循证医学作业 (3).doc

循证医学作业病史：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。收入我院进行手术治疗一 PICO与提出临床问题P直肠癌I腹腔镜手术C开腹手术O根治性如何 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。病人家属提出：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rectal cancer OR rectal carcinoma、开放手术open abdominoperineal resection OR open approach 腹腔镜 laparoscopic (2) 检索词组合：rectal cancer OR rectal carcinoma AND open abdominoperineal resection OR open approach AND laparoscopic (3) 检索结果：A. PUBMED-Clinical Queries-Find Systematic Reviews: 共6篇,其中5篇Review,1篇META分析。1: Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection.Cochrane Database Syst Rev. 2008 Apr 16;(2):CD003432. Review.PMID: 18425886 PubMed - indexed for MEDLINE2: Kuhry E, Saetnan E, Graeslie H, Gaupset R. Laparoscopic surgery for colorectal cancerTidsskr Nor Laegeforen. 2007 Nov 15;127(22):2946-9. Review. Norwegian.PMID: 18026242 PubMed - indexed for MEDLINE3: Breukink S, Pierie J, Wiggers T. Laparoscopic versus open total mesorectal excision for rectal cancer.Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005200. Review.PMID: 17054246 PubMed - indexed for MEDLINE4: Aziz O, Constantinides V, Tekkis PP, Athanasiou T, Purkayastha S, Paraskeva P,Darzi AW, Heriot AG. Laparoscopic versus open surgery for rectal cancer: a meta-analysis.Ann Surg Oncol. 2006 Mar;13(3):413-24. Epub 2006 Feb 1.PMID: 16450220 PubMed - indexed for MEDLINE5: Meyer C, Kanor MA, Rohr S, Reche F. Critical analysis of the laparoscopic approach in colorectal surgery based onthe personal experience of 613 interventionsBull Acad Natl Med. 2003;187(3):507-19. Review. French.PMID: 14556466 PubMed - indexed for MEDLINE6: Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults.Cochrane Database Syst Rev. 2000;(2):CD001758. Review. Update in: CochraneDatabase Syst Rev. 2008;(4):CD001758.PMID: 10796817 PubMed - indexed for MEDLINEB.Cochrane Library： 共13篇,其中Reviews 3篇 ,Clinical Trials 10篇Reviews:1、Long-term results of laparoscopic colorectal cancer resectionEsther Kuhry, Wolfgang Schwenk, Robin Gaupset, Ulla Romild, H. Jaap Bonjer, Year: 20082、Laparoscopic versus open total mesorectal excision for rectal cancerStephanie Breukink, Jean-Pierre Pierie, Theo WiggersYear: 20063、Surgery for complete rectal prolapse in adultsSamson Tou, Steven R Brown, Ali Irqam Malik, Richard L NelsonYear: 2008Clinical Trials 10篇:1、Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ng SS, Leung KL, Lee JF, Yiu RY, Li JC, Teoh AY, Leung WWYear: 20082、Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer. Thorpe H, Jayne DG, Guillou PJ, Quirke P, Copeland J, Brown JM, Medical Research Council Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer Trial GroupYear: 20083、Clinical comparison of systemic stress responses between laparoscopic or open anterior resection in rectal cancer patients with anal sphincter preservation Zhou B-J, Zhang G-J, Duan G-Q, Zhang Z-X, Yan Q-H, Song W-Q, Cai J-HYear: 20074、Lymph node clearance after total mesorectal excision for rectal cancer: laparoscopic versus open approach. Pechlivanides G, Gouvas N, Tsiaoussis J, Tzortzinis A, Tzardi M, Moutafidis M, Dervenis C, Xynos EYear: 20075、Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, Heath RM, Brown JM, UK MRC CLASICC Trial GroupYear: 20076、Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Zhou ZG, Hu M, Li Y, Lei WZ, Yu YY, Cheng Z, Li L, Shu Y, Wang TCYear: 20047、Laparoscopic vs open total mesorectal excision with anal sphincter preservation for low rectal cancer. Zhou Z-G, Hu M, Li Y, Lei W-Z, Yu Y-Y, Cheng Z, Li L, Shu Y,Wang T-CYear: 20048、The incidence of positive peritoneal cytology in colon cancer: a prospective randomized blinded trial. Lucha PA, Ignacio R, Rowley D, Francis MYear: 20029、Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer. Quah HM, Jayne DG, Eu KW, Seow-Choen FYear: 200210、Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Araujo SE, da Silva eSousa AH, de Campos FG, Habr-Gama A, Dumarco RB, Caravatto PP, Nahas SC, da Silva J, Kiss DR, Gama-Rodrigues JJYear: 2003三评价证据 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Clinical Trial, 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