晚期大腸癌外科治療

1、大腸癌的外科治療進(jìn)展,,患者，女，27歲，妊娠37周突發(fā)腹痛---子宮先兆破裂？行剖腹探查術(shù)---乙狀結(jié)腸腫瘤梗阻伴穿孔導(dǎo)致腹膜炎第1 步行剖宮產(chǎn)第2 步乙結(jié)腸腸段腫瘤拖出第3 步術(shù)后第二天縱軸剖開(kāi)行襻式造口第4 步剖宮產(chǎn)恢復(fù)后7天，行FOLFRI方案化療---腫瘤明顯縮小第5 步乙結(jié)腸癌根治術(shù)，目前已無(wú)瘤存活4年,第1 步剖宮產(chǎn) 婦科會(huì)診制第2 步乙結(jié)腸腸段腫瘤拖出

2、第3 步術(shù)后第二天縱軸剖開(kāi)行造口 微創(chuàng)技術(shù)第4 步恢復(fù)后7天，行FOLFRI方案化療 腫瘤科第5 步根治術(shù)，無(wú)瘤存活4年 結(jié)果,快速康復(fù)理念外科損傷控制,微創(chuàng)技術(shù)采用特殊器械縮小手術(shù)創(chuàng)傷范圍，減少應(yīng)激損傷控制采用特殊手術(shù)方案縮小手術(shù)創(chuàng)傷程度，減輕應(yīng)激外科快速康復(fù)理念采用一系列措施，減少應(yīng)激程度，促進(jìn)康復(fù),腹腔鏡(laparoscopy)經(jīng)肛門

3、內(nèi)窺鏡下微創(chuàng)手術(shù)( transanal endoscopic microsurgery,TEM) 腹腔鏡-內(nèi)鏡“雙鏡”聯(lián)合手術(shù)(Laparoscopic in combination with transanal endoscopic microsurgery) 經(jīng)自然腔道內(nèi)鏡手術(shù)(natural orifice transluminal endoscopic surgery, NOTES) 經(jīng)臍單孔腹腔鏡技術(shù)(t

4、ransumbilical laparoendoscopic single site surgery,TU-LESS)機(jī)器人手術(shù)(robotic surgery),微創(chuàng)技術(shù),腹腔鏡對(duì)大腸良性病變及晚期大腸癌的姑息性切除或短路手術(shù)的微創(chuàng)療效已基本得到肯定，并廣泛應(yīng)用，但對(duì)非晚期大腸癌的腹腔鏡腸切除術(shù)，是否能達(dá)到根治目的尚有較多爭(zhēng)議。,腹腔鏡,經(jīng)肛門內(nèi)鏡顯微手術(shù)（Transanal Endoscopic Microsurgery,

5、TEM）,TEM兼?zhèn)淞藘?nèi)鏡、腹腔鏡和顯微手術(shù)的優(yōu)點(diǎn) TEM主要適應(yīng)于距肛門4-20cm范圍內(nèi)的腺瘤或早期直腸癌 如對(duì)不愿或不能耐受經(jīng)腹根治性手術(shù)的高齡或高手術(shù)風(fēng)險(xiǎn)病人的姑息性手術(shù)及有廣泛轉(zhuǎn)移病人的局部控制。,,,,固定支撐架(adjustable holder),,直腸鏡手術(shù)鞘 （operating rectoscope),,工作附件 （working attachment）,,,雙目立體視鏡,單目鏡,,,,,經(jīng)肛門內(nèi)窺鏡下微

6、創(chuàng)手術(shù)（TEM）,我們的經(jīng)驗(yàn)：,Local Resection for Rectal Tumors: Comparative Study of Transanal Endoscopic rosurgery versus Conventional Transanal Excision - The Experience in China. Yi H, Yong-Gang H, Mou-Bin L, Ya-Jie Z, Lu Y, Jin X

7、, Jian-Wen L.Hepatogastroenterology. 2012 Apr 25;59(120).,腹腔鏡-內(nèi)鏡“雙鏡”聯(lián)合技術(shù),按傳統(tǒng)腔鏡技術(shù)行直腸或乙狀結(jié)腸癌切除術(shù)大多數(shù)腫瘤能經(jīng)鏡筒從肛門拖出，避免腹部切口雙鏡操作時(shí)腹腔與直腸內(nèi)壓力保持穩(wěn)定，視野暴露清晰，可精確定位腫瘤下切緣，允許腹腔內(nèi)及肛門內(nèi)同時(shí)操作,完成TME后，經(jīng)肛門取出標(biāo)本,關(guān)閉遠(yuǎn)端殘端后，完成吻合,乙結(jié)腸腫瘤，腔鏡下荷包縫合并放置抵釘座,術(shù)后腹部無(wú)切口

8、,2012年CSCO年會(huì)　北京,腹腔鏡-內(nèi)鏡“雙鏡”聯(lián)合技術(shù),術(shù)后腹部無(wú)切口,腹腔鏡-內(nèi)鏡“雙鏡”聯(lián)合技術(shù),我們的經(jīng)驗(yàn)：,Total laparoscopic sigmoid and rectal surgery in combination with transanal endocopic microsurgery: a preliminary evaluation in China. Han Y, He YG, Zhang HB,

9、Lv KZ, Zhang YJ, Lin MB, Yin L.Surg Endosc. 2012 Jul 18.,損傷控制,對(duì)于嚴(yán)重創(chuàng)傷的病人,改變以往在早期進(jìn)行復(fù)雜、完整手術(shù)的策略, 采取分期救治的原則。手術(shù)的最終目的是挽救病人的生命, 提高病人的生存質(zhì)量, 而不是追求所謂的/ 完美手術(shù)術(shù), 一旦達(dá)到治療目的, 任何多余的操作都可能徒增病人機(jī)體的負(fù)擔(dān)。核心內(nèi)容是盡量減少手術(shù)及各種處置本身所引起的損傷,,快速康復(fù)外科(Fast-Tr

10、ack Surgery，F(xiàn)TS) 主要包括快速通道麻醉、微創(chuàng)技術(shù)、最佳鎮(zhèn)痛技術(shù)及強(qiáng)有力的術(shù)后護(hù)理(如術(shù)后早期進(jìn)食、運(yùn)動(dòng))等，其宗旨是為患者提供最優(yōu)質(zhì)的服務(wù)、最大的益處和最少的損傷。,現(xiàn)代腫瘤外科快速康復(fù)理念,將微創(chuàng)技術(shù)與FTS共同應(yīng)用于腫瘤治療，可以降低患者術(shù)后炎癥反應(yīng)及免疫損傷，減輕患者的疼痛，有利于術(shù)后肺、心、腎、腸道等多器官功能的恢復(fù)，縮短術(shù)后住院時(shí)間，進(jìn)而達(dá)到快速恢復(fù)的目的，為進(jìn)一步的治療打下基礎(chǔ)。,微創(chuàng)技術(shù)與快速康復(fù)理念

11、聯(lián)合應(yīng)用,外科在晚期腫瘤治療中角色的演變,現(xiàn)代腫瘤治療已經(jīng)從單一依靠外科過(guò)渡到多學(xué)科參與的綜合治療 。外科醫(yī)生應(yīng)該熟悉腫瘤治療的各種手段：手術(shù)可以提高腫瘤治療的局部和區(qū)域控制率；化療、放療、內(nèi)分泌治療、生物基因治療和分子靶向治療等可進(jìn)一步減少?gòu)?fù)發(fā)和死亡，提高患者生存率；基因芯片、基因組學(xué)、蛋白質(zhì)組學(xué)以及臨床預(yù)后指標(biāo)檢測(cè)，有助于輔助治療的選擇和判斷預(yù)后，也為腫瘤的分子研究提供了更直觀、更精確的工具。,晚期大腸癌的化療,????

12、?????????????????????????????????????????????,?????????????????????????????????????????????????,?????????,?????????,??????????????????????????????????????????,Lin M, Gu J, Eng C, Ellis LM, Hildebrandt MA, Lin J, Huang M,

13、 Calin GA, Wang D, Dubois RN, Hawk ET, Wu X.Genetic polymorphisms in MicroRNA-related genes as predictors of clinical outcomes in colorectal adenocarcinoma patients. Clin Cancer Res. 2012 15;18(14):3982-91. (SCI 7.742)L

14、in M, Eng C, Hawk ET, Huang M, Lin J, Gu J, Ellis LM, Wu X. Identification of polymorphisms in ultraconserved elements associated with clinical outcomes in locally advanced colorectal adenocarcinoma. Cancer. 2012 15;118(

15、24):6188-98. (SCI 4.771)Lin M, Eng C, Hawk ET, Huang M, Greisinger AJ, Gu J, Ellis LM, Wu X, Lin J. Genetic variants within ultraconserved elements and susceptibility to right- and left-sided colorectal adenocarcinoma.

16、Carcinogenesis. 2012;33(4):841-7. (SCI 5.702) Lin M, Stewart DJ, Spitz MR, Hildebrandt MA, Lu C, Lin J, Gu J, Huang M, Lippman SM, Wu X.Genetic variations in the transforming growth factor-beta pathway as predictors of

17、survival in advanced non-small cell lung cancer. Carcinogenesis. 2011;32(7):1050-6. (SCI 5.702),,,,Macedo LT, da Costa Lima AB, Sasse AD. Addition of bevacizumab to first-line chemotherapy in advanced colorectal cancer:

18、a systematic review and meta-analysis, with emphasis on chemotherapy subgroups.BMC Cancer. 2012 12:89.,Bevacizumab in colorectal cancer was studied initially in the metastatic setting, and was approved by US FDA in 2004,

19、 based on a survival benefit noted in the AVF2107 trial with irinotecan, 5-fluorouracil and leucovorin (IFL) regimen. The increment in OS occurred only for irinotecan-based regimens (HR = 0.78; 95% CI: 0.68-0.89; P = 0.

20、0002) and no oxaliplatinbased treatments presented statistically significant data.,,,The Medical Research Council (MRC) COIN trial has not confirmed a benefit of addition of cetuximab to oxaliplatin-based chemotherapy in

21、 first-line treatment of patients with advanced colorectal cancer. No benefit in progression-free or overall survival in KRAS wild-type patients was observed. The multicenterCRYSTAL trial showed that HR for progression-

22、free survival among patients with wild-type–KRAS tumors was 0.68 (95% CI, 0.50 to 0.94), in favor of the cetuximab–FOLFIRI group.,,,,,Timothy S Maughan, Richard A Adams, Christopher G Smith, et al.Addition of cetuximab t

23、o oxaliplatin-based first-line combination chemotherapy for treatment of advanced colorectal cancer: results of the randomised phase 3 MRC COIN trialLancet. 2011 377(9783): 2103–2114. Van Cutsem E, Kochne C-H, Hitre E,