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7wu1wm0 发表于 2024-6-25 02:37:23

低位直肠癌的困惑与外科治疗选取

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz/gsCSOksyaNK3Sf5xGSfbsiauxiaPrBianCL1aSBpuyHHnUINxlOq3Uf2r6hmCVic1EaiaIV4kXS5rjFkLZt0QYzicjIA/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"><img src="http://mmbiz.qpic.cn/mmbiz/gsCSOksyaNK3Sf5xGSfbsiauxiaPrBianCLIaHuj4ib3IyHQXnDuWJahzEbogLf3Kw39MlFiafIw5oJrIBqbBXP8biaw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
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    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">本文原载于<span style="color: black;">《国际外科学杂志》<span style="color: black;">2015</span>年第<span style="color: black;">8</span>期</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠癌在解剖及诊治上不同于其他部位的结直肠癌，诊治上应有其特殊性，但临床上到<span style="color: black;">日前</span>为止还<span style="color: black;">无</span>真正<span style="color: black;">道理</span>的诊治指南，<span style="color: black;">因此呢</span>在外科治疗上各医疗单位常常各自为阵，<span style="color: black;">乃至</span>同一医院不同治疗小组的治疗<span style="color: black;">办法</span><span style="color: black;">亦</span>截然相反。经验代替规范，临床创新代替治疗<span style="color: black;">办法</span>更新，造<span style="color: black;">成为了</span>许多医师对低位直肠癌外科治疗的<span style="color: black;">许多</span>困惑。探讨低位直肠癌手术治疗规范，对<span style="color: black;">加强</span>低位直肠癌的疗效，减少<span style="color: black;">病人</span>创伤，<span style="color: black;">加强</span><span style="color: black;">病人</span><span style="color: black;">存活</span>质量有<span style="color: black;">要紧</span><span style="color: black;">道理</span>。</span></p>1<span style="color: black;">低位直肠癌的定义</span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠癌<span style="color: black;">日前</span>尚<span style="color: black;">没</span>统一的定义，大部分采用与肛缘的距离进行定义。<span style="color: black;">日前</span>大多把低位直肠癌定义为肿瘤下缘距肛缘为<span style="color: black;">5</span><span style="color: black;">～</span><span style="color: black;">6 cm</span><span style="color: black;">的直肠癌。但这种定义难以分辨个体之间的差异，不同个体之间均以同一长度衡量显然有失偏颇。最为科学或<span style="color: black;">恰当</span>的应是采用解剖标记<span style="color: black;">办法</span>进行定义，如英国结直肠外科专家把低位直肠癌定义为癌瘤下缘<span style="color: black;">位置于</span>盆壁肛提肌起点连线或连线以下的直肠癌，<span style="color: black;">况且</span>这条解剖标记线可在磁共振的冠状位<span style="color: black;">影像</span>上加以标识。</span></span></p>2<span style="color: black;">低位直肠癌的特殊性</span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠邻近肛门口，解剖结构有<span style="color: black;">显著</span>特殊性，此处直肠系膜变薄，且毗邻骶丛神经、盆底、肛提肌，淋巴回流<span style="color: black;">亦</span>较中高位直肠<span style="color: black;">繁杂</span>。<span style="color: black;">因此呢</span>低位直肠癌<span style="color: black;">没</span>论是诊断还是治疗均有其特殊性。<span style="color: black;">(1)</span><span style="color: black;">低位直肠癌临床表现上与中高位直肠癌不同，肛门刺激征及黏液血便症状更为<span style="color: black;">显著</span>，诊断<span style="color: black;">办法</span>上<span style="color: black;">亦</span>有所不同，简单的直肠指检有极其<span style="color: black;">要紧</span>的<span style="color: black;">道理</span>，<span style="color: black;">实质</span>上低位直肠癌临床首次诊断的<span style="color: black;">检测</span>便是直肠指检，而在分期诊断上高分辨率的磁共振及腔内超声有很高的价值。</span><span style="color: black;">(2)</span><span style="color: black;">肿瘤性质特殊。文献<span style="color: black;">科研</span><span style="color: black;">显示</span>：低位直肠癌生物学恶性程度较高，远侧端浸润的范围更广，淋巴结转移方向更为<span style="color: black;">繁杂</span>。</span><span style="color: black;">(3)</span><span style="color: black;"><span style="color: black;">病人</span>在治疗上<span style="color: black;">需求</span>特殊。低位直肠癌<span style="color: black;">病人</span><span style="color: black;">常常</span>既<span style="color: black;">需求</span>彻底根治切除肿瘤，又<span style="color: black;">需求</span>能够<span style="color: black;">保留</span>肛门括约肌功能。</span><span style="color: black;">(4)</span><span style="color: black;">低位直肠癌治疗上的特殊性。低位直肠癌的分离与切除有<span style="color: black;">更加多</span>的手术盲区，<span style="color: black;">因此呢</span>从技术上更为困难，<span style="color: black;">况且</span>治疗上有保肛手术与非保肛手术；有手术、放疗与化疗，新辅助放化疗等治疗技术；有腹部手术、会阴手术及腹会阴联合手术等手术入路。但<span style="color: black;">日前</span>低位直肠癌的诊治均<span style="color: black;">没</span>独立的指南或规范，笼统归类结直肠癌或直肠癌诊治常规或指南，显然有待进一步更正。</span></span></p>3<span style="color: black;">低位直肠癌外科治疗的困惑与策略</span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠癌<span style="color: black;">日前</span>在治疗上存在许多困惑，如<span style="color: black;">怎样</span><span style="color: black;">选取</span>保肛手术或非保肛手术、保肛时行不行预防性造口、非保肛手术方式的<span style="color: black;">选取</span>等。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3．<span style="color: black;">1</span>保肛手术与不保肛手术的<span style="color: black;">选取</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">不保肛手术<span style="color: black;">寓意</span>着<span style="color: black;">必须</span>行永久性的人工肛门，对直肠癌<span style="color: black;">病人</span><span style="color: black;">来讲</span><span style="color: black;">不仅</span>降低了生活质量，<span style="color: black;">况且</span>在心理或生理上都可能<span style="color: black;">导致</span>巨大的影响。而保肛手术后尽管<span style="color: black;">能够</span>从正常肛门排便，生活质量较好，<span style="color: black;">况且</span>对<span style="color: black;">病人</span>的心理及生理影响较小，但手术所<span style="color: black;">导致</span>的排便功能部分丧失，术前、术后的化疗与放疗，对<span style="color: black;">病人</span>的排便功能仍有<span style="color: black;">很强</span>的影响。低位直肠癌什么情况下采用保肛手术，什么<span style="color: black;">状况</span>下采用非保肛手术，<span style="color: black;">日前</span>尚<span style="color: black;">没</span>统一标准，即便是<span style="color: black;">一样</span>部位、同一分期的<span style="color: black;">病人</span>，不同的医师可能采用不同的手术方式。大<span style="color: black;">都数</span>的结直肠外科医师采用的标准是依据肿瘤下缘距肛缘的距离，肿瘤下缘距肛缘越近，保肛的机会越低，且与手术医师的经验有很大的关系，<span style="color: black;">然则</span>随着全直肠系膜切除的开展及手术技巧的进步，这种<span style="color: black;">评定</span><span style="color: black;">办法</span>已较为片面。手术方式<span style="color: black;">选取</span>的影响<span style="color: black;">原因</span>除了肿瘤下缘距肛缘的距离外还与影像学恰当的分期及手术时标本组织病理学<span style="color: black;">检测</span>结果<span style="color: black;">相关</span>。分期越早，保肛机会越高。直肠癌手术<span style="color: black;">日前</span><span style="color: black;">评定</span>手术根治切除的标准是“三缘”的阴性，即上切缘、下切缘及环周切缘阴性的组织学结果，若肿瘤远端肠段最大程度切断后，切缘冰冻病理<span style="color: black;">检测</span>仍有肿瘤细胞残留，<span style="color: black;">病人</span>便失去了保肛的机会。<span style="color: black;">因此呢</span>在<span style="color: black;">选取</span>手术方式时应充分<span style="color: black;">评定</span>肿瘤的分期，精确测算肿瘤的位置，<span style="color: black;">同期</span>还应<span style="color: black;">按照</span>术后的手术切缘病理<span style="color: black;">检测</span>结果进行取舍。有学者<span style="color: black;">意见</span>对低位直肠癌进行<span style="color: black;">归类</span>并相应采用标准化的手术方式：<span style="color: black;">I</span><span style="color: black;">类低位直肠癌为肛管以上的直肠癌，肿瘤下缘距内括约肌上缘的距离大于</span><span style="color: black;">I cm</span><span style="color: black;">的直肠癌，这类直肠癌采用保肛手术直肠肛管吻合术；</span><span style="color: black;">II</span><span style="color: black;">类低位直肠癌是直肠肛管接合部的直肠癌，肿瘤下缘距内括约肌上缘的距离<span style="color: black;">少于</span></span><span style="color: black;">1 em</span><span style="color: black;">的直肠癌，这类直肠癌需行部分内括约肌切除；</span><span style="color: black;">HI</span><span style="color: black;">类低位直肠癌是肛管内的直肠癌，肿瘤浸润内括约肌，这类直肠癌需采用内括肌全切除术；</span><span style="color: black;">1V</span><span style="color: black;">类低位直肠癌是肛管外的直肠癌，肿瘤已侵犯肛门外括约肌，这类直肠癌<span style="color: black;">必要</span>行非保肛手术。总之，非保肛手术的适应证是低位直肠癌肿瘤侵犯肛门外括肌或肛提肌。<span style="color: black;">另外</span>，直肠肿瘤标本下切缘冰冻病理<span style="color: black;">检测</span>肿瘤细胞阳性的<span style="color: black;">病人</span><span style="color: black;">亦</span>是非保肛手术的适应证。理论上说，对可切除的低位直肠癌，除了非保肛手术外，其余的均<span style="color: black;">能够</span>采用保肛手术。</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3．<span style="color: black;">2</span>保肛手术<span style="color: black;">同期</span><span style="color: black;">是不是</span>采用预防性的造口术</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">直肠癌术后吻合口漏是保肛手术的严重并发症，严重的可<span style="color: black;">引起</span><span style="color: black;">病人</span>死亡，<span style="color: black;">同期</span><span style="color: black;">因为</span>术后吻合口漏发病率较高<span style="color: black;">(</span><span style="color: black;">文献<span style="color: black;">报告</span><span style="color: black;">乃至</span>达</span><span style="color: black;">20</span><span style="color: black;">％以上</span><span style="color: black;">，<span style="color: black;">因此呢</span>结直肠外科医师非常<span style="color: black;">注意</span>吻合口漏的预防。吻合口漏的发病率固然与预防性造口<span style="color: black;">没</span><span style="color: black;">显著</span>关系，但预防性造口后吻合口漏<span style="color: black;">出现</span>时对机体的影响要轻的多。</span><span style="color: black;">13j</span><span style="color: black;">。而令医师困惑的是<span style="color: black;">那些</span><span style="color: black;">病人</span>术后会<span style="color: black;">显现</span>吻合口漏</span><span style="color: black;">?</span><span style="color: black;">正<span style="color: black;">由于</span>如此，许多学者强调应常规进行预防性造口<span style="color: black;">亦</span><span style="color: black;">叫作</span><span style="color: black;">守护</span>性造口或去功能性造口术，以避免吻合口漏<span style="color: black;">出现</span>时的严重性。然而预防性造口术本身对<span style="color: black;">病人</span>的影响<span style="color: black;">亦</span>是非常<span style="color: black;">显著</span>的，在造口<span style="color: black;">时期</span><span style="color: black;">不仅</span>造<span style="color: black;">成为了</span><span style="color: black;">病人</span>的生活<span style="color: black;">不方便</span>，<span style="color: black;">同期</span><span style="color: black;">亦</span>存在造口本身的并发症以及术后再次的造口返纳手术。<span style="color: black;">因此呢</span>笔者并不主张对所有低位直肠癌常规进行预防性造口术，而仅对那此<span style="color: black;">危害</span>较高的<span style="color: black;">病人</span>采用此术式。吻合口漏的<span style="color: black;">危害</span>程度<span style="color: black;">评定</span><span style="color: black;">日前</span><span style="color: black;">亦</span><span style="color: black;">没</span>统一的标准，各医院、医师有各自的经验。笔者主张若有</span><span style="color: black;">2</span><span style="color: black;">项非技术<span style="color: black;">原因</span></span><span style="color: black;">(</span><span style="color: black;"><span style="color: black;">包含</span>高龄</span><span style="color: black;">&gt;70</span><span style="color: black;">岁。营养不良、全身<span style="color: black;">基本</span>性<span style="color: black;">疾患</span>、放疗、肿瘤过大、男性<span style="color: black;">病人</span>及<span style="color: black;">肥壮</span></span><span style="color: black;">)</span><span style="color: black;">或</span><span style="color: black;">1</span><span style="color: black;">项技术<span style="color: black;">原因</span></span><span style="color: black;">(</span><span style="color: black;">吻合不良、吻合口血运<span style="color: black;">阻碍</span>、吻合口张力存在</span><span style="color: black;">)</span><span style="color: black;">均应进行预防性的造口术。若<span style="color: black;">没</span><span style="color: black;">危害</span><span style="color: black;">原因</span>存在，术毕仅<span style="color: black;">经过</span><span style="color: black;">安置</span>肛管引流基本上<span style="color: black;">能够</span>预防吻合口漏的<span style="color: black;">出现</span>。当然，<span style="color: black;">咱们</span><span style="color: black;">日前</span><span style="color: black;">亦</span>采用改良的去功能性造口技术，如回肠末端的管状导管转流技术或直肠吻合口上方粪便转流技术，这些技术应用<span style="color: black;">能够</span>避免造口术及后期的再手术，其临床应用正在总结中。</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">3.3</span>非保肛手术的手术方式<span style="color: black;">选取</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">非保肛手术的经典手术是腹会阴联合切除术，但有<span style="color: black;">科研</span>认为：传统的腹会阴联合直肠癌切除术术后<span style="color: black;">存活</span>率较全直肠系膜切除术原则下的保肛手术低，<span style="color: black;">况且</span>术后复发率<span style="color: black;">亦</span>较高。<span style="color: black;">因此呢</span><span style="color: black;">非常多</span>学者<span style="color: black;">意见</span><span style="color: black;">拔除</span>传统的腹会阴联合切除术式，而行扩大的腹会阴联合切除术。欧洲许多国家<span style="color: black;">首要</span>提出了肛提肌外腹会阴联合切除术，<span style="color: black;">因为</span>切除的直肠标本<span style="color: black;">没</span>细腰状形态而呈柱状结构，<span style="color: black;">因此呢</span><span style="color: black;">亦</span><span style="color: black;">叫作</span>为柱状切除术。<span style="color: black;">然则</span>许多学者在实施这项技术过程中<span style="color: black;">发掘</span>，此技术本身存在着许多问题，<span style="color: black;">重点</span>表现是盆底<span style="color: black;">缺失</span>过大，术后需进行肌皮瓣的转移，以及会阴部感染发病率高的并发症心，<span style="color: black;">因此呢</span>推广此技术受限，尤其是在我国，绝大部分学者不主张采用此技术比，而认为应<span style="color: black;">按照</span>肿瘤的侵犯范围采用个体化的切除范围，以最大<span style="color: black;">保存</span>盆底组织，笔者<span style="color: black;">亦</span>主张采用个体化的切除范围。近来笔者正探讨折刀位下会阴部先入路的扩大会阴联合直肠癌切除，可在直视下切除会阴部及盆底，既可<span style="color: black;">保准</span>环周切缘的阴性，减少术中直肠的破溃率，<span style="color: black;">亦</span><span style="color: black;">能够</span>最大程度<span style="color: black;">守护</span>盆底组织，减少盆底<span style="color: black;">缺失</span>的并发症，与传统腹会阴联合直肠癌切除术相比，有很大<span style="color: black;">优良</span>。这项技术<span style="color: black;">亦</span>在总结中，当然<span style="color: black;">亦</span>还<span style="color: black;">必须</span>多中心、前瞻性的<span style="color: black;">科研</span>加以证实。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">总之，低位直肠癌的诊治有其特殊性，在临床诊治过程中应单独作一类<span style="color: black;">疾患</span>进行处理，<span style="color: black;">持续</span>总结经验与教训，优化诊疗技术。<span style="color: black;">最后</span>目的是既要<span style="color: black;">加强</span><span style="color: black;">存活</span>率，又要最大程度减少<span style="color: black;">病人</span>的创伤，<span style="color: black;">加强</span><span style="color: black;">病人</span>的<span style="color: black;">存活</span>质量。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">参考文献（略）</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">(<span style="color: black;">收稿日期：</span><span style="color: black;">2015-06-23)</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz/gsCSOksyaNKicYA9LxaMusTKjasuW0LLsSf885QJVoXQM4a8VQACNmPwhGc9Nibwza9M5YRb8EqnZH60ASiaM96WA/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>

m5k1umn 发表于 前天 16:39

你的话语如春风拂面，让我感到无比温暖。

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