免疫组化S-P法对标本进行CEA检测,应用SPSS软件进行统计学分析.结果:直肠癌组织中CEA高度表达(47/52),肿瘤相对的盆筋膜脏层(环周切缘)中有CEA存在(8/52),在直肠系膜远端及盆筋膜壁层标本中未见CEA表达.结论:直肠癌组织中CEA高度表达,检测直肠癌及周围组织中CEA的表达情况为TME手术的科学性提供理论依据.

单孔腹腔镜设备在经肛微创手术中的应用进展

随着对直肠肿瘤早期诊断水平的提高以及病理和生物学特性认识的深入，直肠肿瘤局部切除在临床上的应用渐趋广泛。单孔腹腔镜设备运用于经肛手术，是借鉴经肛门内镜下微创手术（ Transanal Endoscopic Microsurgery，TEM）理念，将TEM中特制硬性直肠镜替换为软性单孔多套管设备，运用常规腹腔镜器械及标准气腹装置，实现经肛门的直肠腔内、腔外操作。既往文献中称之为“Transanal Minimally Invasive Surgery，TAMIS”。该技术保留了腹腔镜、内镜技术的优点，相比TEM具有设备费用低、学习曲线短、肛门括约肌损伤小等优势。作为新技术，TAMIS主要报道用于直肠良性肿瘤及早期低危恶性肿瘤的局部切除。此外，TAMIS平台在经肛全直肠系膜切除（ Transanal Total Mesorectal Excision， TTME）和机器人经肛微创手术（ Robic-Transanal Minimally Invasive Surgery，Robic-TAMIS）中有较大应用潜力，有望成为结直肠外科领域主要术式之一。本文就该技术基本概况及临床应用作一综述。

直肠癌根治-腔镜下TME:现状与评价

迄今,手术切除仍然是治疗直肠癌的主要手段.近年大宗病例研究表明,在诸多根治术式中,全直肠系膜切除术(total mesorectal excision,TME)在降低局部复发率、提高5年生存率、增加保肛率以及改善病人生活质量等方面正在起着划时代的推动作用,已为越来越多的结直肠外科医生作为直肠癌治疗的金标准.随着TME理念的深入和腹腔镜技术的发展,腹腔镜全直肠系膜切除术(laparoscopic total mesorectal excision,LTME)、低位、超低位、结肠-肛管吻合术等直肠癌微创术式正在兴起,前瞻性临床研究的初步结果已显示出该术式具有良好的应用前景,但其远期疗效还有待大宗病例随访资料客观评估.当前,腹腔镜TME微创化保肛术式主要面临两大方面的挑战:(1)要面对开腹TME及TME保肛术式的同样问题.(2)要面对腔镜下TME及TME保肛术式的特殊手术操作过程而产生的争议.这些前沿的学术争议及思考加快了直肠癌外科的发展进程.

1 SummaryThe 5-year-survival rates of surgically treated patients are varying and depend on UICC stages/substages with remarkable variations in between published reports, surgical hospital units, individual surgeons, and continents. These variations may be due to surgical techniques, training status, hospital and individual case volume, but also on referral patterns, and statistical evaluation methods. Survival time and cure rates are significantly improved by modern adjuvant chemotherapy in colon cancers UICC Ⅲ and in substages of UICC Ⅱ (e.g. UICC Ⅱ B) by 5%-16%, and adjuvant radiochemotherapy in rectal cancer by 10%-14% when compared to surgical controls. In three modern colon cancer trials standard adjuvant chemotherapy was further improved by increasing the survival rates, e.g. from 59% to 71% in stage Ⅲ and IIB patients. In rectal cancer neoadjuvant radio(chemo)therapy decreases local relapse rates vs. postoperative adjuvant radio(chemo)therapy. Since surgery in rectal cancer has also been significantly improved by total mesorectal excision (TME) and better surgical training, the indications and methods for multimodal therapy have changed from UICC Ⅱ+Ⅲ to more individual criteria. Molecular and genetic factors, such as thymidylate synthase (TS), microsatellite instability (MSI) or loss of chromosome 18q/DCC might have an independent impact on prognosis in the spontaneous course, but could also help to individually select colon and rectal cancer patients and treatment protocols for multimodal therapy. Thus, surgery and multimodal therapy has become very complex, needs regularly be updated in competent reviews, and should be conducted in specialized centers of multi-and interdisciplinary excellence.

经肛全直肠系膜切除术治疗直肠癌的优点和局限

在美国,结直肠癌的发病率和死亡率分别位于恶性肿瘤的第4位和第2位,其中直肠癌约占结直肠癌的1/3.对于可切除直肠癌而言,全直肠系膜切除术(total mesorectal excision,TME)仍然是手术的金标准.但骨盆狭窄、新辅助治疗后肿瘤触摸不清、照明及术野显露困难、远切缘确定困难及吻合器无法放置等解剖、技术和患者方面的因素,会使开腹及腹腔镜TME手术困难.在此环境下,"自下而上"的TME手术 ——经肛全直肠系膜切除手术(taTME)应运而生.taTME手术结合了腹腔镜及机器人手术的微创化、高清内镜平台的可视化及功能化以及经肛经腹直肠癌TME手术的优势.2010—2013年期间,Lacy等研究者陆续系列报道了taTME手术的实施情况,将该术式推向了高潮.

螺旋水刀在直肠癌全直肠系膜切除术中的应用

目的 探讨螺旋水刀在直肠癌全直肠系膜切除术中应用的疗效.方法 将89例直肠癌手术患者分为两组,均行全直肠系膜切除术.一组术中应用螺旋水刀进行游离盆腔,另一组使用电刀及常规方法游离盆腔.比较两组在手术时间、术中出血、住院天数、术后局部复发率、术后排尿功能紊乱和性功能障碍等方面的差别.结果 两组在出血量,术后排尿功能紊乱及性功能障碍发生率的差异均有统计学意义(P＜0.05),而在住院天数、手术时问、术后肿瘤局部复发率,差异无统计学意义(P＞0.05).结论 应用螺旋水刀行直肠癌全直肠系膜切除术,对于降低术后暂时性排尿功能紊乱和性功能障碍方面明显优于电刀及常规方法游离组.关犍词:螺旋水刀;直肠肿瘤;全直肠系膜切除术