腹腔镜结直肠癌的治疗进展.ppt

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1、腹腔镜辅助结直肠癌根治术腹腔镜辅助结直肠癌根治术主要内容主要内容腹腔镜结直肠癌根治是否可行？1如何行腹腔镜结直肠癌根治术？2Huashan Hospital Hao Hankun腹腔镜发展史腹腔镜发展史Huashan Hospital Hao Hankun1991年 Flower和Jacobs行腹腔镜乙状结肠切除术1992年 Kokerling首次施行腹腔镜Miles手术1993年 Watanabe日本首例腹腔镜结肠手术1994年 Leahy首次报告手助腹腔镜手术1995年 香港郭宝贤完成亚洲首例乙状结肠手术1997年 上海郑民华完成内地首例乙状结肠手术腹腔镜结直肠手术发展腹腔镜结直肠手术发展

2、Huashan Hospital Hao Hankun腹腔镜面临的质疑腹腔镜面临的质疑Lancet.1994 344(8914):58.Subcutaneous metastases after laparoscopic colectomy.Berends FJ,Kazemier G,Bonjer HJ,Lange JF.Br J Surg.1994 81(5):648-52.Abdominal wall metastases following laparoscopy.Nduka CC1,Monson JR,Menzies-Gow N,Darzi A.Br J Surg.1994 81(11

3、):1697.Abdominal wall metastases following laparoscopy.Prasad A,Avery C,Foley RJ.Huashan Hospital Hao Hankun腹腔镜医生迎接挑战腹腔镜医生迎接挑战COST(Clinical Outcomes of Surgical Therapy)COLOR(COlon cancer Laparoscopic or Open Resection)CLASICC(Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer)Hu

4、ashan Hospital Hao Hankun腹腔镜与结肠癌腹腔镜与结肠癌COST的结果N Engl J Med 2004;350:2050-9.Huashan Hospital Hao HankunConclusionsIn this multi-institutional study,the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy,suggesting that the laparoscopic approach is an a

5、cceptable alternative to open surgery for colon cancer.腹腔镜与结肠癌腹腔镜与结肠癌COLOR的结果Less blood lossRadicality of resection not differEarlier recovery of bowel functionFewer analgesicsShorter hospital stayMorbidity and mortality 28 days after colectomy did not differConclusion：Laparoscopic surgery can be us

6、ed for safe and radical resection of cancer in the right,left,and sigmoid colon.Lancet Oncol 2005;6:47784Huashan Hospital Hao HankunASCRS Practice Parameters ASCRS Practice Parameters(2012)(2012)Laparoscopic and open colectomy achieve equivalent oncological outcomes for localized colon cancer.The us

7、e of the laparoscopic approach should be based on the surgeons documented experience in laparoscopic surgery as well as on patient-and tumor-specific factors.Grade of Recommendation:1ADis Colon Rectum 2012;55:831843 Huashan Hospital Hao HankunNCCNNCCN指南的变化指南的变化拒绝：费用昂贵，术后恢复时间与开腹手术没有区别，且缺乏相关生存数据，不推荐临床

8、常规使用。部分接受：要求术者具有丰富的腹腔镜手术经验；无直肠或远端结肠肿瘤；无远处转移、无梗阻或穿孔、无腹腔粘连；要求术者对腹腔全面探查；较小的肿瘤术前需要定位。Huashan Hospital Hao Hankun医学百事通，在线医生咨询NCCNNCCN指南的变化指南的变化Huashan Hospital Hao Hankun腹腔镜结直肠手术的主要适应证和禁忌证适应证：腹腔镜手术适应证与传统开腹手术相似。包括结肠良恶性 肿瘤、炎性疾病、多发性息肉等；相对手术禁忌：肿瘤直径大于6cm或/和与周围组织广泛侵润；腹部严重粘连、重度肥胖者、大肠癌的急症手术（如急性梗阻、穿孔等）；心肺功能不良者；禁忌

9、证：全身情况不良，虽经术前治疗仍不能纠正者；有严重心肺肝肾疾患，不能耐受手术；随着腹腔镜手术技术和器械的发展，以及麻醉和全身 支持水平的提高，腹腔镜手术适应证将进一步扩大和发展。Huashan Hospital Hao Hankun操作准备之体位选择操作准备之体位选择充分利用地球引力方便术者操作A.头高脚低位 B.头低脚高位 C.分腿位D.左倾、右倾Huashan Hospital Hao Hankun操作准备之操作准备之TrocarTrocar的放置的放置第一穿刺孔往往选择在脐部减少对腹部血管、神经和腹直肌的损伤腹部正中位置,便于术者观察腹壁最薄处脐部穿刺切口更加隐蔽，符合美学要求其余穿刺孔

10、，按手术种类和手术方式决定一般是三到四个选择原则1.便于操作，打结、牵引、吸引2.互不干扰3.统筹兼顾，放置引流、切开、美观Huashan Hospital Hao Hankun医学百事通，网络会诊操作准备之操作准备之气腹的建立气腹的建立在第一穿刺孔气腹针直视下，小切口可视穿刺器气腹压力1.72kPa或1013mmHg）Huashan Hospital Hao Hankun手术操作手术操作-分离技术分离技术电刀分离：1)凝固血管和切断组织2)电钩、电铲等超声刀分离：1)切断5mm以下血管(蛋白质变性)2)多用途：切割、止血、分离、抓持等Huashan Hospital Hao Hankun手术

11、操作手术操作-结扎技术结扎技术夹闭法：l可吸收夹l不可吸收夹l圈套器打结法l体内打结l体外打结Huashan Hospital Hao Hankun手术视频手术视频腹腔镜辅助右半结肠切除术Huashan Hospital Hao Hankun腹腔镜与直肠癌腹腔镜与直肠癌技术上是否可行？肿瘤学是否安全？是否有优势？Huashan Hospital Hao Hankun腹腔镜与低位直肠癌（历史与现实）腹腔镜与低位直肠癌（历史与现实）1991年，Leroy J完成首例腹腔镜TMELaparoscopic surgery is preferred in the setting of a clinica

12、l trialNCCN Guidelines Version 3.2014(Rectal)Huashan Hospital Hao Hankun腹腔镜与低位直肠癌（腹腔镜与低位直肠癌（ASCRSASCRS现状）现状）Current evidence indicates that laparoscopic TME can be performed with equivalent oncological outcomes in comparison with open TME when performed by experienced laparoscopic surgeons possessin

13、g the necessary technical expertise.Grade of Recommendation:Strong recommendation based on moderate quality evidence,1B.Dis Colon Rectum 2013;56:535550腹腔镜直肠癌手术的循证医学依据腹腔镜直肠癌手术的循证医学依据Conclusions：According to these results,laparoscopic surgery is the best option for the surgical treatment of rectal can

14、cer,with similar rates of local recurrence and survival.Surg Endosc(2013)27:295302Huashan Hospital Hao Hankun腹腔镜直肠癌手术的循证医学依据腹腔镜直肠癌手术的循证医学依据To date,the highest level of evidence for the benefits of the laparoscopic approach comes from the CLASICC trialCLASICC:The Medical Research Council Conventional

15、 versus Laparoscopic-Assisted Surgery In Colorectal Cancer trial(1996)NCCN Guidelines Version 3.2014 Rectal CancerHuashan Hospital Hao HankunFive-year follow-up of CLASICC Five-year follow-up of CLASICC trialtrialBritish Journal of Surgery 2010;97:16381645No differences were found between laparoscop

16、ically assisted and open surgery in terms of overall survival,disease-free survival,and local and distant recurrence.The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancerHuashan Hospital Hao HankunLong-term follow-up of Long-term follow-up of C

17、LASICC trialCLASICC trialBritish Journal of Surgery 2013;100:7582There were no statistically significant differences between open and laparoscopic groups in overall survivalLong-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancerHuashan Hospital Hao Ha

18、nkun腹腔镜直肠癌根治术腹腔镜直肠癌根治术TME指征2IMA高位/低位结扎1植物神经如何保护4Huashan Hospital Hao HankunAPR/LAR/ISR5下切缘要求3IMAIMA处理细节处理细节IMA低位结扎/高位结扎？低位结扎理由：生存率与高位相当高位结扎理由：更高的淋巴结检出率、更准确的分期利于降低张力，尤其是低位直肠前切理论上更好的预后并不增加手术风险和时间高位清扫、低位结扎美国结直肠外科医师协会（2013）to the level of the origin of the superior rectal arteryHuashan Hospital Hao Hank

19、unDis Colon Rectum 2013;56:535550TMETME指征指征Miles的贡献（1908）Heald的贡献（1993）TME的指征 直肠中1/3和下1/3的肿瘤,无论行低位前切除术(LAR)还是腹会阴联合切除术(APR),均应采用全直肠系膜切除技术(TME)TSME、PME 对于直肠上1/3的肿瘤,可根据肿瘤情况进行系膜的切除,但要保证远切缘距肿瘤5 cm以上Huashan Hospital Hao HankunDistal resection marginsDistal resection marginsBr J Surg 1951;39:199Dis ColonRe

20、ctum 2005;48:411Ann Surg Oncol 2003;10:805 cm 2 cm1 cmHuashan Hospital Hao HankunNCCNNCCN关于下切缘要求关于下切缘要求对于超低位直肠癌（5cm），1-2cm的阴性下切缘是可以接受的，但必须送冰冻证实。Huashan Hospital Hao HankunASCRSASCRS关于下切缘关于下切缘Huashan Hospital Hao HankunDis Colon Rectum 2013;56:535550A 2-cm distal mural margin is adequate for most rec

21、tal cancers when combined with a TME.For cancers located at or below the mesorectal margin,a 1-cm distal mural margin is acceptable.Grade of Recommendation:Strong recommendation based on moderate quality evidence,1B.植物神经保护植物神经保护Huashan Hospital Hao Hankun植物神经保护植物神经保护Huashan Hospital Hao Hankun医学百事通，

22、咨询医师植物神经保护植物神经保护Huashan Hospital Hao Hankun植物神经保护植物神经保护Huashan Hospital Hao Hankun 植物神经保护植物神经保护Huashan Hospital Hao Hankun肿瘤学原则：充分的切缘功能学原则：良好的括约肌功能医生的选择：技术难度、潜在风险患者的选择：充分的医患沟通LAR,ISR or APR?LAR,ISR or APR?Huashan Hospital Hao HankunLAR or ISR?LAR or ISR?LAR指征：肿瘤下缘距离齿状线大于3cm无括约肌和周围脏器侵犯双吻合器ISR指征：肿瘤下缘距

23、离齿状线小于3cm肿瘤下缘距离括约肌间沟大于1cm无外括约肌或提肛肌侵犯Huashan Hospital Hao Hankun括约肌间切除(ISR)括约肌间切除（intersphincteric resection,ISR)最早(1994)由Schiessel等详细描述 提高保肛率获得更确切的下切缘潜在的劣势：增加手术并发症局部复发控便功能损害Br J Surg.1994 Sep;81(9):1376-8.Huashan Hospital Hao HankunISRISR评价评价Dis Colon Rectum 2005;48:18581867Intersphincteric resectio

24、n is a valuable procedure for sphincter-saving rectal surgery.We showed that this technique has satisfactory long-term results in functional and oncologic respects.Huashan Hospital Hao HankunISRISR评价评价Oncological outcomes after ISR for low rectal cancer are acceptable,with diverse,oftenimperfect fun

25、ctional results.These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.British Journal of Surgery 2012;99:603612Huashan Hospital Hao HankunISRISR分类分类Dis Colon Rectum 2009;52:64-70Huashan Hospital Hao Hankun选择选择ISRISR需谨慎需谨慎肿瘤分期基础括约肌功能是否需要辅助放疗患者性别以及年龄患者主观意愿Huashan Hospital Hao HankunAPRAPR指征指征APR适用于肿瘤侵犯外括约肌或提肛肌，或可能导致肛门失禁的保肛术。Huashan Hospital Hao Hankun直肠癌手术原则直肠癌手术原则肿瘤学良好的结果良好的功能保护不要盲目保肛Huashan Hospital Hao Hankun手术视频手术视频腹腔镜低位直肠癌根治（LAR）1Huashan Hospital Hao Hankun复旦大学附属华山医院 蒿汉坤