循证病历 实例.doc

病例：病史：患者男性，45岁，因“反复便血2月”入院。近两月前，患者无明显诱因下出现反复出现便血,呈暗红色,量不多,无发热、无恶心、呕吐，无腹痛腹胀，无肛周疼痛，大便次数增多，一天2-3次，大便成形，无大便变细。体格检查：体温：37.2；脉搏：85次/分；呼吸：20次/分；血压：128/72mmHg。一般情况尚好，自动体位。皮肤巩膜无明显黄染，心肺（）。腹部平坦，腹无压痛、反跳痛（-），肝脾肋下未触及，未及腹部肿块。双侧下肢无水肿，神经系统体征（）。肛门指检：未及直肠肿块，指套染血。入院后检查：B超：肝、胆、脾、胰、肾未见明显异常。电子肠镜提示：距肛约10厘米一直肠肿块，占肠腔1/3圈，取活检二处，余结肠未见明显异常。活检病理：直肠中分化腺癌。诊断：直肠癌。构建背景问题P：直肠中分化腺癌男性患者I：直肠癌根治术C:腹腔镜手术O:术后并发症及癌症复发一提出临床问题患者直肠癌诊断明确，治疗方式传统术式为：直肠癌根治术（Dixon）。但随着腹腔镜技术的发展，以及其给病人带来创伤少，恢复快的特点越来越引起重视。提出：像患者的病情是否适合腹腔镜手术，与开腹手术相比其根治性如何，是否安全？二证据检索1. 证据来源：PUBMED和Cochrane图书馆2.检索词和检索策略：1. 检索词：直肠癌rectalcancerORrectalcarcinoma、开放手术openabdominoperinealresectionORopenapproach腹腔镜laparoscopic(2)检索词组合：rectalcancerORrectalcarcinomaANDopenabdominoperinealresectionORopenapproachANDlaparoscopic(3)检索结果：A.PUBMED-ClinicalQueries-FindSystematicReviews:共6篇,其中4篇Review,1篇META分析。1:KuhryE,SchwenkWF,GaupsetR,RomildU,BonjerHJ.Long-termresultsoflaparoscopiccolorectalcancerresection.CochraneDatabaseSystRev.2008Apr16;(2):CD003432.Review.PMID:18425886PubMed-indexedforMEDLINE2:KuhryE,SaetnanE,GraeslieH,GaupsetR.LaparoscopicsurgeryforcolorectalcancerTidsskrNorLaegeforen.2007Nov15;127(22):2946-9.Review.Norwegian.PMID:18026242PubMed-indexedforMEDLINE3:BreukinkS,PierieJ,WiggersT.Laparoscopicversusopentotalmesorectalexcisionforrectalcancer.CochraneDatabaseSystRev.2006Oct18;(4):CD005200.Review.PMID:17054246PubMed-indexedforMEDLINE4:MeyerC,KanorMA,RohrS,RecheF.Criticalanalysisofthelaparoscopicapproachincolorectalsurgerybasedonthepersonalexperienceof613interventionsBullAcadNatlMed.2003;187(3):507-19.Review.French.PMID:14556466PubMed-indexedforMEDLINE5:BachooP,BrazzelliM,GrantA.Surgeryforcompleterectalprolapseinadults.CochraneDatabaseSystRev.2000;(2):CD001758.Review.Updatein:CochraneDatabaseSystRev.2008;(4):CD001758.PMID:10796817PubMed-indexedforMEDLINEB.CochraneLibrary：共13篇,其中Reviews2篇,ClinicalTrials8篇Reviews:1、Long-termresultsoflaparoscopiccolorectalcancerresectionEstherKuhry,WolfgangSchwenk,RobinGaupset,UllaRomild,H.JaapBonjer,Year:20082、LaparoscopicversusopentotalmesorectalexcisionforrectalcancerStephanieBreukink,Jean-PierrePierie,TheoWiggersYear:2006ClinicalTrials10篇:1、Laparoscopic-assistedversusopenabdominoperinealresectionforlowrectalcancer:aprospectiverandomizedtrial.NgSS,LeungKL,LeeJF,YiuRY,LiJC,TeohAY,LeungWWYear:20082、Patientfactorsinfluencingconversionfromlaparoscopicallyassistedtoopensurgeryforcolorectalcancer.ThorpeH,JayneDG,GuillouPJ,QuirkeP,CopelandJ,BrownJM,MedicalResearchCouncilConventionalversusLaparoscopic-AssistedSurgeryInColorectalCancerTrialGroupYear:20083、ClinicalcomparisonofsystemicstressresponsesbetweenlaparoscopicoropenanteriorresectioninrectalcancerpatientswithanalsphincterpreservationZhouB-J,ZhangG-J,DuanG-Q,ZhangZ-X,YanQ-H,SongW-Q,CaiJ-HYear:20074、Lymphnodeclearanceaftertotalmesorectalexcisionforrectalcancer:laparoscopicversusopenapproach.PechlivanidesG,GouvasN,TsiaoussisJ,TzortzinisA,TzardiM,MoutafidisM,DervenisC,XynosEYear:20075、Randomizedtrialoflaparoscopic-assistedresectionofcolorectalcarcinoma:3-yearresultsoftheUKMRCCLASICCTrialGroup.JayneDG,GuillouPJ,ThorpeH,QuirkeP,CopelandJ,SmithAM,HeathRM,BrownJM,UKMRCCLASICCTrialGroupYear:20076、Laparoscopicversusopentotalmesorectalexcisionwithanalsphincterpreservationforlowrectalcancer.ZhouZG,HuM,LiY,LeiWZ,YuYY,ChengZ,LiL,ShuY,WangTCYear:20047、Laparoscopicvsopentotalmesorectalexcisionwithanalsphincterpreservationforlowrectalcancer.ZhouZ-G,HuM,LiY,LeiW-Z,YuY-Y,ChengZ,LiL,ShuY,WangT-CYear:20048、Theincidenceofpositiveperitonealcytologyincoloncancer:aprospectiverandomizedblindedtrial.LuchaPA,IgnacioR,RowleyD,FrancisMYear:2002三评价证据根据所要解决的临床问题：腹腔镜直肠癌手术效果如何，它的根治性、安全性如何？在直肠癌手术治疗方面，很多报告均比较了开腹手术与腹腔镜手术的疗效，并发症及近期随访结果。表明两者在肿瘤根治性及手术安全性上无显著性差异，而且腹腔镜手术在术中出血，术后恢复时间等方面有更多的优势。其中的文献包括有ClinicalTrial,Meta-Analysis,Review等，证据级别分别在I-II级之间。有一项META分析,比较腹腔镜与开放手术作为治疗原发直肠癌患者对于短期和长期的结果。方法:检索从1993年和2004年的关于腹腔镜和开放手术治疗直肠癌的所有研究。亚组分析进行开腹切除手术病人直肠。下面的终点是评价结果:手术结果,术后恢复,早期和晚期的不良事件。结果:20项研究和报告了2071例手术,其中909例(44%)接受腹腔镜与1162例(56%)接受开腹手术直肠癌。肠功能恢复时间(WMD加权平均差异,-1.52;95%CI95%可信区间,-2.20-1.01),首次大便(WMD、-.72;95%可信区间,-1.21-.22)、进食固体饮食(WMD,-.92;95%可信区间,-1.35,-.50),住院时间(WMD,-2.67;95%可信区间,-3.81-1.54)腹腔镜手术都是显著降低。在进腹切除直肠癌手术的病人,伤口感染(似然比0.15;95%可信区间,.03,.73)和要求术后镇痛(WMD,-.63;95%可信区间,-1.22、-.04)也被大大降低。两组之间在肿瘤根方面没有显著性差异。结论:在腹腔镜手术在