【作者】 金哲柱；

【导师】 汲崇德； 张秀和； 韩振国； 那万里；

【作者基本信息】 吉林大学 ， 临床医学， 2007， 硕士

【摘要】 目的比较低位直肠癌应用吻合器保肛手术与Miles手术术后局部复发率及各期5年生存率的差异,探讨低位直肠癌外科治疗的术式选择及应用吻合器保肛手术的适应证。方法回顾分析2000年3月至2002年3月间在我院手术治疗的196例低位直肠癌病例资料,其中应用吻合器保肛手术者89例,Miles手术者107例。对两种手术治疗组病例分别按AJCC第六版TNM分期标准进行分期,并比较两组患者术后局部复发率及各期5年生存率。结果①两组病例在性别、年龄、有无肝转移、病理类型、原发肿瘤大小、浸润深度、癌肿部位、组织学分化程度、侵犯肠管周径、有无区域淋巴结转移方面差异均无统计学意义,P>0.05。②两组病例在第六版TNMⅠ、Ⅱ、Ⅲ期中的各期及各亚期间2、5年生存率差异均无统计学意义(P >0.05),而单因素分析Ⅳ期患者切除原发肿瘤后平均生存时间Miles手术(20.10±1.52个月)组优于应用吻合器保肛手术(13.33±0.81个月)组,经Log-rank检验该期两组间的生存率曲线差异有显著统计学意义,P< 0.01。③肿瘤下缘距肛缘5～7cm的低位直肠癌中应用吻合器保肛手术组与Miles手术组患者术后2年内局部复发率及2、5年生存率差异均无统计学意义,P>0.05。结论①对距肛缘5～7cm的低位直肠癌应根据个体情况、浸润程度、分化程度、淋巴结转移、有无远处转移、侵犯肠管周径及设备的条件等综合状况选择吻合器保肛手术。②对AJCC第六版TNMⅠ、Ⅱ、Ⅲ期低位直肠癌患者可行应用吻合器保肛手术,值得推广应用。但对于全身状况良好、转移负荷较小、肝脏无明显受损的Ⅳ期低位直肠癌患者,应争取采用Miles手术彻底切除原发肿瘤并给予有效的化学治疗。③本研究发现各期肿瘤下切缘长度满足以下条件者可选择低位直肠癌应用吻合器保肛手术:①TNM分期Ⅰ期(T1 N0 M0、T2N0M0),高中分化腺癌,侵犯肠管周径≤1/2周,下切缘距离≥2cm者;②ⅡA期(T3 N0 M0)、ⅡB期(T4 N0 M0)、ⅢA期(T1 / T2N1 M0),侵犯肠管周径>1/2周,高中分化腺癌,下切缘距离为≥2.5cm者;③ⅢB期(T3/ T4 N1 M0)、ⅢC期(T任何N2 M0),侵犯肠管周径≤1/2周,中低分化腺癌,下切缘距离为≥3.0cm作为癌肿远侧肠管切断线,术中快速病检直肠远切端均无癌细胞残留者。值得注意的是,对ⅢB、ⅢC期病例选择保肛手术时严格掌握适应证,不能片面追求保肛而忽视切除的彻底性。更多还原

【Abstract】 Objective:To compare the difference between local recurrence rate and 5-year survival rate of Miles surgery and anal sphincter preservation surgery using stapler on low rectum cancer. And to explore the indication of the using of stapler for low rectal cancer during sphincter preservation surgery, and the selection of surgical options for low rectal cancer.Methods:196 cases of low rectal cancer who admitted to China-Japan Union Hospital of Jilin University and accepted operative treatment between March 2000 and March 2002 were analyzed retrospectively. 53 rectal tumours were located in 3-5cm from anus, 61 were located in 5-6cm, 82 in 6-7cm. Miles surgery were performed on 107 patients, and stapling device application on Sphincter-saving surgery were performed on 89 patients. Two groups were conducted in accordance with the new TNM stage, and compare local recurrence rate and 5-year survival rate of the two .Results:(1)There is no significant difference on gender, age, liver metastasis, pathological type, the primary tumor size, depth of invasion, tumor location, histological degree of penetration, infiltrated circumference of intestine, and the regional lymph node metastasis between the two groups (p>0.05). (2) In accordance with the late TNM,there is no statistically difference between the 2- and 5-year survival rates of the two groups on I, II and III (p>0.05), while in TNM IV,the two ways of the surgery is analyzed by univariate analysis, we found the mean survival duration is longer in Mile’s procedure(20.10±1.52 months versus 13.33±0.81 months), and there is remarkable difference in this issue of two groups handled by the Log-rank survival ratecurve (p<0.01).(3)Inthe patients whose tumors were in 5-7cm from anus, there is no significant difference between the 2- and 5-year survival rates of the two groups (p>0.05).Conclusion:(1)Stapling device application on sphincter-saving surgery should be performed to consult the individual condition, location of tumor, depth of infiltration, degree of differentiation, with lymph nodes metastasis or not and the instruments.(2)We find out that the sphincter preservation surgery with stapler can be performed to the low rectal cancer in the stage of TNM I, II and III, which is worthy to spread out. But if it’s in TNM IV Patients who have a good performance status , minimal metastatic disease and normalpreoperative liver function tests and complete resection can be carried out , we should resect the primary carcinoma via Mile’s surgery and aggressive systemic chemotherapy.(3)Stapling device application on sphincter-saving surgery in low rectal carcinoma,the resection length of carcinoma’s margin matchs each of the following conditions can prognosticate good outcome:①TNM- stageⅠ(T1 N0 M0、T2 N0 M0) , Well-Differentiated and moderately differentiated adenocarcinoma,infiltrated circumference≤1/2,the length≥2.0cm,②ⅡA(T3 N0 M0)、ⅡA(T3 N0 M0)、ⅡB(T4 N0 M0)、ⅢA(T1/T2N1M0),infiltrated circumference > 1/2 ; Well-Differentiated and moderately differentiated adenocarcinoma,the length≥2.5cm.③ⅢB(T3/ T4 N1 M0)、ⅢC(TanyN2 M0) ,infiltrated circumference≤1/2; moderately differentiated and poorly differentiated adenocarcinoma,the length≥3.0cm, pathological examination after surgery,there is no cancer cell residues distal colorectal cancer. However, the choice of surgery indications is very important for carcinomas ofⅢB、ⅢC.Not only preserved anus but ignore the complete removal of carcinoma.更多还原