腹腔镜结直肠癌的治疗进展.ppt

,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,Company Logo,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,腹腔镜辅助结直肠癌根治术,医学百事通转载,刘志华医师-直肠癌治疗,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？,2,Huashan Hospital Hao Hankun,腹腔镜发展史,Huashan Hospital Hao Hankun,1991,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,Huashan Hospital Hao Hankun,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):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,COST,(Clinical Outcomes of Surgical Therapy),COLOR,(COlon cancer Laparoscopic or Open Resection),CLASICC,(Conventional,versus,Laparoscopic-Assisted Surgery In Colorectal Cancer),Huashan Hospital Hao Hankun,腹腔镜与结肠癌,COST,的结果,N Engl J Med 2004;350:2050-9.,Huashan Hospital Hao Hankun,Conclusions,In 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 acceptable alternative to open surgery for colon cancer.,腹腔镜与结肠癌,COLOR,的结果,Less blood loss,Radicality of resection not differ,Earlier recovery of bowel function,Fewer analgesics,Shorter hospital stay,Morbidity and mortality 28 days after colectomy did not differ,Conclusion,：,Laparoscopic surgery can be used for safe and radical resection of cancer in the right,left,and sigmoid colon.,Lancet Oncol,2005;6:47784,Huashan Hospital Hao Hankun,ASCRS Practice Parameters(2012),Laparoscopic and open colectomy achieve equivalent oncological outcomes for localized colon cancer.The use 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:1A,Dis Colon Rectum 2012;55:831843,Huashan Hospital Hao Hankun,NCCN,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,NCCN,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,充分利用地球引力,方便术者操作,头高脚低位,头低脚高位,分腿位,左倾、右倾,Huashan Hospital Hao Hankun,操作准备之,Trocar,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，按手术种类和手术方式决定,一般是三到四个,选择原则,便于操作，打结、牵引、吸引,互不干扰,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,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,1.7,2kPa,或,10,13mmHg,）,Huashan Hospital Hao Hankun,手术操作-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5,mm,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,手术操作-结扎技术,夹闭法：,可吸收夹,不可吸收夹,圈套器,打结法,体内打结,体外打结,Huashan Hospital Hao Hankun,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,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）,1991,年，,Leroy J,完成首例腹腔镜,TME,Laparoscopic surgery is preferred in the setting of a clinical trial,NCCN Guidelines Version 3.2014(Rectal),Huashan Hospital Hao Hankun,腹腔镜与低位直肠癌（,ASCRS,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,possessing 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,Conclusions,：,According to these results,laparoscopic surgery is the best option for the surgical treatment of rectal cancer,with similar rates of local recurrence and survival.,Surg Endosc(2013)27:295302,Huashan Hospital Hao Hankun,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 trial,CLASICC:The Medical Research Council Conventional,versus,Laparoscopic-Assisted Surgery In Colorectal Cancer trial(1996),NCCN Guidelines Version 3.2014 Rectal Cancer,Huashan Hospital Hao Hankun,Five-year follow-up of CLASICC trial,British Journal of Surgery,2010;,97,:16381645,No differences were found between laparoscopically 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 cancer,Huashan Hospital Hao Hankun,Long-term follow-up of CLASICC trial,British Journal of Surgery,2013;,100,:7582,There were no statistically significant differences between open and laparoscopic groups in overall survival,Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer,Huashan Hospital Hao Hankun,腹腔镜直肠癌根治术,TME,指征,2,IMA,高位,/,低位结扎,1,植物神经如何保护,4,Huashan Hospital Hao Hankun,APR/LAR/ISR,5,下切缘要求,3,IMA,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 artery,Huashan Hospital Hao Hankun,Dis Colon Rectum 2013;56:535550,TME,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 Hankun,Distal resection margins,Br J Surg 1951;39:199,Dis Colon,Rectum 2005;48:411,Ann Surg Oncol 2003;10:80,5 cm,2 cm,1 cm,Huashan Hospital Hao Hankun,NCCN,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 Hankun,ASCRS,关于下切缘,Huashan Hospital Hao Hankun,Dis Colon Rectum 2013;56:535550,A 2-cm distal mural margin is adequate for most rectal 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,Huashan Hospital Hao Hankun,植物神经保护,Huashan Hospital Hao Hankun,医学百事通，,咨询医师,植物神经保护,Huashan Hospital Hao Hankun,植物神经保护,Huashan Hospital Hao Hankun,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?,Huashan Hospital Hao Hankun,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 Hankun,ISR,评价,Dis Colon Rectum 2005;48:18581867,Intersphincteric resection 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 Hankun,ISR,评价,Oncological outcomes after ISR for low rectal cancer are acceptable,with diverse,often,imperfect functional 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,:603612,Huashan Hospital Hao Hankun,ISR,分类,Dis Colon Rectum 2009;52:64-70,Huashan Hospital Hao Hankun,选择,ISR,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 Hankun,APR,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,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,腹腔镜低位直肠癌根治（,LAR,）,1,Huashan Hospital Hao Hankun,Thank You!,复旦大学附属华山医院 蒿汉坤,haohankun,