完整结肠系膜切除对Ⅲ期结肠癌患者的手术治疗及疗效研究

发布时间：2018-06-17 23:24

本文选题：Ⅲ期结肠癌 + 完整结肠系膜切除　；参考：《新乡医学院》2016年硕士论文

【摘要】：背景:结肠癌是常见的恶性肿瘤之一,近年来其发病率不断升高,由于国内早期筛查力量及民众医疗意识薄弱,多数患者发现时已为中晚期。传统结肠癌根治术在系膜游离、血管根部结扎及淋巴结清扫上未予以重视,从而使Ⅲ期结肠癌患者术后出现复发与转移者不在少数。自Hohenberger教授首次提出完整结肠系膜切除(CME)这一理念后,多数学者在其意义论述上给予肯定,但国内CME的相关研究还不够充分,实际操作过程中依然让多数医生无据可循,使得外科的手术操作不能规范。目的:回顾性分析行不同手术方式的两组Ⅲ期结肠癌患者的病理和临床资料,比较完整结肠系膜切除术与传统结肠癌根治术在术中指标、病理学指标、术后恢复及复发与转移等方面的差异,探讨完整结肠系膜切除术应用于Ⅲ期结肠癌患者的手术操作要点及临床疗效。方法:回顾性分析2012年1月-2014年12月武警后勤学院附属医院肿瘤外科及胃肠外科收治的85例Ⅲ期结肠癌患者,根据手术方式分为CME组(47例)和传统组(38例)。传统组实行传统结肠癌根治术,切除肠管的远近切缘距肿瘤至少8cm,清扫肠周及中间站淋巴结,但不强调肠管、系膜后叶的分离层次及血管根部结扎和主淋巴结清扫。CME组采用对侧站位,锐性游离系膜,血管根部高位结扎。主淋巴结则根据右半与左半结肠的不同,分别采用以Henle血管干走行为基础的三方向清扫和以肠系膜下动脉根部为中心的立体式清扫。分析对比两组在术中指标、病理学指标、术后恢复、复发与转移等方面的差异是否具有统计学意义。所有数据应用SPSS16.0软件进行统计分析,计量资料采用独立样本t检验或Mann-Whitney U检验;计数资料采用卡方检验或Fisher精确检验,设P0.05为差异有统计学意义。结果:本实验结果显示CME组淋巴结清扫总数[(20.44±7.26)枚]和阳性淋巴数[4(2~7)枚]明显多于传统组[(16.11±5.00)枚、2(1~5)枚](P0.05),CME组手术时间[(208.00±32.93)min]、术中出血量[(154.44±68.94)m L]明显少于传统组[(223.84±18.80)min、(234.21±96.63)m L](P0.05);CME组术后排气时间[(3.93±1.15)day]、进食时间[(5.09±0.92)day]与传统组[(4.00±1.07)day]、[(5.61±1.42)day]比较无统计学差异(P0.05)。CME组右半及左半结肠的肠系膜切除面积[165.3(112.7,196.8)、134.4(130.4,187.5)cm2]、肿瘤至血管高位结扎点最短距离[13.8(9.8,15.4)、14.6(10.4,16.8)cm]、肠壁至血管高位结扎点最短距离[11.3(8.6,12.8)、10.7(8.4,12.3)cm]明显多于传统组的[116.2(75.6,136.2)、95.3(82.8,135.3)cm2]、[10.7(8.1,13.2)、11.8(8.9,13.8)cm]和[8.2(7.1,11.5)、9.3(7.9,10.4)cm],二者比较有统计学意义(P0.05)。CME组术后并发症发生率(17.02%)与传统组(15.79%)比较无统计学差异(P0.05)。CME组术后复发转移1例(2.13%),传统组术后复发转移4例(10.53%)差异有统计学意义(P0.05)。结论:1.Ⅲ期结肠癌患者行完整结肠系膜切除术与行传统结肠癌根治术相比,在淋巴结清扫总数、阳性淋巴结清扫数、手术时间、术中出血量、肠系膜切除面积、肿瘤至血管高位结扎点最短距离、肠壁至血管高位结扎点最短距离及术后复发转移率等方面占有优势,故Ⅲ期结肠癌患者应用完整结肠系膜切除优于传统手术方式。2.行完整结肠系膜切除术时,术者采用对侧站位,操作过程中左手牵拉组织保持张力,右手行系膜锐性游离,利于保证Toldt筋膜剥离的完整性,能增加操作的便利性,可操作性强。3.完整结肠系膜切除术在右半及左半结肠的主淋巴结清扫分别采用沿Henle血管干三个走行方向清扫及以肠系膜下动根部为中心的立体式清扫方式,能增加淋巴结清扫数量,减少肿瘤残留,降低患者术后复发转移率。
[Abstract]:Background: colon cancer is one of the most common malignant tumors. In recent years, the incidence of cancer is increasing. Most patients have been found in the middle and late stages because of the early screening force in China and the weak awareness of the people's medical treatment. Most scholars have given the concept of complete colon mesangial excision (CME) for the first time since Hohenberger. Most scholars have given affirmation in their significance, but the relevant research in domestic CME is not enough. In the actual operation, many doctors still have no evidence to follow. Objective: To review and analyze the pathological and clinical data of two groups of stage III colon cancer patients with different surgical methods, and compare the differences of complete colectomy and traditional colon cancer radical operation in the intraoperative index, pathological index, postoperative recovery and recurrence and metastasis, and discuss the application of complete colectomy in stage III of the colon. Surgical operation points and clinical efficacy of colon cancer patients. Methods: retrospective analysis of 85 patients with stage III colon cancer admitted in the cancer surgery and gastrointestinal surgery department of the Affiliated Hospital of armed police Logistics Institute in December -2014 January 2012, divided into group CME (47 cases) and traditional group (38 cases) according to the operation method. Traditional group performed radical resection of colon cancer, resection of intestine The distant adjacent margin of the tube was at least 8cm, dissection of the pericenteric and intermediate lymph nodes, but did not emphasize the intestinal canal, the separation level of the posterior mesangial lobe, the ligature of the roots of the blood vessel and the main lymph node dissection in the.CME group, the opposite position, the sharp free mesangial and the high ligation of the vascular roots. The main lymph nodes were used in Hen respectively according to the difference between the right and the left semicolons. The three direction cleaning and the stereoscopic scan with the base of the inferior mesenteric artery as the basis of the behavior of Le blood vessels. The analysis and comparison of the differences between the two groups in the intraoperative indexes, pathological indexes, postoperative recovery, recurrence and metastasis were statistically significant. All data were statistically analyzed with SPSS16.0 software, and the measurement data adopted the only one. T test of vertical samples or Mann-Whitney U test; counting data using chi square test or Fisher accurate test, P0.05 was statistically significant. Results: the results of this experiment showed that the total number of lymph node dissection in CME Group [(20.44 + 7.26)] and positive lymph nodes [4 (2~7)) were significantly more than that of the traditional group [(16.11 + 5), 2 (1~5)] (P0.05), CME group operation Time [(208 + 32.93) min]), the amount of intraoperative bleeding [(154.44 + 68.94) m L] was significantly less than that of the traditional group [(223.84 + 18.80) min, (234.21 + 96.63) m L] (P0.05); after CME group, the exhaust time [(3.93 + 1.15) day], feeding time [(5.09 + 0.92) day]] was compared with the traditional group [(4 +]) day]. The mesenteric resection area of the colon was [165.3 (112.7196.8), 134.4 (130.4187.5) cm2], the shortest distance from the tumor to the high ligation point of the vessel was [13.8 (9.8,15.4), 14.6 (10.4,16.8) cm], and the shortest distance between the intestinal wall and the high ligation point of the blood vessel was [11.3 (8.6,12.8), and 10.7 (8.4,12.3) cm] was more than that of the traditional group (8). 8 .1,13.2), 11.8 (8.9,13.8) cm] and [8.2 (7.1,11.5), 9.3 (7.9,10.4) cm], two were statistically significant (P0.05) the incidence of postoperative complications in the group.CME (17.02%) compared with the traditional group (15.79%), there was no statistical difference (P0.05).CME group postoperative recurrence and metastasis 1 cases (2.13%), traditional group postoperative recurrence and metastasis 4 cases (10.53%) difference was statistically significant (P0.05). The total number of lymph node dissection, the number of positive lymph nodes, the time of operation, the amount of bleeding, the area of mesentery resection, the shortest distance from the tumor to the high ligation point, the shortest distance to the high ligation point of the intestinal wall to the high ligation of the vessel and the recurrence after operation, compared with the traditional radical colectomy for colon cancer in 1. stage colon cancer patients. When the total colectomy in stage III colon cancer patients is superior to the complete colon mesangial excision, it is superior to the traditional surgical mode.2. for complete colectomy. The patients adopt the contralateral position, keep the tension of the left hand pull tissue during the operation, the right hand line of the mesangial membrane and the integrity of the Toldt fascia, and increase the operation. Convenient and operable.3. complete colectomy in the main lymph node dissection of the right and left semicolons in the right and left semicolons to clear the three walking directions along the Henle vascular trunk and take the inferior mesenteric root as the center, which can increase the number of lymph node dissection, reduce the residual tumor and reduce the recurrence and metastasis of the patients after operation. Rate.
【学位授予单位】：新乡医学院
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R735.35

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