晚期大肠癌的外科治疗.ppt

大肠癌的外科治疗进展,患者，女，27岁，妊娠37周 突发腹痛-子宫先兆破裂？ 行剖腹探查术-乙状结肠肿瘤梗阻伴穿孔导致腹膜炎 第1 步 行剖宫产 第2 步 乙结肠肠段肿瘤拖出 第3 步 术后第二天纵轴剖开行襻式造口 第4 步 剖宫产恢复后7天，行folfri方案化疗-肿瘤明显缩小 第5 步 乙结肠癌根治术，目前已无瘤存活4年,第1 步 剖宫产 妇科会诊制 第2 步 乙结肠肠段肿瘤拖出 第3 步 术后第二天纵轴剖开行造口 微创技术 第4 步 恢复后7天，行folfri方案化疗 肿瘤科 第5 步 根治术，无瘤存活4年 结果,快速康复理念 外科损伤控制,微创技术 采用特殊器械缩小手术创伤范围，减少应激 损伤控制 采用特殊手术方案缩小手术创伤程度，减轻应激 外科快速康复理念 采用一系列措施，减少应激程度，促进康复,腹腔镜 (laparoscopy) 经肛门内窥镜下微创手术 ( transanal endoscopic microsurgery,tem) 腹腔镜-内镜“双镜”联合手术 (laparoscopic in combination with transanal endoscopic microsurgery) 经自然腔道内镜手术 (natural orifice transluminal endoscopic surgery, notes) 经脐单孔腹腔镜技术 (transumbilical laparoendoscopic single site surgery,tu-less) 机器人手术 (robotic surgery),微创技术,腹腔镜对大肠良性病变及晚期大肠癌的姑息性切除或短路手术的微创疗效已基本得到肯定，并广泛应用，但对非晚期大肠癌的腹腔镜肠切除术，是否能达到根治目的尚有较多争议。,腹腔镜,经肛门内镜显微手术 （transanal endoscopic microsurgery, tem）,tem兼备了内镜、腹腔镜和显微手术的优点 tem主要适应于距肛门4-20cm范围内的腺瘤或早期直肠癌 如对不愿或不能耐受经腹根治性手术的高龄或高手术风险病人的姑息性手术及有广泛转移病人的局部控制。,固定支撑架 (adjustable holder),直肠镜手术鞘 （operating rectoscope),工作附件 （working attachment）,双目立体视镜,单目镜,经肛门内窥镜下微创手术（tem）,我们的经验：,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, jian-wen l.hepatogastroenterology. 2012 apr 25;59(120).,腹腔镜-内镜“双镜”联合技术,按传统腔镜技术行直肠或乙状结肠癌切除术 大多数肿瘤能经镜筒从肛门拖出，避免腹部切口 双镜操作时腹腔与直肠内压力保持稳定，视野暴露清晰，可精确定位肿瘤下切缘，允许腹腔内及肛门内同时操作,完成tme后，经肛门取出标本,关闭远端残端后，完成吻合,乙结肠肿瘤，腔镜下荷包缝合并放置抵钉座,术后腹部无切口,2012年csco年会 北京,腹腔镜-内镜“双镜”联合技术,术后腹部无切口,腹腔镜-内镜“双镜”联合技术,我们的经验：,total laparoscopic sigmoid and rectal surgery in combination with transanal endocopic microsurgery: a preliminary evaluation in china. han y, he yg, zhang hb, lv kz, zhang yj, lin mb, yin l.surg endosc. 2012 jul 18.,损伤控制,对于严重创伤的病人,改变以往在早期进行复杂、完整手术的策略, 采取分期救治的原则。 手术的最终目的是挽救病人的生命, 提高病人的生存质量, 而不是追求所谓的/ 完美手术术, 一旦达到治疗目的, 任何多余的操作都可能徒增病人机体的负担。 核心内容是尽量减少手术及各种处置本身所引起的损伤,快速康复外科(fast-track surgery，fts) 主要包括快速通道麻醉、微创技术、最佳镇痛技术及强有力的术后护理(如术后早期进食、运动)等，其宗旨是为患者提供最优质的服务、最大的益处和最少的损伤。,现代肿瘤外科快速康复理念,将微创技术与fts共同应用于肿瘤治疗，可以降低患者术后炎症反应及免疫损伤，减轻患者的疼痛，有利于术后肺、心、肾 、肠道等多器官功能的恢复，缩短术后住院时间，进而达到快速恢复的目的，为进一步的治疗打下基础。,微创技术与快速康复理念联合应用,外科在晚期肿瘤治疗中角色的演变,现代肿瘤治疗已经从单一依靠外科过渡到多学科参与的综合治疗 。外科医生应该熟悉肿瘤治疗的各种手段： 手术可以提高肿瘤治疗的局部和区域控制率； 化疗、放疗、内分泌治疗、生物基因治疗和分子靶向治疗等可进一步减少复发和死亡，提高患者生存率； 基因芯片、基因组学、蛋白质组学以及临床预后指标检测，有助于辅助治疗的选择和判断预后，也为肿瘤的分子研究提供了更直观、更精确的工具。,晚期大肠癌的化疗,lin m, gu j, eng c, ellis lm, hildebrandt ma, lin j, huang m, 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) lin 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(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. 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 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: 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, 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 = 0.0002) 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 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-free survival among patients with wild-typekras tumors was 0.68 (95% ci, 0.50 to 0.94), in favor of the cetuximabfolfiri group.,timothy s maughan, richard a adams, christopher g smith, et al.addition of cetuximab to oxaliplatin-based first-line combination chemotherapy for treatment of advanced colorectal cancer: results of the randomised