循证医学实践汇报.ppt

循证医学实践汇报,成员： 汇报：,王某，男，71岁，永宁县人，农民，回族。 主诉：肛门憋胀感进行性加重4月。 现病史：患者自述4月前开始无明显诱因出现肛门憋胀感，无肛门疼痛，偶有里急后重感，无腹痛腹胀，无便血便细，无恶心呕吐，大便次数逐渐从1天1次变为1天34次，大便性状无改变，自行口服和外用类治痔疮药，效果无好转。10天前到永宁县医院做肛门指检后未作治疗，隔日就诊于五医院行直肠镜检查，考虑直肠肿瘤。为求进一步诊治，于10月19日来门诊就诊并收住我院结直肠外科。自发病以来，患者饮食睡眠精神尚可，小便正常，体重下降5kg左右。 既往史：30年前因颅骨骨折行外科手术，否认冠心病、糖尿病、高血压病史，无输血史和过敏史，否认传染病史。 体格检查：视诊肛门外形正常，触诊下腹正中有压痛，肛门括约肌张力及紧张度正常。肛门指诊距肛门缘2cm处有一34cm大小的肿块，活动度差，质韧、占据肠腔体积1/2。指套退出时无血，肛周触痛阴性。 诊断：直肠中分化腺癌。,循证问题构建,英语检索策略：Colorectal Cancer OR Large Intestine Cancer OR Colonic Neoplasm OR Rectal neoplasm AND Surgery AND laparoscopy AND RCT,1,经过初筛，阅读文献摘要、全文等过程，共收集6篇符合标准的文献。,纳入标准：（1）原始资料为已公开发表的文献；（2）研究对象为病理学诊断的结直肠癌患者；（3）文献类型为前瞻性随机对照研究；（4）干预方式为LS与OS比较，包括右半结肠切术、左半结肠切除术、乙状结肠切除术、腹会阴联合切除术、直肠前切除术等，LS为全腹腔镜手术或腹腔镜辅助手术；（5）原始文献中有患者特征、并发症，明确的随访截尾时的计数或计量资料等；（6）近5年发表的研究。 排除标准：（1）研究对象包括结直肠良性疾病，结直肠癌存在远处转移或周围器侵袭；（2）研究目的不是比较LS和OS的临床疗效以及动物实验和细胞实验；（3）未提供具体数据；（4）重复发表；（5）统计学分析违反处理意向原则。,2,3,4,5,6,中文文献：经过与之前相同的初筛，阅读文献摘要、全文等过程，共收集2篇符合标准的文献。分别列出文献结果：,临床指南：检索PubMed及中国生物医学文献数据库，共检出1个相关指南：,Background The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic sur-gery in colon cancer has been proved to be safe and fea-sible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncolog-ical outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efcacious, but indications and limitations are not clearly dened. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, there commendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (mid-and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery. Conclusions Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.,结果：腹腔镜手术治疗腹膜外（中，低）直肠癌是可行的并且被广泛接受。腹腔镜方法必须提供与开放手术相同质量的手术标本。腹腔镜方法可以略微改善肠道功能，手术部位感染，疼痛和住院时间等短期结果。腹腔镜直肠癌切除术在无病生存率，总体生存率或局部复发方面并不逊于开放性。像开放手术一样，腹腔镜下盆腔夹层可能会影响直肠切除后的泌尿生殖系统和性功能。 结论：在最佳条件下，可推荐腹腔镜手术治疗中，低位直肠癌。尽管如此，大多数1级证据仍然是结肠癌手术而不是直肠癌。正在等待大型随机试验即将出现的结果，以加强证据，以改善短期结果和与开放方法相比的长期结果。,所检出的6篇英文文献中，前五篇为原始研究证据，均采用的随机对照实验，达b级论证强度；第六篇为二次研究证据，但其真实性较低，且为同质性队列研究的系统综述，论证强度为a级。 所检出的2篇中文文献均采用回顾性队列研究，论证强度为级。 目前基于循证医学基础上建立起来的临床实践指南是指导临床实践的最佳证据，为a级。,将所得证据结果告诉患者家属：本例老年男性患者完全满足腹腔镜下直肠癌根