本文選題：直腸癌 + 直腸低位前切除術(shù)��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景目前,我國(guó)結(jié)直腸癌發(fā)病率和病死率持續(xù)上升,已成為我國(guó)最常見(jiàn)的消化道惡性腫瘤之一。相對(duì)高位直腸癌以及結(jié)腸癌來(lái)說(shuō),中低位直腸癌的預(yù)后較差,五年生存率約為40%左右。由此可見(jiàn),中低位直腸癌在我國(guó)存在著發(fā)病率高,預(yù)后差的顯著特點(diǎn),對(duì)我國(guó)國(guó)民生命健康及生活質(zhì)量有著顯著影響。中低位直腸癌的主要治療方式是以手術(shù)治療為主的綜合治療措施,隨著社會(huì)的發(fā)展和人民對(duì)生活質(zhì)量的要求,腹腔鏡外科技術(shù)的熟練,腹腔鏡下直腸低位前切除術(shù)稱(chēng)為了臨床治療中最常見(jiàn)的手術(shù)方式。其恢復(fù)快,創(chuàng)傷小以及對(duì)腸系膜下動(dòng)脈(inferior mesenteric artery,IMA)根部淋巴結(jié)清掃更徹底的優(yōu)點(diǎn),成為越來(lái)越多中國(guó)結(jié)直腸外科大夫的首選。腹腔鏡Dixon手術(shù)中對(duì)于IMA的處理目前主要有HT(high tie,HT)和LT(lowtie,LT)兩種。HT主要有操作簡(jiǎn)單,腸管松弛、吻合口張力小、可以減少對(duì)腹腔自主神經(jīng)的損傷等優(yōu)點(diǎn),但同時(shí)可能影響吻合口血供,部分患者可能需要游離脾曲。LT對(duì)于吻合口血供的維持有更好效果,且部分學(xué)者認(rèn)為可以減少術(shù)中出血量,但在行IMA根部三角區(qū)淋巴清掃時(shí)難度較大。綜合文獻(xiàn)報(bào)道,兩種方法(D3清掃)對(duì)淋巴結(jié)清掃數(shù)目、吻合口漏發(fā)生率、復(fù)發(fā)率及生存率等影響孰優(yōu)孰劣尚存爭(zhēng)議。研究目的1.探討分析直腸癌患者在腹腔鏡下直腸低位前切除術(shù)(low anterior resection,LAR)中IMAHT后吻合口瘺發(fā)生率、游離脾曲的發(fā)生率、預(yù)防性造瘺的發(fā)生率的風(fēng)險(xiǎn)。2.探討LAR術(shù)中HT和LT對(duì)于吻合口血供的影響。3.探討不同吻合口血供對(duì)于游離脾曲發(fā)生率,預(yù)防性造瘺發(fā)生率以及吻合口瘺發(fā)生率的影響。研究方法按照如下入組標(biāo)準(zhǔn),收集2012年1月—2016年12月于山東大學(xué)齊魯醫(yī)院結(jié)直腸外科接受直腸低位前切除術(shù)的101例,并收集患者完整住院病歷。入組標(biāo)準(zhǔn):(1)術(shù)前經(jīng)腸鏡活檢和組織病理學(xué)檢測(cè)證實(shí)腫塊為直腸癌;(2)經(jīng)術(shù)前影像學(xué)、直腸指診及腸鏡檢查證實(shí)癌腫位于直腸中下段,即腫瘤距肛緣5cm 但12cm;(3)腫瘤無(wú)遠(yuǎn)處轉(zhuǎn)移及局部其他器官的浸潤(rùn);(4)手術(shù)方式為腹腔鏡下直腸低位前切除術(shù);排除標(biāo)準(zhǔn):(1)術(shù)前已經(jīng)行新輔助放化療的患者;(2)下腹部手術(shù)史;(3)因并發(fā)急性腸梗阻、腸穿孔并急性腹膜炎、急性大出血等行急診手術(shù)的患者;(4)手術(shù)過(guò)程中發(fā)現(xiàn)的腹腔廣泛轉(zhuǎn)移或鄰近其他臟器的浸潤(rùn)轉(zhuǎn)移。按照IMA的結(jié)扎方式,將入組病例分為HT組和LT組,其中HT組包括病號(hào)39例,LT組62例。回顧性分析總結(jié)所有入組患者的臨床資料;運(yùn)用卡方檢驗(yàn)分析HT組和LT組吻合口瘺、游離脾曲、預(yù)防性造瘺發(fā)生率和吻合口血供分級(jí)的組間差異。按照入組病例吻合口血供分級(jí)重新分組:A組為切割閉合器切斷后,斷端可見(jiàn)明顯搏動(dòng)性出血,· B組為切割閉合器切斷后,斷端可見(jiàn)較明顯滲血;C組為切割閉合器切斷后,斷端未見(jiàn)明顯出血及滲血;運(yùn)用卡方檢驗(yàn)分析不同等級(jí)吻合口血供在吻合口瘺、游離脾曲和預(yù)防性造瘺發(fā)生率的組間差異。研究結(jié)果1.入組病例基本資料對(duì)比與HT組相比,LT組在年齡、性別、吸煙、飲酒、高血壓、糖尿病、家族史、血白蛋白、血紅蛋白(hemoglobin,HGB)、白細(xì)胞(white blood cell,WBC)、谷丙轉(zhuǎn)氨酶(glutamic-pyruvic transaminase,ALT)、谷草轉(zhuǎn)氨酶(glutamic-oxalacetic transaminase,AST)、肌酐(creatinine,Cr)、凝血酶原時(shí)間(prothrombin time,PT)等無(wú)統(tǒng)計(jì)學(xué)差異(p0.05);與HT組相比,LT組的癌胚抗原(carcinoembryonic antigen,CEA)和手術(shù)時(shí)間顯著減少(p0.05)。見(jiàn)表1。2.HT組和LT組吻合口瘺、游離脾曲、預(yù)防性造瘺發(fā)生率和吻合口血供分級(jí)的組間比較2.1病例組吻合口瘺發(fā)生率的組間比較與HT組相比,LT組吻合口瘺發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。2.2病例組游離脾曲發(fā)生率的組間比較與HT組相比,LT組游離脾曲發(fā)生率更小,有統(tǒng)計(jì)學(xué)差異(p0.05)。2.3病例組預(yù)防性造瘺發(fā)生率的組間比較與HT組相比,LT組行預(yù)防性造瘺的發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。2.4病例組吻合口血供分級(jí)的組間比較與HT組相比,LT組吻合口血供更豐富,差別有統(tǒng)計(jì)學(xué)意義(p0.01)。3.不同吻合口血供分級(jí)間吻合口瘺、游離脾曲和預(yù)防性造瘺發(fā)生率的比較3.1不同吻合口血供分級(jí)間吻合口瘺發(fā)生率的比較與A組相比,B組吻合口瘺發(fā)生率增加(p0.01),C組吻合口瘺發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05);與B組相比,C組吻合口瘺發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05);3.2不同吻合口血供分級(jí)間游離脾曲發(fā)生率的比較與A組相比,B組和C組游離脾曲發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05);與B組相比,C組游離脾曲發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05);3.3不同吻合口血供分級(jí)間預(yù)防性造瘺發(fā)生率的比較與A組相比,B組和C組預(yù)防性造瘺發(fā)生率有統(tǒng)計(jì)學(xué)差異(p0.05);而與B組相比,C組預(yù)防性造瘺發(fā)生率有統(tǒng)計(jì)學(xué)差異(p0.01)。結(jié)論1.在直腸低位前切除術(shù)中IMA行高位結(jié)扎不是吻合口瘺發(fā)生的獨(dú)立危險(xiǎn)因素。2.IMA中高位結(jié)扎組相對(duì)低位結(jié)扎組游離脾曲發(fā)生率更小,吻合口血供更豐富。3.入組病例按吻合口血供分級(jí)重新分組,血供越豐富,吻合口瘺發(fā)生率越低,預(yù)防性造瘺發(fā)生率越小。
[Abstract]:Background: at present, China's colorectal cancer incidence and mortality rates continue to rise, China has become one of the most common malignant tumor of digestive tract. The relatively high rectal cancer and colon cancer, poor prognosis in rectal cancer, five year survival rate is about 40%. Thus, in low rectal cancer in our country there is a disease high rate, obvious characteristics of poor prognosis, has a significant impact on the health and quality of life of our national life. The main treatment of low rectal cancer is surgical treatment, with the requirements of the quality of life and social development and people, skilled laparoscopic surgery, laparoscopic low anterior resection of rectum the most common way to surgical operation in clinical treatment. The quick recovery, small trauma and the inferior mesenteric artery (inferior mesenteric, artery, IMA) root lymph node thoroughly The advantages, become more and more China colorectal surgeons preferred. Laparoscopic Dixon surgery for the treatment of IMA is the main HT (high tie HT) and LT (lowtie, LT) two.HT mainly has simple operation, small bowel relaxation, anastomotic tension, can reduce the injury of abdominal cavity of autonomic nerve etc. but at the same time, may affect the anastomotic blood supply, some patients may need to be free of splenic flexure of.LT has better effect for maintaining the anastomotic blood supply, and some scholars think that can reduce the amount of bleeding, but the lymph in IMA triangle root cleaning difficult. According to literature reported, two methods (D3.) the number of lymph node dissection, anastomotic leakage rate, recurrence rate and survival rate of the merits is controversial. Objective: 1. of rectal cancer patients in laparoscopic low anterior resection (low anterior resection, LAR IM) The incidence of anastomotic fistula after AHT, the incidence of splenic flexure free HT and LT LAR, to investigate the preventive effect of the postoperative anastomotic blood supply of.3. on different anastomotic blood supply for free of splenic flexure of the occurrence of the risk of.2. fistula, fistula incidence and prevention of anastomotic fistula. Effect of birth rate. Methods according to the following group, from January 2012 to December 2016 in Qilu Hospital of Shandong University accepted 101 cases of colorectal surgery rectal low anterior resection, and complete medical records were collected. Inclusion criteria: (1) preoperative colonoscopy biopsy and histopathology confirmed the tumor for rectal cancer (2;) by preoperative imaging, digital rectal examination and colonoscopy confirmed cancer in the lower rectum, tumor from the anal margin of 5cm 12cm; (3) the tumor metastasis and other local organs; (4) surgery for abdominal laparoscopic rectal low anterior 鍒囬櫎鏈，

本文編號(hào)：1763431