腹腔镜结直肠癌的治疗进展ppt演示课件

腹腔镜辅助结直肠癌根治术.CompanyLogo主要内容HuashanHospitalHaoHankun.CompanyLogo腹腔镜发展史HuashanHospitalHaoHankun.CompanyLogo 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HuashanHospitalHaoHankun.CompanyLogo腹腔镜面临的质疑 Lancet. 1994344(8914):58.Subcutaneousmetastasesafterlaparoscopiccolectomy.BerendsFJ, KazemierG, BonjerHJ, LangeJF. BrJSurg. 199481(5):648-52.Abdominalwallmetastasesfollowinglaparoscopy.NdukaCC1, MonsonJR, Menzies-GowN, DarziA. BrJSurg. 199481(11):1697.Abdominalwallmetastasesfollowinglaparoscopy.PrasadA, AveryC, FoleyRJ.HuashanHospitalHaoHankun.CompanyLogo腹腔镜医生迎接挑战 COST(ClinicalOutcomesofSurgicalTherapy) COLOR(COloncancerLaparoscopicorOpenResection) CLASICC(ConventionalversusLaparoscopic-AssistedSurgeryInColorectalCancer)HuashanHospitalHaoHankun.CompanyLogo腹腔镜与结肠癌 COST的结果NEnglJMed2004;350:2050-9.HuashanHospitalHaoHankunConclusionsInthismulti-institutionalstudy,theratesofrecurrentcancerweresimilarafterlaparoscopicallyassistedcolectomyandopencolectomy,suggestingthatthelaparoscopicapproachisanacceptablealternativetoopensurgeryforcoloncancer..CompanyLogo腹腔镜与结肠癌 COLOR的结果LessbloodlossRadicalityofresectionnotdifferEarlierrecoveryofbowelfunctionFeweranalgesicsShorterhospitalstayMorbidityandmortality28daysaftercolectomydidnotdifferConclusion：Laparoscopicsurgerycanbeusedforsafeandradicalresectionofcancerintheright,left,andsigmoidcolon.LancetOncol2005;6:477–84HuashanHospitalHaoHankun.CompanyLogoASCRSPracticeParameters(2012)Laparoscopicandopencolectomyachieveequivalentoncologicaloutcomesforlocalizedcoloncancer.Theuseofthelaparoscopicapproachshouldbebasedonthesurgeon’sdocumentedexperienceinlaparoscopicsurgeryaswellasonpatient-andtumor-specificfactors.GradeofRecommendation:1ADisColonRectum2012;55:831–843HuashanHospitalHaoHankun.CompanyLogoNCCN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：①要求术者具有丰富的腹腔镜手术经验；②无直肠或远端结肠肿瘤；③无远处转移、无梗阻或穿孔、无腹腔粘连；④要求术者对腹腔全面探查；⑤较小的肿瘤术前需要定位。HuashanHospitalHaoHankun医学百事通，在线医生咨询.CompanyLogoNCCN指南的变化HuashanHospitalHaoHankun.CompanyLogo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。HuashanHospitalHaoHankun.CompanyLogo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HuashanHospitalHaoHankun.CompanyLogo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HuashanHospitalHaoHankun医学百事通，网络会诊www.12320bst.com.CompanyLogo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）HuashanHospitalHaoHankun.CompanyLogo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5mm以下血管(蛋白质变性)2)多用途：切割、止血、分离、抓持等HuashanHospitalHaoHankun.CompanyLogo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HuashanHospitalHaoHankun.CompanyLogo手术视频HuashanHospitalHaoHankun.CompanyLogo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？HuashanHospitalHaoHankun.CompanyLogo腹腔镜与低位直肠癌（历史与现实） 1991年，LeroyJ完成首例腹腔镜TME LaparoscopicsurgeryispreferredinthesettingofaclinicaltrialNCCNGuidelinesVersion3.2014(Rectal)HuashanHospitalHaoHankun.CompanyLogo腹腔镜与低位直肠癌（ASCRS现状）CurrentevidenceindicatesthatlaparoscopicTMEcanbeperformedwithequivalentoncologicaloutcomesincomparisonwithopenTMEwhenperformedbyexperiencedlaparoscopicsurgeonspossessingthenecessarytechnicalexpertise.GradeofRecommendation:Strongrecommendationbasedonmoderatequalityevidence,1B.DisColonRectum2013;56:535–550.CompanyLogo腹腔镜直肠癌手术的循证医学依据Conclusions：Accordingtotheseresults,laparoscopicsurgeryisthebestoptionforthesurgicaltreatmentofrectalcancer,withsimilarratesoflocalrecurrenceandsurvival.SurgEndosc(2013)27:295–302HuashanHospitalHaoHankun.CompanyLogo腹腔镜直肠癌手术的循证医学依据 Todate,thehighestlevelofevidenceforthebenefitsofthelaparoscopicapproachcomesfromtheCLASICCtrial CLASICC:TheMedicalResearchCouncilConventionalversusLaparoscopic-AssistedSurgeryInColorectalCancertrial(1996)NCCNGuidelinesVersion3.2014RectalCancerHuashanHospitalHaoHankun.CompanyLogoFive-yearfollow-upofCLASICCtrialBritishJournalofSurgery2010;97:1638–1645Nodifferenceswerefoundbetweenlaparoscopicallyassistedandopensurgeryintermsofoverallsurvival,disease-freesurvival,andlocalanddistantrecurrence.The5-yearanalysesconfirmtheoncologicalsafetyoflaparoscopicsurgeryforbothcolonicandrectalcancerHuashanHospitalHaoHankun.CompanyLogoLong-termfollow-upofCLASICCtrialBritishJournalofSurgery2013;100:75–82TherewerenostatisticallysignificantdifferencesbetweenopenandlaparoscopicgroupsinoverallsurvivalLong-termresultscontinuetosupporttheuseoflaparoscopicsurgeryforbothcolonicandrectalcancerHuashanHospitalHaoHankun.CompanyLogo腹腔镜直肠癌根治术HuashanHospitalHaoHankun.CompanyLogoIMA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）totheleveloftheoriginofthesuperiorrectalarteryHuashanHospitalHaoHankunDisColonRectum2013;56:535–550.CompanyLogoTME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5cm以上｡HuashanHospitalHaoHankun.CompanyLogoDistalresectionmarginsHuashanHospitalHaoHankun.CompanyLogoNCCN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。HuashanHospitalHaoHankun.CompanyLogoASCRS关于下切缘HuashanHospitalHaoHankunDisColonRectum2013;56:535–550A2-cmdistalmuralmarginisadequateformostrectalcancerswhencombinedwithaTME.Forcancerslocatedatorbelowthemesorectalmargin,a1-cmdistalmuralmarginisacceptable.GradeofRecommendation:Strongrecommendationbasedonmoderatequalityevidence,1B..CompanyLogo植物神经保护HuashanHospitalHaoHankun.CompanyLogo植物神经保护HuashanHospitalHaoHankun医学百事通，咨询医师.CompanyLogo植物神经保护HuashanHospitalHaoHankun.CompanyLogo植物神经保护HuashanHospitalHaoHankun.CompanyLogo植物神经保护HuashanHospitalHaoHankun.CompanyLogo 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,ISRorAPR?HuashanHospitalHaoHankun.CompanyLogoLARorISR? 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HuashanHospitalHaoHankun.CompanyLogo括约肌间切除(ISR) 括约肌间切除（intersphinctericresection,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BrJSurg.1994Sep;81(9):1376-8.HuashanHospitalHaoHankun.CompanyLogoISR评价DisColonRectum2005;48:1858–1867Intersphinctericresectionisavaluableprocedureforsphincter-savingrectalsurgery.Weshowedthatthistechniquehassatisfactorylong-termresultsinfunctionalandoncologicrespects.HuashanHospitalHaoHankun.CompanyLogoISR评价OncologicaloutcomesafterISRforlowrectalcancerareacceptable,withdiverse,oftenimperfectfunctionalresults.ThesedatawillaidtheclinicianwhencounsellingpatientsconsideringanISRformanagementoflowrectalcancer.BritishJournalofSurgery2012;99:603–612HuashanHospitalHaoHankun.CompanyLogoISR分类DisColonRectum2009;52:64-70HuashanHospitalHaoHankun.CompanyLogo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HuashanHospitalHaoHankun.CompanyLogoAPR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。HuashanHospitalHaoHankun.CompanyLogo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HuashanHospitalHaoHankun.CompanyLogo手术视频HuashanHospitalHaoHankun.复旦大学附属华山医院蒿汉坤haohankun@gmail.com.