本文選題：直腸癌 + 腹腔鏡手術(shù)��； 參考：《上海交通大學(xué)》2015年博士論文

【摘要】：第一部分：三孔腹腔鏡直腸癌手術(shù)可行性研究目的：近年來,陸續(xù)有人提出腹腔鏡直腸癌手術(shù)的新技術(shù),是對傳統(tǒng)常規(guī)腹腔鏡術(shù)式的補充與發(fā)展。這些新的技術(shù)各有特點,但目前均未被廣泛推廣。大部分新技術(shù)的安全性、可行性尚待進(jìn)一步論證。我們自2011年提出“三孔”腹腔鏡直腸癌根治術(shù),至今已累積了不少病例。本文目的在于比較這一技術(shù)與常規(guī)腹腔鏡技術(shù),并進(jìn)一步論證該技術(shù)的可行性。方法：回顧2013年6月至2014年12月,筆者研究團(tuán)隊所行腹腔鏡直腸癌手術(shù)病例,行回顧性病例對照研究。依據(jù)特定的納入標(biāo)準(zhǔn)篩選合適病人,歸入“三孔組”和“常規(guī)組”(包括“四孔”和“五孔”腹腔鏡直腸癌手術(shù))。就術(shù)前基本情況、腫瘤特點、術(shù)中情況、短期預(yù)后、標(biāo)本情況等方面展開比較。結(jié)果：經(jīng)過篩選總共175例病例符合條件,納入研究。排除接受腹會陰聯(lián)合切除的病人,得到三孔組80例,常規(guī)組66例。兩組病人的基本術(shù)前情況在年齡、性別比例、BMI、T分期、N分期方面數(shù)據(jù)無顯著差異。在腫塊位置的比較上,三孔組腫塊位置較常規(guī)組位置高,差異顯著(P=0.000)。術(shù)中情況各項指標(biāo),兩組并無顯著差異。術(shù)后短期預(yù)后上,三孔組有5(6.3%)例出現(xiàn)了吻合口瘺,常規(guī)組6(9.1%)例；三孔組另有2(2.5%)例術(shù)后短期內(nèi)腸梗阻病例,常規(guī)組無此病例。在此次研究中,這兩類并發(fā)癥的總發(fā)生率為8.9%。除此之外,兩組在開放飲食時間、留置導(dǎo)尿及術(shù)后住院時間上,無顯著差異。結(jié)論：對于中高位直腸癌病人,三孔技術(shù)可以取得與常規(guī)腹腔鏡直腸癌手術(shù)相當(dāng)?shù)氖中g(shù)效果。在低位直腸癌、肥胖病人中,三孔技術(shù)的應(yīng)用尚需更多研究支持。第二部分：三孔腹腔鏡直腸癌術(shù)后泌尿生殖功能研究目的：隨著直腸癌治療水平的不斷提高,我們在直腸癌病人的生存率方面已經(jīng)取得了巨大的進(jìn)步。隨之而來的,患者對術(shù)后功能保留的需求也越來越高。關(guān)于腹腔鏡直腸癌手術(shù)后,泌尿生殖功能保留情況的研究并不豐富,尤其是對于腹腔鏡新技術(shù),更缺乏這方面數(shù)據(jù)。本篇文章的目的,在于研究腹腔鏡技術(shù)對保留直腸癌手術(shù)后泌尿生殖功能的作用,以及泌尿生殖功能障礙的危險因素。重點探討腹腔鏡新技術(shù)——“三孔”腹腔鏡直腸癌手術(shù)對術(shù)后功能的影響。方法：回顧2013年6月至2014年12月,筆者研究團(tuán)隊所行腹腔鏡直腸癌手術(shù)病例,行回顧性病例對照研究。依據(jù)特定的納入標(biāo)準(zhǔn)篩選合適病人,歸入“三孔組”和“常規(guī)組”。收集術(shù)前基本情況、腫塊特點、手術(shù)類型、病理資料、術(shù)后并發(fā)癥、后續(xù)治療等隨訪資料。另外,采用IPSS、IIEF、FSFI量表,評估病例術(shù)后泌尿、性功能。對數(shù)據(jù)進(jìn)行統(tǒng)計分析。結(jié)果：經(jīng)過篩選共111例病人納入研究,其中“三孔組”病例49例,“常規(guī)組“病例62例；所有病例中男性69例,女性42例。在對基礎(chǔ)情況的組間比較中,在中位年齡(P=0.014),手術(shù)類型(P=0.002),腫塊距肛緣距離(P=0.000),術(shù)后化療(P=0.022)這四個方面顯示出差異。兩組男性病人的性功能評分在術(shù)前、術(shù)后一月、術(shù)后三月未表現(xiàn)出顯著性差異,但在術(shù)后半年(P=0.026)、術(shù)后一年(P=0.017)時,“三孔組”好于“常規(guī)組”。對男性術(shù)后性功能行多因素分析,發(fā)現(xiàn)僅BMI(P=0.022)對術(shù)后性功能存在明顯影響,孔數(shù)與術(shù)后性功能相關(guān)性不明顯。女性病例性功能隨訪中失訪較多。對術(shù)后泌尿功能行單因素分析,發(fā)現(xiàn)手術(shù)的類型(P=0.058)、腫塊的位置(P=0.056,0.043)、術(shù)后放療(P=0.024)對泌尿功能的影響達(dá)到了統(tǒng)計顯著差異,而在多因素分析時,各項因素對結(jié)果均無顯著影響�？讛�(shù)對泌尿功能預(yù)后相關(guān)性不明顯。結(jié)論：三孔腹腔鏡直腸癌手術(shù)與常規(guī)腹腔鏡手術(shù),在術(shù)后泌尿生殖功能上,并無明顯差異。術(shù)中神經(jīng)的暴露與保護(hù)在合適病例中,可達(dá)到與常規(guī)腹腔鏡手術(shù)相同的水平,提示三孔技術(shù)安全可行。
[Abstract]:The first part: the feasibility study of three hole laparoscopic surgery for rectal cancer: in recent years, new techniques for laparoscopic rectal cancer have been proposed, which are complementary and developed to traditional conventional laparoscopic surgery. These new techniques have their own characteristics but are not widely popularized. The safety and feasibility of most new technologies have yet to be advanced. The purpose of this study is to compare this technique with conventional laparoscopy and to further demonstrate the feasibility of this technique. Methods: a retrospective review of the laparoscopic rectal cancer surgery from June 2013 to December 2014. A retrospective case control study was performed. The appropriate patients were selected according to the specific inclusion criteria and included in the "three holes" group and the "routine group" (including the "four holes" and "five holes" laparoscopic rectal cancer surgery). The preoperative basic conditions, tumor characteristics, intraoperative conditions, short-term, and specimen conditions were compared. Results: after screening, the results were screened. A total of 175 cases were included in the study. The patients were excluded from the co resection of the abdominal perineum, 80 cases in the three hole group and 66 cases in the routine group. The basic preoperative conditions of the two groups were not significantly different in age, sex ratio, BMI, T staging, and N staging. The difference was significant (P=0.000). There was no significant difference between the two groups. In the short term prognosis, there were 5 (6.3%) cases of anastomotic fistula in the three hole group, 6 (9.1%) in the routine group, and 2 (2.5%) in the three hole group, and there were no cases in the conventional group. In this study, the total incidence of these two complications was 8.9%.. In addition, there is no significant difference between the two groups in the open diet time, indwelling catheterization and postoperative hospitalization. Conclusion: for the patients with middle and high rectal cancer, the three hole technique can be equivalent to the conventional laparoscopic operation for rectal cancer. In the low rectal cancer patients, the application of the three hole technique still needs more research support. The two part: the study of urinary and reproductive function after three hole laparoscopic rectal cancer surgery: with the continuous improvement of the treatment level of rectal cancer, we have made great progress in the survival rate of rectal cancer patients. The study of reproductive function retention is not abundant, especially for new laparoscopic techniques. The purpose of this article is to study the role of laparoscopy in preserving urogenital function after the operation of rectal cancer and the risk factors of urogenital dysfunction. The focus is to explore the new laparoscopic technique - "three The effect of laparoscopic rectal cancer surgery on postoperative function. Methods: a retrospective case control study was performed from June 2013 to December 2014. A retrospective case control study was performed. The appropriate patients were selected according to the specific inclusion criteria and included in the "three hole group" and the "routine group". Block characteristics, surgical types, pathological data, postoperative complications, follow-up treatment and other follow-up data. In addition, the IPSS, IIEF, FSFI scales were used to assess the urinary and sexual functions of the cases after the operation. The data were statistically analyzed. Results: a total of 111 patients were selected to be included in the study, including 49 cases of "three hole" cases, 62 cases of "conventional group" cases, and all diseases. In the case of 69 male and 42 female cases, the difference between the middle age (P=0.014), the type of operation (P=0.002), the distance from the tumor to the anal margin (P=0.000), and the postoperative chemotherapy (P=0.022) were shown in the four aspects. The sexual function scores of the two groups of men were not significantly different before and after the operation one month after the operation, but in March. Three months after the operation (P=0.026) and one year after the operation (P=0.017), the three hole group was better than the conventional group. The sexual function of the male was analyzed by multiple factors. It was found that only BMI (P=0.022) had obvious influence on the postoperative sexual function, and the correlation between the number of holes and the postoperative sexual function was not obvious. The single factor analysis showed that the type of operation (P=0.058), the location of the lump (P=0.056,0.043), the effect of postoperative radiotherapy (P=0.024) on the urinary function had reached significant difference, while in the multifactor analysis, all the factors had no significant influence on the results. There is no significant difference in the postoperative urogenital function between the operation and the conventional laparoscopy. The exposure and protection of the nerve in the appropriate cases can reach the same level as that of the conventional laparoscopy, suggesting that the three hole technique is safe and feasible.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R735.37

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