第六节结肠癌（sixth colon cancer）

第六节结肠癌（SIXTHCOLONCANCER）第六节结肠癌结肠癌（结肠癌）是胃肠道中常见的恶性肿瘤，以41岁发病率高在我国65。近20年来尤其在大城市，发病率明显上升，且有结肠癌多于直肠癌的趋势。从病因看半数以上来自腺瘤癌变，从形态学上可见到增生、腺瘤及癌变各阶段（图4013）以及相应的染色体改变。随分子生物学技术的发展，同时存在的分子事件基因表达亦渐被认识，从中明确癌的发生发展是一个多步骤、多阶段及多基因参与的细胞遗传性疾病。大肠癌时从细胞向癌变演进，从腺瘤一癌序列约经历1015年，在此癌变过程中，遗传突变包括癌基因激活（KRAS、CMYC、EGFR）、抑癌基因失活（APC、DCC，P53）、错配修复基因突变（HMSHI，何梁何利，PMS1，PMS2，GTBP）及基因过度表姨发减一FF一尹1E）所日马所有目APCKRAS基因DCCP53NM23MMR染色体改变去甲基MMR5Q12Q18Q17Q突变缺失突变突变缺失突变缺失缺失突变图4013大肠癌变过程模式图（错配修复基因）HMSH2、HMLH1、创新1创新2达（COX2，CD44V）OAPC基因失活致杂合性缺失，APC/汗连环通路启动促成腺瘤进程；错配修复基因突变致基因不稳定，可出现遗传性非息肉病结肠癌（遗传性非息肉性结肠癌，HNPCC）综合征。结肠癌病因虽未明确，但其相关的高危因素渐被认识，如过多的动物脂肪及动物蛋白饮食，缺乏新鲜蔬菜及纤维素食品；缺乏适度的体力活动。遗传易感性在结肠癌的发病中也具有重要地位，如遗传性非息肉性结肠癌的错配修复基因突变携带的家族成员，应视为结肠癌的一组高危人群。有些病如家族性肠息肉病，已被公认为癌前期疾病；结肠腺瘤、溃疡性结肠炎以及结肠血吸虫病肉芽肿，与结肠癌的发生有较密切的关系。病理与分型根据肿瘤的大体形态可区分为1。肿块型（图4014）肿瘤向肠腔内生长，好发于右侧结肠，特别是盲肠。2。浸润型（图4015）沿肠壁浸润，容易引起肠腔狭窄和肠梗阻，多发生于左侧结肠。3。溃疡型（图4016）其特点是向肠壁深层生长并向周围浸润，是结肠癌常见类型。图4014肿块型结肠癌显微镜下组织学分类较常见的为腺癌占结肠癌的大多数粘液癌预后较腺。癌差。未分化癌易侵人小血管和淋巴管，预后最差。临床病理分期分期目的在于了解肿瘤发展过程，指导拟定治疗方案及估计预后。国M际一般仍沿用改良的公爵分期及UICCTNM分期法提出的。根据我国对公爵法的补充，分为癌仅限于肠壁内为公爵穿透肠壁侵人期。浆膜或/及浆膜外，但无淋巴结转移者为B期。有淋巴结转移者为C期，其中淋巴结转移仅限于癌肿附近如结肠壁及结肠旁淋巴结者为C1期；转移至系膜和系膜根部淋巴结者为C期。已有远处转移或腹腔转移，或广泛侵及邻近脏器无法切除者为1之期。TNM分期法T代表原发肿瘤，TX为无法估计原发肿瘤。无原发肿瘤证据为来；原位癌为T；G；肿瘤侵及粘膜肌层与粘膜下层为T1；侵及固有肌层为TZ；穿透肌层至浆膜下为T3；PENETRATINGDIRTPERITONEUMORINVASIONOFOTHERORGANSORTISSUESIST4NWASREGIONALLYMPHNODE,N,ANDNOLYMPHNODECOULDBEESTIMATEDNOLYMPHNODEMETASTASISWASNOLYMPHNODEMETASTASISWAS13ONEWASN,ANDTHEOTHER4ANDMORETHAN4LYMPHNODESWERENZOMFORDISTANTMETASTASIS,DISTANTMETASTASISCANNOTBEESTIMATEDFORMXNODISTANTMETASTASISTODISTANTMETASTASISFORALLQUACKM,TNMSTAGINGCOMPAREDWITHDUKESSTAGINGISSHOWNINTABLE4010TABLE401COMPARISONOFTNMSTAGINGWITHDUKESSTAGINGTNMSTAGINGDUKESSTAGINGNCTISTITZPLUSHOIANYTN,NZANYTNMCOLONCANCERISMAINLYLYMPHATICMETASTASIS,FIRSTTOTHECOLONWALLANDTHECOLONLYMPHNODE,ANDTHENTOTHEMESENTERICVASCULARAROUNDANDINTESTINALMESENTERICLYMPHNODEHEMATOGENOUSMETASTASISISMORECOMMONINTHELIVER,FOLLOWEDBYLUNG,BONE,ETCCOLONCANCERCANALSOBEDIRECTLYINFILTRATEDINTOTHEVICINITYORGANSUCHASTHESIGMOIDCOLON,BLADDER,UTERUS,OFTENINVADEURETERTRANSVERSECOLONCANCERCANINVADETHESTOMACHWALL,ANDEVENFORMTHEINTERIOREXFOLIATEDCANCERCELLSCANALSOBETRANSFERREDINPERITONEALIMPLANTSTHECLINICALMANIFESTATIONOFCRCISTHATITUSUALLYHASNOSPECIALSYMPTOMSINTHEEARLYSTAGEOFDEVELOPMENTTHEMAINSYMPTOMSAREFOLLOWINGSYMPTOMS1THECHANGEOFDEFECATIONHABITANDFECALCHARACTERISUSUALLYTHEEARLIESTSYMPTOMMOSTOFTHEMWEREINCREASEDDEFECATIONFREQUENCYANDABDOMENCONTAININGBLOOD,PUS,ORMUCUSINTHESTOOLTHEABDOMINALPAINISONEOFTHE2EARLYSYMPTOMS,OFTENPERSISTENTPAINPOSITIONINGISNOTCLEAR,ORONLYFORABDOMINALDISCOMFORTORABDOMINALDISTENSIONOFTHEABDOMENANDTHEPRESENCEOFINTESTINALOBSTRUCTIONAREAGGRAVATEDBYABDOMINALPAINORPAROXYSMALANGINA3,THEABDOMINALMASSISMOSTLYTUMORBODYITSELF,ANDSOMETIMESMAYBEOBSTRUCTIONINTHEPROXIMALGUTCAVITYFECALACCUMULATIONMOSTOFTHELUMPSAREHARD,NODULARASFORTHETRANSVERSEANDSIGMOIDCOLONCANCERCANHAVECERTAINACTIVITYIFTHECANCERPENETRATESTHECONCURRENTINFECTION,THETUMORISSOLIDDEFINITEANDMARKEDTENDERNESS4,INTESTINALOBSTRUCTIONSYMPTOMSAREGENERALLYCOLONCANCERINTHEMIDDLEANDLATESYMPTOMS,MOSTLYCHRONIC,INCOMPLETEINTESTINALOBSTRUCTION,THELORDTHESYMPTOMSAREBLOATINGANDCONSTIPATIONABDOMINALPAINORPAROXYSMALANGINAWHENACOMPLETEOBSTRUCTIONOCCURS,THESYMPTOMSAREEXACERBATEDLEFTCOLONCANCERCANSOMETIMESBEACUTEANDCOMPLETECOLONICOBSTRUCTIONISTHEFIRSTSYMPTOMBERELUCTANTTOLEAVEDIPINTHEFRAGRANCE,LOOKFORWARDTOL5,SYSTEMICSYMPTOMSDUETOCHRONICBLEEDING,CANCERULCERATION,INFECTION,TOXINSABSORPTION,ETC,PATIENTSCANAPPEARANEMIAANDDISAPPEARLEAN,WEAK,LOWHEAT,ETCTHEDISEASEMAYOCCURLATEHEPATOMEGALY,JAUNDICE,EDEMA,ASCITES,RECTALTUMOR,SUPRACLAVICULARCONCAVELYMPHNODEENLARGEMENTANDCACHEXIABECAUSEOFTHEPATHOLOGICALTYPEANDLOCATIONOFTHECANCER,THECLINICALMANIFESTATIONSAREDIFFERENTINGENERAL,RIGHTCOLONCANCERISCHARACTERIZEDBYSYSTEMICSYMPTOMS,ANEMIA,ABDOMINALMASSWERETHEMAINMANIFESTATIONSOFLEFTCOLONCANCERWITHINTESTINALOBSTRUCTION,CONSTIPATION,DIARRHEA,HEMATOCHEZIAANDOTHERSYMPTOMSTHEEARLYSYMPTOMSOFCOLONCANCERARENOTOBVIOUSANDEASILYOVERLOOKEDANYPERSONWHOISOVER40YEARSOFAGEANDANYOFTHEFOLLOWINGSHALLBELISTEDASHIGHRISKPOPULATIONOILEVELRELATIVESWITHCOLORECTALCANCERHISTORYTHEHISTORYOFCANCERORINTESTINALADENOMASORPOLYPSHISTORYTHEFECALOCCULTBLOODTESTTESTPOSITIVETHEFOLLOWINGFIVEPERFORMANCETHANTWOITEMSMUCOUSBLOODYSTOOL,CHRONICDIARRHEA,CHRONICCONSTIPATION,CHRONICAPPENDICITISHISTORYANDHISTORYOFTRAUMAINTHISGROUP,THEHIGHRISKGROUPUNDERWENTFIBERCOLONOSCOPYORXRAYBARIUMENEMAORBARIUMGASDOUBLECONTRASTITISNOTDIFFICULTTOMAKEADEFINITEDIAGNOSISTYPEBULTRASONOGRAPHYANDCTSCANWEREPERFORMEDTOUNDERSTANDABDOMINALMASSESANDENLARGEDLYMPHNODESANDTODETECTTHELIVERWHETHERTHEREAREANYTRANSFERSANDSOONAREHELPFULSERUMCARCINOEMBRYONICANTIGENCEAVALUESWEREAPPROXIMATELY60HIGHERINBOWELTHANINNORMALCOLONCANCERPATIENTS,HOWEVERTHEOPPOSITESEXISNOTHIGHFORPOSTOPERATIVEJUDGMENT,PROGNOSISANDRECURRENCE,THEREWILLBESOMEHELPTHEPRINCIPLEOFTREATMENTISCOMPREHENSIVETREATMENTBASEDONSURGICALRESECTION1RADICALRESECTIONOFCOLONCANCERSHOULDINCLUDETHEBOWELMIXANDITSMESENTERYANDREGIONALLYMPHNODESOFTHECARCINOMA1RIGHTHEMICOLECTOMYFORTHECECUMANDASCENDINGCOLON,HEPATICFLEXUREOFCOLONCANCERTHECECUMANDASCENDINGCOLONCANCERRESECTION,INCLUDINGRIGHTTRANSVERSECOLON,ASCENDINGCOLONANDCECUM,INCLUDINGSOME1520CMTERMINALILEUMFIGURE4017,FORTHEENDORENDTOSIDEANASTOMOSISOFILEUMANDCOLONFORTHECANCEROFTHEHEPATICFLEXUREOFTHECOLON,ITMUSTBEEXCISEDINADDITIONTOTHEABOVERANGETHELYMPHNODESOFTHECOLONANDGASTROOMENTALRIGHTARTERYGROUPFIGURE4017RIGHTHALFCOLONRESECTIONRANGE2THETRANSVERSECOLONRESECTIONFIGURE4018SUITABLEFORTRANSVERSECOLONCANCERINCLUDESRESECTIONOFTHEHEPATICFLEXUREOFTHECOLONANDSPLENICFLEXUREANDTHEGASTROCOLICLIGAMENTOFLYMPHNODEFORASCENDINGANDDESCENDINGCOLONICANASTOMOSISIFTHETENSIONATBOTHENDSISTOOLARGETOKISSTOGETHER,TRANSVERSECOLONRESECTIONOFTHELEFTSIDEOFTHEDESCENDINGCOLON,ASCENDINGCOLON,SIGMOIDCOLONANASTOMOSISFOR3LEFTHEMICOLECTOMYSUITABLEFORCOLON,SPLENICFLEXUREANDDESCENDINGCOLONCANCERTHEEXTENTOFRESECTIONINCLUDINGTRANSVERSECOLON,LEFTHALFTHEBOWELISRESECTED,ANDPARTIALORALLSIGMOIDCOLONFIG4019ISREMOVEDACCORDINGTOTHELOCATIONOFTHEDESCENDINGCOLON,ANDTHENTHECOLONORTHECOLONISREMOVEDENDTOENDANASTOMOSISOFINTESTINEANDRECTUM4RADICALRESECTIONOFSIGMOIDCOLONCANCERSHOULDBEDONEACCORDINGTOTHELENGTHOFSIGMOIDCOLONANDTHELOCATIONOFTHECANCERTHEENTIRESIGMOIDCOLONANDALLTHEDESCENDINGCOLONWERERESECTED,ORTHEWHOLESIGMOIDCOLON,PARTOFTHEDESCENDINGCOLONANDPARTOFTHERECTUMWEREREMOVED,ANDTHECOLONWASREMOVEDFORTIETHCHAPTERSA,FIGURE4018COLONRESECTIONFIGURE4019LEFTHALFCOLECTOMYRANGEANASTOMOSISOFRECTUMFIGURE402002COLORECTALCANCERASSOCIATEDWITHACUTEINTESTINALOBSTRUCTIONSURGERYSHOULDBECARRIEDOUTINGASTROINTESTINALREDUCTIONPRESSURE,CORRECTWATERANDELECTROLYTEDISTURBANCES,ANDACIDBASEIMBALANCEAFTERPROPERPREPARATION,EARLYSURGERYRIGHTCOLONCANCERISRESECTIONOFRIGHTCOLONFORPRIMARYILEUMANASTOMOSISIFTHEPATIENTISNOTALLOWED,HEWILLHAVEACOLOSTOMYFIRSTTORELIEVETHEOBSTRUCTIONTHETWOSTAGERADICALRESECTIONWASPERFORMEDIFTHECANCERCANNOTBEREMOVED,THEDISTALILEUMCANBESEVERED,INTHECUTENDILEOTRANSVERSOENDTOSIDEANASTOMOSIS,THEDISTALTERMINALILEUMPROXIMALCOLOSTOMYLEFTWHENCOLONCANCERISCOMPLICATEDWITHACUTEINTESTINALOBSTRUCTION,ITSHOULDBEDONEINTHEPROXIMALPARTOFTHEOBSTRUCTIONTRANSVERSOSTOMY,FULLYPREPAREDININTESTINALCONDITIONS,THENTHETWOSTAGEOPERATIONFORROOTTHERAPEUTICRESECTIONIFTHETUMORCANNOTBEREMOVED,THENPALLIATIVECOLOSTOMYWILLBEPERFORMEDINTHESPECIFICOPERATIONOFCOLONCANCERRESECTION,THETUMORSHOULDBELOCATEDFIRSTTHEPROXIMALBOWELWITHGAUZETIEDTOPREVENTCANCERCELLSINTHEINTESTINALCAVITYEXPANSIONLOOSEPLANTINGTHEBLOODVESSELSARETHENLIGATEDTOPREVENTMETASTASISOFTHECANCERCELLSANANTICANCERDRUG,SUCHAS5FU,ISTHENREMOVEDWITHINTESTINALRESECTIONFIGURE4020EXTENTOFRESECTIONOFSIGMOIDCOLONCANBEDILUTEDINTHECLOSEDLUMENOFTHEINTESTINECOLONCANCERSURGERYUSUALLYREQUIRESADEQUATEBOWELPREPARATION,ANDBOWELPREPARATIONISPRIMARILYTHEEVACUATIONOFINTESTINALTRACTANDPROPERINTESTINALANTIBIOTICSAPPLICATIONINTESTINALEMPTYINGTHEREAREMANYMETHODS,AND1224HOURSBEFORETHEOPERATION,THECOMPOUNDPOLYETHYLENEGLYCOLELECTROLYTEPOWDER2000ISTAKENORALLY3000MLORORALMANNITOLALSOTHEDAYBEFORESURGERY,ORALLAXATIVES,SUCHASCASTOROILANDSENNAORMAGNESIUMSULFATELIQUIDETCUNLESSTHEREISASUSPECTEDINTESTINALOBSTRUCTION,THEREISASMALLBOWELCLEANSINGMETHODFORREPEATEDCLEANSINGENEMATHEMAKINGOFINTESTINALANTIBIOTICSUSAGEROUTINEUSEOFMETRONIDAZOLE,04G,THREETIMESADAY,NEOMYCIN1G,TWOTIMESADAY,ONEDAYBEFORESURGERYNOTRECOMMENDEDBOW