初期直肠癌怎么样治疗 有哪些好的办法能既“保命”又“保肛”
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">初期</span>直肠癌<span style="color: black;">包含</span>了肿瘤分期为T1到T2未见淋巴结转移<span style="color: black;">亦</span>未见远处转移的<span style="color: black;">病人</span>，这类<span style="color: black;">病人</span><span style="color: black;">能够</span><span style="color: black;">经过</span>手术治疗达到根治的效果，预后相对较好。但<span style="color: black;">因为</span>直肠远端连接肛门，能否<span style="color: black;">保存</span>肛门<span style="color: black;">作为</span>了直肠癌<span style="color: black;">病人</span>最关心的问题，<span style="color: black;">那样</span><span style="color: black;">初期</span>直肠癌<span style="color: black;">病人</span><span style="color: black;">怎样</span>治疗？有<span style="color: black;">那些</span>好的治疗<span style="color: black;">方法</span>能<span style="color: black;">保存</span>肛门功能？</p>
<h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;">1、</span><span style="color: black;">保存</span>肛门括约肌<span style="color: black;">没</span>困难的治疗</h2>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">部分<span style="color: black;">病人</span>病灶距齿状线较远，手术治疗<span style="color: black;">针对</span><span style="color: black;">保存</span>肛门并<span style="color: black;">没</span>困难，这类<span style="color: black;">病人</span>在<span style="color: black;">大夫</span><span style="color: black;">评定</span>后直接进行直肠癌根治术<span style="color: black;">就可</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">为了避免复发转移，全直肠系膜切除术（TME）是标准且常用的手术方式，切除范围<span style="color: black;">包括</span>了内脏筋膜中的<span style="color: black;">全部</span>直肠系膜，<span style="color: black;">倘若</span>是高位直肠癌<span style="color: black;">病人</span>，系膜的切除范围还需增大。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">TME的<span style="color: black;">显现</span>大大降低了<span style="color: black;">初期</span>直肠癌的复发率，有学者分析了5个机构1411名直肠癌<span style="color: black;">病人</span>的手术<span style="color: black;">状况</span>，结果<span style="color: black;">表示</span>，行TME术后的<span style="color: black;">初期</span>直肠癌<span style="color: black;">病人</span>局部复发率仅为4％-9％，<span style="color: black;">明显</span>优于传统手术观察到的32％-35％的复发<span style="color: black;">危害</span><a style="color: black;"></a>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">况且</span><span style="color: black;">针对</span><span style="color: black;">无</span>任何转移迹象的<span style="color: black;">病人</span>，<span style="color: black;">没</span>需扩大清扫范围至髂血管旁淋巴结。</p>
<h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;">2、</span><span style="color: black;">保存</span>肛门括约肌有困难的治疗</h2>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">初期</span><span style="color: black;">病人</span><span style="color: black;">保存</span>肛门括约肌有困难<span style="color: black;">一般</span>都是<span style="color: black;">由于</span>病灶位置太低，距离肛门括约肌齿状线太近。但<span style="color: black;">亦</span>有不少方式能<span style="color: black;">帮忙</span><span style="color: black;">病人</span>避免腹会阴联合切除术（APR），使保肛的愿望得以实现。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1、经肛门局部切除术</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">针对</span>分期为T1、边界清晰、病理分化较好的<span style="color: black;">病人</span>，<span style="color: black;">能够</span>经<span style="color: black;">评定</span>后<span style="color: black;">思虑</span>经肛门仅对肿瘤病灶进行局部的切除，局部切除范围小、损失小、术后并发症少。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">但若局部切除术后病理<span style="color: black;">检测</span><span style="color: black;">表示</span>以下特征，则仍<span style="color: black;">必须</span>进行挽救性直肠癌根治术<a style="color: black;"></a>：</p>肿瘤组织学分化差；脉管浸润；切缘阳性；肿瘤浸润超过黏膜下肌层外1/3；黏膜下层浸润＞1mm或T2期肿瘤；<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">这些病理特征都<span style="color: black;">表示</span>着病灶<span style="color: black;">处在</span><span style="color: black;">发展</span>期，<span style="color: black;">倘若</span>不进行挽救性<span style="color: black;">办法</span>，复发<span style="color: black;">危害</span>会非常大。<span style="color: black;">能够</span><span style="color: black;">尽可能</span>找有经验的专家<span style="color: black;">评定</span>后抉择最初的治疗方式，<span style="color: black;">非常多</span>权威的三甲医院会有规范的多学科诊疗体系，其中病理科<span style="color: black;">亦</span>会参与讨论决定<span style="color: black;">病人</span>的治疗方式。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2、经腹直肠癌切除术（LAR）</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">LAR是一种从腹部入路的切除术，对比经腹会阴直肠肛管根治切除术不仅能保肛、安全性更高，且有着更好的5年<span style="color: black;">存活</span>率。该术式<span style="color: black;">通常</span>用于病灶下缘距齿状线＞5cm的<span style="color: black;">病人</span>，且<span style="color: black;">一般</span><span style="color: black;">需求</span>2cm的安全切缘，但随着技术设备的<span style="color: black;">加强</span>和吻合器的应用，<span style="color: black;">倘若</span>找到有经验的专家，<span style="color: black;">针对</span>距齿状线3至4cm的直肠癌<span style="color: black;">病人</span><span style="color: black;">亦</span><span style="color: black;">一样</span>能<span style="color: black;">经过</span>该手术方式<span style="color: black;">得到</span>保肛的机会。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3、括约肌间切除术（ISR）</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">肛门括约肌<span style="color: black;">能够</span>分为内括约肌和外括约肌，ISR<span style="color: black;">选取</span>性地切除肛门内括约肌，留下肛门外括约肌，从而<span style="color: black;">保存</span>了肛门功能，<span style="color: black;">按照</span><span style="color: black;">病人</span>的<span style="color: black;">详细</span><span style="color: black;">状况</span>，内括约肌的切除范围<span style="color: black;">亦</span>会有所变化。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">ISR的<span style="color: black;">显现</span>使靠近肛门的低位直肠癌<span style="color: black;">亦</span>有了保肛的可能性。有学者对低位直肠癌ISR后功能和预后进行了分析<span style="color: black;">评定</span>，纳入了612名行ISR的直肠癌<span style="color: black;">病人</span>，数据<span style="color: black;">评定</span>结果<span style="color: black;">表示</span>，局部复发率为9.5％，5年<span style="color: black;">存活</span>率为81.5％，近远期预后良好<a style="color: black;"></a>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3、拖出式直肠切除术</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">针对</span><span style="color: black;">有些</span>超低位的直肠癌，经腹部的手术比较难完全将病灶切除，<span style="color: black;">能够</span><span style="color: black;">思虑</span>先经腹对病灶和直肠进行游离和松解，<span style="color: black;">而后</span>将直肠翻转后从直肠内拖出到肛门外，<span style="color: black;">大夫</span>在直视下对肿瘤进行切除。<span style="color: black;">针对</span>病灶下缘距齿状线3-2厘米的直肠癌<span style="color: black;">病人</span>，<span style="color: black;">倘若</span>专家手法到位，在<span style="color: black;">保证</span>切除边缘距病灶下缘2厘米后，行结肠-肛管吻合术从而达到保肛的目的。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4、同步放化疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">针对</span>有<span style="color: black;">剧烈</span>保肛意愿的<span style="color: black;">病人</span>，经<span style="color: black;">评定</span>后<span style="color: black;">能够</span>先进行同步放化疗，<span style="color: black;">倘若</span><span style="color: black;">病人</span>对放化疗<span style="color: black;">敏锐</span>，肿瘤缩小，治疗后<span style="color: black;">表示</span>完全临床缓解（cCR），则<span style="color: black;">能够</span>进行观察等待<span style="color: black;">按照</span><span style="color: black;">详细</span><span style="color: black;">发展</span><span style="color: black;">状况</span><span style="color: black;">思虑</span>进一步保肛手术<span style="color: black;">办法</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">日前</span>国际公认的cCR标准有三点<a style="color: black;"></a>：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1）肛门指诊原肿瘤区域正常，<span style="color: black;">无</span>肿瘤性肿块可触及；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2）内窥镜下<span style="color: black;">能够</span><span style="color: black;">发掘</span>白色、扁平的黏膜瘢痕、伴<span style="color: black;">周边</span>毛细血管扩张，未见肿瘤性溃疡或结节，黏膜活检为癌细胞阴性；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3）盆腔高分辨率MRI<span style="color: black;">检测</span>，T2加权图像仅表现为黑的T2信号而<span style="color: black;">无</span>中等强度的T2信号，且<span style="color: black;">没</span>肿大的淋巴结征象；DW图像在B800-B1000<span style="color: black;">时期</span><span style="color: black;">没</span>可视化信号，肿瘤区域的肠管肠壁表现为均质、线性的信号；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（以上标准医学术语看不懂<span style="color: black;">不碍事</span>，这些病历资料齐全的话，完全<span style="color: black;">能够</span>以远程会诊</p>
<h2 style="color: black; text-align: left; margin-bottom: 10px;">参考</h2><a style="color: black;">^</a><span style="color: black;">Havenga K, Enker WE, Norstein J, Moriya Y, Heald RJ, van Houwelingen HC, et al. Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients. Eur J Surg Oncol. 1999;25:368–74.</span><a style="color: black;">^</a><span style="color: black;">YAMAMOTO S, WATANABE M, HASEGAWA H, et al. The risk of lymph node metastasis in T1 colorectal carcinoma. Hepatogastroenterology, 2004, 51: 998-1000.</span><a style="color: black;">^</a><span style="color: black;">Tilney H S, Tekkis P P. Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Disease, 2008, 10(1): 3-15.</span><a style="color: black;">^</a><span style="color: black;">SMITH J J, CHOW O S, GOLLUB M J, et al. Organ Preservation in Rectal Adenocarcinoma: a phase Ⅱ randomized controlled trial evaluating 3-year disease-free survival in patients with locally advanced rectal cancer treated with chemoradiation plus induction or consolidation chemotherapy, and total mesorectal excision or nonoperative management. BMC Cancer, 2015, 15: 767</span>
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