肠梗阻导管治疗低位癌性肠梗阻结肠冲洗的护理研究

目的:探讨肠梗阻导管治疗低位癌性肠梗阻结肠冲洗的临床疗效。方法:将48例肠梗阻导管治疗低位癌性肠梗阻患者随机分为A,B组各24例。A组经肠梗阻导管注入石蜡油保留后,再滴注温盐水无间歇性结肠冲洗;B组经肠梗阻导管滴注温盐水行间歇性结肠冲洗,观察并比较两组患者的腹痛腹胀缓解时间、腹围缩小速度、每日引流液量、冲洗天数及临床疗效。结果:A组腹痛腹胀缓解时间、冲洗天数少于B组(P<0.05),腹围缩小速度、每日引流液量高于B组(P<0.05),治疗效果优于B组(P<0.05)。结论:采用石蜡油保留灌肠后无间歇性温盐水结肠冲洗方案能迅速有效缓解肠梗阻症状,为结直肠癌一期根治手术奠定基础,是肠梗阻导管治疗低位癌性肠梗阻理想的结肠冲洗方式。

肠梗阻导管治疗低位癌性肠梗阻的综合护理措施及临床效果

目的探讨肠梗阻导管治疗低位癌性肠梗阻的护理措施,并分析其临床效果。方法选择恶性肿瘤所致低位肠梗阻患者80例,随机分为2组,各40例,观察组实施本研究护理方法包括(患者病情的观察护理、导管的固定护理、保持导管引流通畅及可能相关并发症的护理),对照组实施常规护理,如心理护理、定期注药等处理,观察1周后,比较2组患者预后情况,并统计2组患者治疗后肛门排气、肠鸣音恢复及引流正常时间。结果观察组发生腹胀缓解和腹围缩小的比例显著低于对照组(P<0.05),而因症状无缓解需手术治疗的比例显著少于对照组(P<0.05);治疗后,观察组肛门排气时间显著早于对照组(P<0.05),肠鸣音恢复时间显著早于对照组(P<0.05),引流正常时间显著早于对照组(P<0.05)。结论做好肠梗阻导管治疗低位癌性肠梗阻患者的护理,能有效缓解患者临床症状,改善治疗效果,值得临床重视。

TME技术在中、低位直肠癌手术中的应用价值

目的:探讨TME技术在中、低位直肠癌手术中的应用。方法:回顾性分析采用TME技术治疗37例直肠中、低位癌病人资料,评价采用TME技术的治疗结果及与传统手术技术的区别。结果:37例病人中,AR 3例、L AR 2 5例、APR 7例、Parks 2例,吻合口瘘2例、口狭窄1例、直肠阴道瘘1例、骶前出血1例,保肛率81%、骶前出血率2 .7%。结论:TME技术是中、低位直肠癌手术应遵循的原则,不仅能提高保肛率、减少出血率、降低并发症发生率,而且能明显改善性功能和膀胱功能,提高患者的生活质量。

低位直肠肛管癌行原位肛门重建术临床研究

目的 :评价低位直肠肛管癌 (LAC)行原位肛门重建术 (OAR)的临床疗效。方法 :OAR(手术组 ) 2 0例行重建直肠瓣、直肠角 ,保留耻骨直肠肌和内外括约肌成形的重建术。术后观察控便功能 ,同时行肛肠测压 ,并与正常人 (对照组 ) 2 0例比较。结果 :术后 6个月 ,手术组肛门功能优良率达到 90 0 % ,肛管静息压 ,肛管最大挤压压 ,直肠顺应性与对照组比较无统计学意义 (P >0 0 5 )。结论 :OAR治疗LAC是一种可行的术式 。

经括约肌间切除术治疗超低位直肠/肛管癌15例临床观察

目的:观察经括约肌间切除术治疗超低位直肠/肛管癌的治疗效果。方法:选取超低位直肠/肛管癌患者30例作为研究对象,依据治疗方式不同分为对照组15例和观察组15例。对照组给予Dixon手术治疗,观察组经括约肌间切除术治疗。观察两组超低位直肠/肛管癌术后疼痛时间、排便时间、引流时间、住院时间、并发症发生率和复发率。结果:观察组超低位直肠/肛管癌术后疼痛时间、排便时间、引流时间、住院时间、并发症发生率、复发率均明显优于对照组,观察组超低位直肠/肛管癌术后排便功能评分和满意度均明显优于对照组,差异均有统计学意义(P<0.05)。结论:经括约肌间切除术治疗超低位直肠/肛管癌创伤小,恢复快,预后好,值得临床推广应用。

机器人与腹腔镜辅助下低位直肠腺癌根治术应用效果对比

目的:对比分析机器人与腹腔镜辅助下低位直肠腺癌根治术的应用效果。方法:104例低位直肠腺癌(肿瘤下缘距离肛缘≤5 cm)患者,53例行机器人辅助根治性切除术(机器人组),51例行腹腔镜辅助根治性切除术(腹腔镜组)。比较两组的根治性、安全性以及保肛率。结果:两组患者基线资料和临床病理特征的差异无统计学意义(P均>0.05)。所有患者均顺利完成手术,两组术后环周切缘均阴性。机器人组手术时间(283.06±63.99)min,保肛率达58.5%,首次排气时间(2.42±0.98)d,住院时间(14.47±3.79)d;腹腔镜组分别为(248.94±49.19)min、37.3%、(2.83±0.95)d、(19.37±5.26)d,机器人组手术时间更长,但保肛率高,首次排气时间和住院时间缩短(P均<0.05)。机器人组和腹腔镜组清扫淋巴结数分别为(14.11±5.91)和(11.98±5.64)枚,尿管拔除时间分别为(11.15±3.62)和(11.16±2.65)d,术后并发症发生率分别为5.7%和11.8%,差异均无统计学意义(P均>0.05)。结论:机器人手术具有保肛概率高,术后恢复快的优点。

低位直肠癌保肛术后肠道症状、自我管理行为与生活质量的相关性分析

目的分析低位直肠癌保肛术后肠道症状、自我管理行为与生活质量的相关性。方法收集2016年7月至2019年7月80例低位直肠癌保肛术患者为研究对象,采用肠道功能问卷、癌症生活质量量表、自我管理量表对患者进行评价,对其肠道症状、自我管理行为与生活质量进行Pearson相关性分析。结果80例患者肠道功能、生活质量、自我管理行为总分分别为(60.51±0.37)分、(51.29±5.69)分、26.31±8.92分,各个量表评分均处于中低水平;肠道症状、自我管理行为与生活质量呈正相关(P<0.05)。结论低位直肠癌保肛术后可出现多种肠道不适症状,增强患者肠道症状的自我管理行为,可有效改善生活质量。

低位直肠早癌及癌前病变患者的病理学特征及内镜黏膜下剥离术的治疗效果

目的分析低位直肠早癌及癌前病变患者的病理学特征及内镜黏膜下剥离术的治疗效果。方法选取2018年3月至2020年6月本院收治的44例低位直肠早癌及其癌前病变患者作为研究对象。所有患者均行内镜黏膜下剥离术治疗,分析低位直肠早癌及癌前病变病理学特征及术后近期疗效。结果44例患者中,腺瘤20例,占比45.45%,肿瘤最大直径(16.45±5.76)mm;锯齿状病变13例,占比29.55%,最大直径(15.37±6.08)mm;腺癌11例,占比25.00%,肿瘤最大直径(23.47±7.84)mm。20例腺瘤中,管状腺瘤9例,占比最高为45.00%;高级别上皮内瘤变13例,占比最高为65.00%。13例锯齿状病变中,传统型锯齿状瘤变8例,占比最高为61.54%;高级别上皮内瘤变7例,占比最高为53.85%。11例腺癌中,直肠癌8例,占比最高为72.73%;高分化癌6例,占比最高为54.55%;浸润深度pTlb27例,占比最高为63.64%。44例患者术后病变完整切除率为84.09%,腺瘤、锯齿状病变与腺癌的完整切除率分别为80.00%、84.62%、90.91%。结论内镜黏膜下剥离术可有效治疗低位直肠早癌及癌前病变,标本精细化处理可保障病理学检查的准确性。

高龄对超低位直肠或肛管癌患者行经内外括约肌间切除术后近期疗效的影响

目的探讨高龄对超低位直肠或肛管癌患者行经内外括约肌间切除(ISR)术后的近期疗效是否有影响。方法前瞻性纳入2016年2月至2017年2月期间符合本研究纳入条件的患者共196例,根据患者年龄进行分组,将年龄≥75岁的患者纳入高龄组,<75岁的患者纳入非高龄组,比较2组患者行内外括约肌间切除术后的近期疗效。结果高龄组113例,非高龄组83例,2组患者在性别构成、体质量指数、肿瘤组织学类型、分化程度、肿瘤大小和肿瘤距肛缘距离方面比较差异均无统计学意义(P>0.05),但高龄组的麻醉ASA分级明显高于非高龄组(P=0.002),且合并肺功能不全、低蛋白血症、贫血、高血压、糖尿病和心功能不全的比例均明显高于非高龄组(P值分别为0.005、0.048、0.009、0.001、<0.001、0.042),其他内科合并症如冠心病、胃溃疡、精神疾病和血栓的比例2组间比较差异均无统计学意义(P>0.05)。2组患者的手术时间及术中出血量比较差异均无统计学意义(P>0.05),高龄组患者的首次排气时间、首次进食时间、首次排便时间、首次下床活动时间及总住院时间均较非高龄组长(P值分别为0.023、0.037、0.019、0.020及0.012)。2组术后总并发症发生率比较差异无统计学意义(P>0.05),2组吻合口漏、肛周感染、肠梗阻及切口感染发生率比较差异均无统计学意义(P>0.05)。196例患者均获得随访,随访率为100%;平均随访7个月。随访期间出现复发患者4例,其中高龄组3例,非高龄组1例。随访期间死亡患者3例,其中高龄组组2例,非高龄组1例。结论高龄超低位直肠或肛管癌患者由于术前状态较差,行内外括约肌间切除术后较非高龄患者的近期恢复更缓慢,但是高龄并没有增加超低位直肠或肛管癌患者行内外括约肌间切除术后的并发症发生。因此,对于高龄超低位直肠或肛管癌患者行内外括约肌间切除术仍然是安全、有效的,但这需要手术医师具备较高的手术技术能力并且多学科的良好协作。

预防性造口对超低位直肠/肛管癌患者保肛术后肛门功能及生存质量的影响

目的:探讨预防性造口对超低位直肠/肛管癌患者保肛术后肛门功能及生存质量的影响。方法:前瞻性纳入符合本研究条件的超低位直肠/肛管癌患者87例,按手术方式分组,直接保肛未行预防性造口者为A组,联合小肠预防性造口者为B组,比较两组患者术后肛门功能及生存质量。结果:A组术后1、3个月Wexner评分均低于B组(均P<0.05);术后1个月A组排便频率、排气失禁、排便失禁评分均低于B组,焦虑评分高于B组(均P<0.05);术后3个月A组排便频率、排气失禁、排便失禁评分均低于B组,焦虑评分高于B组(均P<0.05)。结论:预防性造口对超低位直肠/肛管癌患者保肛术后肛门功能的恢复有明显的负面影响,同时会造成患者术后不良排便习惯增加,从而严重影响患者的生存质量,因此,对超低位直肠/肛管癌患者是否应实施预防性造口应综合患者术前及术中情况决定,而不应常规使用。

结肠套叠式原位人工肛门术的临床初探

本文报道我院自1988－1992年应用结肠套叠式原位人工肛门术治疗6例低位直肠肛营癌，结果是排便功能随时间推移而改善，手术有一定的并发症。认为本术式不宜作为直肠癌的首选术式，仅对个别低位直肠肛管癌。DuKcs C期的病人，不适合做其他保留肛门手术，又拒绝行腹壁人工肛门者，可采用本术式。

Primary adenocarcinomas of lower esophagus,esophagogastric junction and gastric cardia:in special reference to China

Gastric cardia adenocarcinoma (GCA) is an under-studied subject. The pathogenesis, molecular changes in the early stage of carcinogenesis and related risk factors have not been well characterized. There is evidence, however, that GCA differs from cancer of the rest of the stomach in terms of natural history and histopathogenesis. Adenocarcinomas of the lower esophagus, esophagogastric junction (EGJ)and gastric cardia have been given much attention because of their increasing incidences in the past decades, which is in striking contrast with the steady decrease in distal stomach adenocarcinoma. In China, epidemiologically, GCA shares very similar geographic distribution with esophageal squamous cell carcinoma (SCC), especially in Linzhou (formerly Linxian County), Henan Province, North China,the highest incidence area of esophageal SCC in the world.Historically, both GCA and SCC in these areas were referred to as esophageal cancer (EC) by the public because of the common syndrome of dysphagia. In Western countries,Barrett's esophagus is very common and has been considered as an important precancerous lesion of adenocarcinoma at EGJ. Because of the low incidence of Barrett's esophagus in China, it is unlikely to be an important factor in early stage of EGJ adenocarcinoma development.However, Z line up-growth into lower esophagus may be one of the characteristic changes in these areas in early stage of GCA development. Whether intestinal metaplasia (IM) is a premalignant lesion for GCA is still not clear. Higher frequency of IM observed at adjacent GCA tissues in Henan suggests the possibility of IM as a precancerous lesion for GCA in these areas. Molecular information on GCA,especially in early stage, is very limited. The accumulated data about the changes of tumor suppressor gene, such as p53 mutation, and ontogeny, such as C-erbB2, especially the similar alterations in GCA and SCC in the same patient,indicated that there might be some similar risk factors,such as nitrosamine, involved in both GCA and SCC in Henan population. The present observations also suggest that GCA should be considered as a distinct entity.

Telerobotic-assisted laparoscopic abdominoperineal resection for low rectal cancer: Report of the first case in Hong Kong and China with an updated literature review

Telerobotic surgery is the most advanced development in the field of minimally invasive surgery. The da Vinci surgical system, which is currently the most widely used telerobotic device, was approved by the Food and Drug Administration of the United States of America for clinical use in all abdominal operations in July 2000. The first da Vinci surgical system in China was installed in November 2005 at our institution. We herein report the first telerobotic-assisted laparoscopic abdominoperineal resection using the 3-arm da Vinci surgical system for low rectal cancer in Hong Kong and China, which was performed in August 2006. The operative time and blood loss were 240 min and 200 mL, respectively. There was no complication, and the patient was discharged on postoperative day five. An updated review of published literature on telerobotic-assisted colorectal surgery is included in this report, with special emphasis on its advantages and limitations.

Risk factors for local recurrence of middle and lower rectal carcinoma after curative resection

AIM： To explore the risk factors for local recurrence of middle and lower rectal carcinoma after curative resection. METHODS： Specimens of middle and lower rectal carcinoma from 56 patients who received curative resection at the Department of General Surgery of Guangdong Provincial People＇s Hospital were studied. A large slice technique was used to detect mesorectal metastasis and evaluate circumferential resection margin status. The relations between clinicopathologic characteristics, mesorectal metastasis and circumferential resection margin status were identified in patients with local recurrence of middle and lower rectal carcinoma. RESULTS： Local recurrence of middle and lower rectal carcinoma after curative resection occurred in 7 of the 56 patients （12.5%）, and was significantly associated with family history （Х^2= 3.929, P = 0.047）, high CEA level （Х^2 = 4.964, P = 0.026）, cancerous perforation （Х^2 = 8.503, P = 0.004）, tumor differentiation （Х^2 = 9.315, P = 0.009） and vessel cancerous emboli （Х^2 = 11.879, P = 0.001）. In contrast, no significant correlation was found between local recurrence of rectal carcinoma and other variables such as age （Х^2 = 0.506, P = 0.477）, gender （Х^2 = 0.102, Z2 = 0.749）, tumor diameter （Х^2 = 0.421, P = 0.516）,tumor infiltration （Х^2 = 5.052, P = 0.168）, depth of tumor invasion （Х^2 = 4.588, P = 0.101）, lymph node metastases （Х^2 = 3.688, P = 0.055） and TNM staging system （Х^2 = 3.765, P = 0.152）. The local recurrence rate of middle and lower rectal carcinoma was 33.3% （4/12） in patients with positive circumferential resection margin and 6.8% （3/44） in those with negative circumferential resection margin. There was a significant difference between the two groups （Х^2 = 6.061, P = 0.014）. Local recurrence of rectal carcinoma occurred in 6 of 36 patients （16.7%） with mesorectal metastasis, and in 1 of 20 patients （5.0%） without mesorectal metastasis. However, there was no significant difference between the two groups （Х^2 = 1.600, P = 0.206）. CONCLUSION： Family history, high CEA level, cancerous perforation, tumor differentiation, vessel cancerous emboli and circumferential resection margin status are the significant risk factors for local recurrence of middle and lower rectal carcinoma after curative resection. Local recurrence may be more frequent in patients with mesorectal metastasis than in patients without mesorectal metastasis.

Pathological study of distal mesorectal cancer spread to determine a proper distal resection margin

AIM: Local recurrence after curative surgical resection for rectal cancer remains a major problem. Several studies have shown that incomplete removal of cancer deposits in the distal mesorectum contributes a great share to this dismal result. Clinicopathologic examination of distal mesorectum in lower rectal cancer was performed in the present study to assess the incidence and extent of distal mesorectal spread and to determine an optimal distal resection margin in sphincter-saving procedure.METHODS: We prospectively examined sepecimens from 45 patients with lower rectal cancer who underwent curative surgery. Large-mount sections were performed to microscopically observe the distal mesorectal spread and to measure the extent of distal spread. Tissue shrinkage ratio was also considered. Patients with involvement in the distal mesorectum were compared with those without involvement with regard to clinicopathologic features.RESULTS: Mesorectal cancer spread was observed in 21patients (46.7%), 8 of them (17.8%) had distal mesorectal spread. Overall, distal intramural and/or mesorectal spreads were observed in 10 patients (22.2%) and the maximum extent of distal spread in situ was 12 mm and 36 mm respectively. Eight patients with distal mesorectal spread showed a significantly higher rate of lymph node metastasis compared with the other 37 patients without distal mesorectal spread (P = 0.043).CONCLUSION: Distal mesorectal spread invariably occurs in advanced rectal cancer and has a significant relationship with lymph node metastasis. Distal resection margin of 1.5 cm for the rectal wall and 4 cm for the distal mesorectum is proper to those patients who are arranged to receive operation with a curative sphincter-saving procedure for lower rectal cancer.

Using Gluteus Maximus Muscle to Reconstruct the Anal Sphincter for Very Low Rectal Cancer

OBJECTIVE To assess the use of gluteus maximus muscle to recon- struct the anal sphincter for very low rectal cancer. This study aimed to evaluate the local recurrence and function of the new anal sphincter after operation. METHODS Sixteen patients underwent the replacement operation, and then received biofeedback treatments 1 month after the operation. The therapeutic responses were evaluated using the Vaizey and Wexner scoring systems and vectorial manometry. The controls were 30 cases who had undergone a low anterior resection for rectal cancer and 30 healthy people. RESULTS Median follow-up was 4.2 years. No local recurrence was observed. The Vaizey and Wexner scores and vectorial manometry 1 month after operation were significantly lower than those of the healthy and low anterior resection controls （ P 〈0.001） . After biofeedback treatments, the above indexes improved significantly （ P 〈0.001）, especially after 1 year （ P 〈0.001）, but still remained lower than the controls（ P 〈0.001）. The rectoanal reflex only increased to 31.3 % 1 year after operation. CONCLUSION The local recurrence after the replacement operation was low. The defecation function was poor early after operation, but increased markedly after biofeedback treatments and long-term functional exercise. This therapy can be one choice for very low rectal cancer.

腹会阴联合切除肛门成形术治疗低位直肠肛管癌的疗效评价

为探讨直肠肛管癌腹会阴联合切除肛门成形术外科处理原则、效果和方法，将行腹会阴联合切除肛门成形术的36例低位直肠肛管癌分为A，B两组，A组28例行人工直肠瓣、肛直角成形术，B组8例行近端降结肠套入式加权侧带蒂臀大肌束环绕下拉、肛管括约肌重建成形术。术后经3个月至2年的临床随访，A组27例术后有便意感，大便控制均满意，1例术后出现结肠远端坏死；B组术后4例出现肛门狭窄及排便困难，需定期扩肛。A组术后并发症明显低于B组。结果表明，低位直肠肛管癌腹会阴联合切除行人工直肠瓣、肛直角成形术在减少术后并发症方面，明显优于近端降结肠套入式加双侧带蒂臀大肌束环绕下拉、肛门括约肌重建成形术。

Five-year oncologic outcomes and prognostic factors for locally advanced low rectal cancer after low anterior resection

Objective： The aim of the study is to investigate the longterm oncologic outcomes including local recurrence, distant metastases and overall survival （OS） for patients with low rectal cancer underwent low anterior resection （LAR） with total mesorectal excision （TME）, and to analyze the prognostic factors for them. Methods： Between January 2001 and December 2009, 147 patients with clinical stage II and III rectal cancers located 3-6 cm from the anal verge underwent LAR with TME without temporary diverting stoma. The median distal resection margin （DRM） was 1.0 （range, 0.3-5） cm. Anastomostic leakage occurred in 29 （19.7%） patients. Thirty patients received surgery alone, 20 patients received preoperative chemoradiotherapy （CRT）, 43 patients received postoperative CRT, and adjuvant chemotherapy was administered for 108 patients. The median cycle of adjuvant chemotherapy was 6 （range, 2-20） cycles. The median followup was 74.8 （range, 30.1-146.3） months. Results： In all patients, 5-year recurrence-free survival （RFS）, disease-free survival （DFS） and OS were 70.4%, 54.2% and 60.5%, respectively. Forty-three （29.3%） patients suffered local recurrence. Patients received preoperative CRT with a downstaging yp0/1 who had a better 5-year RFS, DFS and OS, which were 100%, 90.9%, and 90.9%, respectively. For patients with pathologic stage Ⅱ and stage Ⅲ, the 5-year RFS, DFS, and OS were 79.2% and 60.1%, 67.9% and 39.1%, 72.1% and 48.2%, respectively. On multivariable analysis, RFS was associated with anostomostic leakage, DFS was associated with anastomostic leakage and pathologic N stage, and OS was associated with anastomostic leakage, pathologic N and T stage. For patients with anastomostic leakage, the 5-year RFS, DFS, and OS were 51.7%, 32.4%, and 38.3%, respectively, which were worse than that for patients without anastomostic leakage, the latter were 75.2%, 59.7%, 65.7%, respectively （P 〈 0.05）. DRM and radiotherapy were associated with RFS on univariable analysis （P 〈 0.05）, but not on multivariable analysis. Tumor grade was prognostic factors for RFS and OS on univariable analysis, but not on multivariable analysis. The other factors including sex, age, tumor size and adjuvant chemotherapy were not associated with RFS, DFS and OS on univariable analysis. Conclusion： For patients with low rectal caner underwent LAR and TME, the long-term oncologic outcomes were satisfactory for patients with stage yp0/1, but not for patients with pathologic stage II1. Anastomositic leakage negatively affect long-term oncologic outcomes. Radiotherpy, adjuvant chemotherapy and distal resection margin were not associated with long-term outcomes.