努力提高直肠癌外科治疗水平

Make efforts to elevate the level of surgical treatment of rectal cancer

对我国直肠癌外科治疗发展现状及如何提高外科治疗水平进行了全面的阐述，并对外科治疗相关问题进行了初步探讨。作者认为直肠癌早期发现、早期诊断、早期治疗是提高术后5年生存率的关键，强调对直肠癌高发区域进行普查，加大对高危人群的监测，及时发现早期癌。纤维结肠镜、钡灌肠造影、B超、CT等检查诊断率可达95％～100％，肛门指诊检查可发现约70％的中下段直肠癌。作者强调正确合理选择术式是提高手术疗效的重要前提。选择保肛术式如Parks结肠肛管吻合术式、吻合器吻合保肛术式、腹腔镜保肛术式、保留盆腔自主神经保肛术式、LSY套入式结肠直肠黏膜吻合保肛术式等，都必须遵循TME原则，既要保证癌肿切除的根治性和淋巴结清除的彻底性，又要保留正常肛门排便功能。因此，术式应根据直肠癌的部位、生物学特性、临床分期，进行个体化选择。保肛术式已占直肠癌手术的70％以上，其术后局部复发和5年生存率与Miles手术相似，但患者生活质量明显提高，已成为目前直肠癌治疗首选的术式。作者强调对直肠癌术后局部复发和转移的综合治疗是提高生存率的重要环节。单一外科手术治疗直肠癌术后5年生存率目前尚无明显提高。应重视术后辅以化疗、放疗、免疫等综合治疗。强调术后早期诊断、早期治疗复发和转移癌，原则是对局部复发癌灶和肝转移癌灶积极行再手术切除，对无法切除者先行放、化疗，肿块缩小后行再手术切除，其5年生存率可达40％，对肝转移癌灶手术切除困难者，如原发灶无局部复发且无淋巴结转移，肝移植是惟一选择。这些积极有效的综合治疗可明显改善预后并提高5生存率。

With a comprehensive elaboration of the development of the level of surgical treatment of the rectal cancer, with a preliminarily analysis of the related questions in the surgery, it is the assertion of the author that early discovery, diagnosis and treatment are the key points in raising the five-year survival rate. Constant surveillance in the region of prevalence, constant survey and close inspection of high risk groups are much more important to detect early stage cancers in time. Diagnostic rates can reach 95%-100% by fibercoloscope, barium enema, B-ultrasound and CT, etc. About 70% of rectal cancers situated at middle and desending colon can be found by anal palpation. It is important to select correct and appropriate operative modality to raise the treatment efficacy. We should follow the TME principle to select which sphincter-preserving operation should be done： Parks operation, anastomat operation, peritoneoscope operation, autonomic nerve of pelvic cavity preservation operation, or LSY operation, etc. So that not only a radical cure of the tumor is ensured, also the lymph nodes are removed, and to ensure to preserve the normal defecation function. Thus, we should individualize operation according to the site, biological character, and clinical stages. Sphincter-preserving operation accounts for above 70% of resection of rectal cancer, and its local recurrence and five-year survival rate is similar to that of Mile＇s operation, but the patient＇s life quality is obviously raised. Recently, phincter-preserving operation has been the first choice for resection of the rectal cancer. The author emphasizes that the combined therapy to local recurrence and metastasis is important to raise five-year survival rate. Operation only is insufficient, we should pay attention to combined therapy, such as pro-operative chemotherapy, radiotherapy and irnmunotherapy. We should pay more attention to detecting, diagnosing and treating the local recurrence and metastasis in early stage after operation, and resect them aggressively. When they cannot be resected, give chemotherapy and radiotherapy first, when it shrinks, it can be resected again. The five-year survival rate can reach 40%. As it is difficult to resect the liver metastasis, so when the primary cancer does not recur, liver transplantation is the first choice. Obvionsly, to raise the rate of a prolonged survival, combined therapy including chemotherapy, radiotherapy, irnrnunotherapy and biotherapy should be instituted besides surgical excision.