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中华胃肠外科杂志
中华胃肠外科杂志

汪建平

月刊

1671-0274

china_gisj@vip.163.com

020-38254955

510655

广东省广州市天河区员村二横路26号

中华胃肠外科杂志/Journal Chinese Journal of Gastrointestinal SurgeryCSCD北大核心CSTPCD
查看更多>>1998年5月创刊，中国科协主管，中华医学会、中山大学主办。本刊是我国惟一的胃肠外科专业学术期刊，办刊宗旨为全面系统地反映国内外胃肠外科领域的学术动态，促进胃肠外科的学科发展和学术交流。本刊的主要读者对象为从事胃肠外科、普通外科及相关专业的临床、科研、教学的高、中级医师。设置的栏目有述评、专家笔谈、论著、短篇论著、临床经验、病例报告、术式交流、MDT病例讨论、诊治指南、讲座、综述及医学信息等。
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    中国直肠癌侧方淋巴结转移诊疗专家共识（2024版）

    周总光王锡山张忠涛池畔...
    1-14页
    查看更多>>摘要：侧方淋巴结是中低位直肠癌常见的转移部位，亦是术后局部复发的主要原因。目前国际上针对直肠癌侧方转移的诊断、治疗尚存争议。本共识在《中国直肠癌侧方淋巴结转移诊疗共识（2019版）》的基础上，结合国内外最新研究成果，国内42位结直肠癌研究领域的专家针对直肠癌侧方淋巴结转移的诊断、治疗策略、随诊以及复发处理4个方面进行修订，提出18条侧方淋巴结诊疗相关共识，并采用美国预防医学工作组的评价标准进行等级推荐，旨在进一步规范直肠癌侧方淋巴结转移的诊断标准及治疗策略。在本共识中未解决的相关问题，尚需进一步临床实践，并积极开展高质量的临床研究逐步探索和解决。 Lateral lymph node metastasis (LLNM) is common in mid-low rectal cancer and is also a major cause of postoperative local recurrence. Currently, there is still controversy regarding the diagnosis and treatment of LLNM in rectal cancer. This consensus, based on the "Chinese Consensus on Diagnosis and Treatment of Lateral Lymph Node Metastasis in Rectal Cancer (2019 edition)," incorporates the latest domestic and international research findings and revises aspects related to the diagnosis, treatment strategies, follow-up, and management of recurrence of LLNM in rectal cancer. A total of 42 domestic colorectal cancer experts participated in this consensus. It proposes 18 consensus statements on the diagnosis and treatment of LLNM, using the evaluation criteria of the U.S. Preventive Services Task Force for grading recommendations. The aim is to standardize further the diagnostic criteria and treatment strategies for LLNM in rectal cancer. Unresolved issues in this consensus require further clinical practice and active engagement in high-quality clinical research to explore and address them progressively.

    直肠肿瘤,中低位侧方淋巴结转移侧方淋巴结清扫新辅助治疗专家共识

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    人工智能在结直肠癌诊疗中的研究进展及前景展望

    魏炜何坤山胡振远刘振宇...
    15-23页
    查看更多>>摘要：结直肠癌是全球最常见的恶性肿瘤之一，由于患者对标准治疗方案存在异质性的治疗反应及预后，其个性化诊疗策略一直是备受关注的研究热点。近年来，随着人工智能（AI）技术在医疗领域的迅猛发展，AI在辅助结直肠癌的术前、术中、术后各阶段诊疗方案决策方面均涌现出大量阶段性研究成果，展现出了巨大的应用潜力，为结直肠癌患者的个体化评估和辅助诊疗提供了全新且高效的解决方案。未来，AI系统可能会进一步向多模态、多组学、实时化方向发展。本文旨在探讨AI在结直肠癌诊疗多个方面的辅助应用研究现状，并对AI技术在未来结直肠癌个性化诊疗中可能带来的创新和面临的挑战予以展望。 Colorectal cancer is one of the most common malignant tumors worldwide. Due to the heterogeneity in patient outcomes and treatment responses to standard therapy regimens, personalized diagnostic and therapeutic strategies have remained a focus of sustained interest in research. In recent years, with the rapid progression of artificial intelligence (AI) technology in the medical field, an abundance of phased research results has emerged in the decision-making for preoperative, intraoperative, and postoperative diagnostic and therapeutic plans for colorectal cancer, demonstrating great potential for application. This new and efficient solution provides for the personalized evaluations and auxiliary diagnoses and treatments of patients with colorectal cancer. In the future, AI systems may continue to advance towards multimodal, multi-omics, and real-time directions. This paper aims to explore the current state of research on the multi-faceted auxiliary applications of AI in the diagnosis and treatment of colorectal cancer, as well as to present a prospective view of the innovations that AI technology could bring to personalized colorectal cancer treatment in the future and the challenges it may face.

    人工智能结直肠肿瘤手术导航医学影像精准医学

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    免疫治疗在胃肠道肿瘤中的研究进展及实践挑战

    陈帆王峰徐瑞华汪挺...
    24-34页
    查看更多>>摘要：胃肠道恶性肿瘤是最常见的消化系统肿瘤，其高发病率和癌症相关高死亡率严重威胁着民众的健康。随着免疫治疗研究的进展，其在胃肠道恶性肿瘤围手术期和晚期肿瘤治疗中的重要性日渐凸显。目前，免疫治疗已成为高度微卫星不稳定型晚期结直肠癌的标准一线治疗方案；而在晚期胃癌的一线治疗中，免疫治疗联合化疗以及在人表皮生长因子受体2（HER2）阳性患者中联合HER2靶向治疗和化疗也取得显著疗效和长期生存获益。免疫治疗在胃肠道肿瘤围手术期治疗以及晚期二线及后线治疗中的研究进展也展现出良好的潜力。目前的研究亟需探索更多的免疫联合用药方案，为胃肠道肿瘤患者，特别是微卫星稳定型结直肠癌患者的治疗带来曙光。 Gastrointestinal (GI) cancers are the most common tumors of the digestive system, and their high morbidity and cancer-related mortality dramatically threaten the health of the population. With the researching progress of immunotherapy, its use in the treatment of GI cancers in the perioperative and advanced stages is becoming more and more important. Currently, immunotherapy has become the standard first-line treatment for MSI-H late-stage colorectal cancer, while in the first-line treatment of late-stage gastric cancer, immunotherapy combined with chemotherapy and HER2-targeted drugs (in HER2-positive patients) has also achieved significant efficacy and long-term survival benefits. Advances in immunotherapy in the neoadjuvant and adjuvant treatment and in the second- and later-line treatment of late-stage GI cancers have demonstrated its promising therapeutic potential. However, there is still an urgent need for future studies to explore more immunotherapy combination strategies for patients with GI cancers, especially with MSS colorectal cancers.

    胃肠道肿瘤免疫治疗微卫星状态人表皮生长因子受体2阳性

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    机器人未来应是胃肠外科的主流术式

    余佩武李政焰汪挺
    35-40页
    查看更多>>摘要：经过20余年发展，机器人胃肠手术的临床应用取得了长足进步。越来越多研究表明，机器人胃肠手术安全可行，较传统腹腔镜手术操作更精细，在淋巴结清扫、狭窄空间操作、术中缝合等方面具有技术优势，临床疗效满意。但是也面临着手术费用高，高级别循证医学证据少，智能化水平有待提升等问题。随着更多高质量循证医学研究以及新型智能化手术机器人的研发，机器人胃肠手术将进一步规范化推广，我们相信，未来机器人手术一定会成为胃肠外科手术的主流术式。 The clinical application of robotic gastrointestinal surgery has made significant progress during the past 20 years. Increasing research have demonstrated that the robotic gastrointestinal surgery is safe and feasible, with the advantages in lymph node dissection, precise manipulation in narrow space, intraoperative suturing, and achieves satisfactory clinical outcomes. However, it also face challenges such as high costs, lack of high quality studies, and limited intelligent level. With the advancement of more high-quality evidence-based medical research and the development of new intelligent surgical robots, the robotic gastrointestinal surgery will be further standardized. We believe that the robotic surgery will become the mainstream of surgical treatment for gastrointestinal surgery.

    机器人手术系统胃肠手术微创手术

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    三十而立，三十而已——我国腹腔镜结直肠手术技术进阶

    郑民华马君俊赵轩卜建红...
    41-46页
    查看更多>>摘要：腹腔镜结直肠手术在我国开展30年，在技术层面经历了“摸索和成型-优化和规范-至臻和再创新”的三阶梯高速发展。基于腹腔镜技术的加持和助力，结直肠外科在亚微观解剖、手术的术式和理念以及器械设备等方面呈现了全方位突飞猛进的发展。如今，腹腔镜结直肠手术技术和疗效已逐步触及“天花板”，面对当下尚存的痛点和未来发展的方向，我们该何去何从？本文将总结过去30年的经验，固化已有的成果，以期指引未来的实践和前行的路线。 Laparoscopic colorectal surgery has been carried out in China for more than 30 years and has experienced a three-stage high-speed development of "exploring and designing,optimising and standardising, perfecting and re-innovating" at the technical level. Based on the support and assistance of laparoscopic technology, colorectal surgery has made rapid progress in sub-microscopic anatomy, surgical procedures, surgical concepts, instruments and equipment. Nowadays, the technology and efficacy of laparoscopic colorectal surgery have gradually reached the ceiling, and in view of the existing pain points and the future direction of development, where will we go? This article summarised the past three decades of experience and consolidate the results to guide the future practice and the way forward.

    结直肠肿瘤腹腔镜技术

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    SiewertⅡ型食管胃结合部腺癌根治性切除全腹腔镜Overlap吻合与腹腔镜辅助端侧吻合的短期安全性比较：多中心回顾性队列研究

    周海鲲高晓鹏时飞宇王靖宇...
    47-53页
    查看更多>>摘要：目的 比较Siewert Ⅱ型食管胃结合部腺癌根治性切除后全腹腔镜Overlap吻合与腹腔镜辅助端侧吻合两种消化道重建方式的短期安全性。 方法 本研究采用回顾性队列研究的方法。其中空军军医大学第一附属医院2021年11月至2023年7月收治89例、西安交通大学第一附属医院2020年12月至2021年6月期间收治36例和山西省运城市中心医院2021年9月至2022年11月期间收治14例，共计139例行根治性手术切除的SiewertⅡ型食管胃结合部腺癌患者临床资料纳入分析。全组男性107例（77.0%），女性32例（23.0%）；年龄（62.5±9.3）岁。48例行全腹腔镜Overlap吻合（Overlap吻合组），91例行腹腔镜辅助端侧吻合（端侧吻合组）。比较两组患者的临床资料、手术信息、病理结果、术后恢复情况及相关并发症发生情况。 结果 Overlap吻合组与端侧吻合组患者的一般临床资料比较差异无统计学意义（均P>0.05），两组具有可比性。Overlap吻合组与端侧吻合组的手术时间比较，差异无统计学意义［（267.2±60.1）min比（262.8±70.6）min，t=0.370，P=0.712］，但Overlap吻合组的术中出血量更少［100（50，100）ml比100（50，175）ml，Z=2.776，P=0.005］。与端侧吻合组比较，Overlap吻合组可获得更长的肿瘤距离上切缘［（1.7±1.0）cm比（1.3±0.9）cm，t=2.487，P=0.014］，更长的肿瘤距离下切缘［（9.5±2.9）cm比（7.9±3.5）cm，t=2.667，P=0.009］。与端侧吻合组比较，Overlap吻合组患者术后首次下床活动时间更早［1.0（1.0，2.0）d比2.0（1.0，3.0）d，Z=3.117，P=0.002］，首次饮水时间更早［（4.7±2.6）d比（6.2±3.0）d，t=2.851，P=0.005］，首次进食时间更早［（6.0±2.7）d和（7.1±3.0）d，t=2.170，P=0.032］，差异均有统计学意义（均P<0.05）；但住院费用较高［（113 105.5±37 766.3）元比（97 250.2±27 746.9）元］，差异有统计学意（t=2.818，P=0.006）。两组术后住院时间、清扫淋巴结总数及术后首次排气时间比较，差异均无统计学意义（均P>0.05）。Overlap吻合组与端侧吻合组手术相关并发症的发生率分别为22.9%（11/48）和19.8%（18/91），两组比较差异无统计学意义（χ²=0.187，P=0.831）；进一步比较并发症Clavien-Dindo分级，差异也无统计学意义（Z=0.406，P=0.685）。 结论 全腹腔镜Overlap吻合和腹腔镜辅助端侧吻合均可用于SiewertⅡ型食管胃结合部腺癌的根治手术，全腹腔镜Overlap吻合可获得更好的上切缘和下切缘，更有利于术后恢复；但端侧吻合费用更低。 Objective In this study, we aimed to compare the short-term safety of two digestive tract reconstruction techniques, laparoscopic total abdominal overlap anastomosis and laparoscopic-assisted end-to-side anastomosis, following radical resection of Siewert Type II adenocarcinoma of the esophagogastric junction. Methods In this retrospective cohort study, we analyzed relevant clinical data of 139 patients who had undergone radical surgery for Siewert Type II esophagogastric junction adenocarcinoma. These included 89 patients treated at the First Affiliated Hospital of Air Force Medical University from November 2021 to July 2023, 36 patients treated at the First Affiliated Hospital of Xi'an Jiaotong University from December 2020 to June 2021, and 14 patients treated at the Yuncheng Central Hospital in Shanxi Province from September 2021 to November 2022. The group consisted of 107 men (77.0%) and 32 women (23.0%) of mean age 62.5±9.3 years. Forty-eight patients underwent laparoscopic total abdominal overlap anastomosis (overlap group), and 91 laparoscopic-assisted end-to-side anastomosis (end-to-side group). Clinical data, surgical information, pathological findings, postoperative recovery, and related complications were compared between the two groups. Results There were no significant differences in general clinical data between the overlap and end-to-side anastomosis groups (all P>0.05), indicating comparability. There was no significant difference in operation time (267.2±60.1 minutes vs. 262.8±70.6 minutes,t=0.370, P=0.712). However, the intraoperative blood loss in the overlap group (100 [50, 100] mL) was significantly lower compared to the end-to-side group (100[50, 175] mL,Z=2.776, P=0.005). Compared to the end-to-side group, longer distances between the tumor and distal resection margin proximal(1.7±1.0 cm vs. 1.3±0.9 cm, t=2.487, P=0.014) and the tumor and distal resection margin (9.5±2.9 cm vs. 7.9±3.5 cm, t=2.667, P=0.009) were achieved in the overlap group. Compared with the end-to-side group, the overlap group achieved significantly earlier postoperative ambulation (1.0 [1.0, 2.0] days vs. 2.0 [1.0, 3.0] days,Z=3.117, P=0.002), earlier time to first drink (4.7±2.6 days vs. 6.2±3.0 days, t=2.851, P=0.005), and earlier time to first meal (6.0±2.7 days vs. 7.1±3.0 days, t=2.170, P=0.032). However, the hospitalization costs were higher in the overlap group (113, 105.5±37, 766.3) yuan vs. (97, 250.2±27, 746.9) yuan this difference is significant (t=2.818, P=0.006). There were no significant differences between the two groups in postoperative hospital stay, total number of lymph nodes cleared, or time to first postoperative flatus (all P>0.05). The incidence of surgery-related complications was 22.9%(11/48) in the overlap group and 19.8% (18/91) in the end-to-side group this difference is not significant (χ²=0.187,P=0.831). Further comparison of complications using the Clavien-Dindo classification also showed no significant differences (Z=0.406, P=0.685). Conclusions Both laparoscopic total abdominal overlap anastomosis and laparoscopic-assisted end-to-side anastomosis are feasible for radical surgery for Siewert Type II esophagogastric junction adenocarcinoma. Laparoscopic total abdominal overlap anastomosis achieves longer proximal and distal resection margins and better postoperative recovery however, end-to-side anastomosis is more cost-effective.

    食管胃结合部肿瘤胃癌根治术腹腔镜食管空肠吻合术

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    可切除SiewertⅡ~Ⅲ型食管胃结合部腺癌治疗前应用那不勒斯预后评分的临床价值

    金鹏马刚刘勇柯彬...
    54-62页
    查看更多>>摘要：目的 探讨那不勒斯预后评分（NPS）在可切除SiewertⅡ~Ⅲ型食管胃结合部腺癌（AEG）治疗前应用的临床价值。 方法 采用回顾性观察性研究方法，收集2014年1月至2018年12月期间天津医科大学肿瘤医院胃部肿瘤科收治的可切除SiewertⅡ~Ⅲ型AEG患者病例资料等进行回顾性统计分析。根据术前白蛋白浓度、总胆固醇水平、中性粒细胞/淋巴细胞比值、淋巴细胞/单核细胞比值计算NPS，并分为NPS-0（0分）、NPS-1（1和2分）和NPS-2（3和4分）。采用Kaplan-Meier进行不同NPS评分组间无病生存期（DFS）和总生存期（OS）描述，使用log-rank检验进行组间比较，Cox回归模型进行单因素和多因素生存分析，并采用时间依赖性ROC（t-ROC）曲线比较NPS、全身炎性反应评分（SIS）、营养控制状态（CONUT）和预后营养指数（PNI）4个常用的炎性反应-营养评价系统与预后的关系。 结果 共纳入221例AEG患者，中位年龄63.0（36.0~87.0）岁；男性190例（86.0%），女性31例（14.0%）。根据pTNM分期，Ⅰ期47例（21.3%）、Ⅱ期为68例（30.8%）、Ⅲ期为106例（48.0%）。SiewertⅡ型147例（66.5%）、Ⅲ型74例（33.5%）。NPS-0组45例（20.4%）、NPS-1组142例（64.2%）和NPS-2组34例（15.4%）。NPS评分高与患者年龄偏大（χ²=5.056，P=0.027）和TNM分期偏晚（H=5.204，P<0.001）有关。中位随访39（6~105）个月，16例（7.2%）失访。NPS-0组、NPS-1组与NPS-2组中位OS分别为78.4、63.1和37.0个月，组间比较差异具有统计学意义（P=0.021）。单因素和多因素Cox回归分析显示：影响SiewertⅡ~Ⅲ型AEG患者OS的因素包括TNM分期（Ⅱ期：HR=2.182，95%CI：1.227~3.878，P=0.008；Ⅲ期：HR=3.534，95%CI：1.380~6.654，P<0.001）、肿瘤分化程度（G3：HR=1.995，95%CI：1.141~3.488，P=0.015）、血管侵犯（HR=2.172，95%CI：1.403~3.363，P<0.001）、辅助化疗（HR=0.326，95%CI：0.200~0.531，P<0.001）、PS（NPS-1：HR=2.331，95%CI：1.371~3.964，P=0.002；NPS-2：HR=2.494，95%CI：1.165~5.341，P=0.019）、SIS（NPS-1：HR=2.170，95%CI：1.244~3.784，P=0.006；NPS-2：HR=2.291，95%CI：1.052~4.986，P=0.037）和CONUT（HR=1.597，95%CI：1.187~2.149，P=0.038）。NPS-0组、NPS-1组与NPS-2组间中位DFS分别为68.6、52.5和28.3个月，组间差异也具有统计学意义（P=0.009）。单因素和多因素Cox回归分析显示，影响SiewertⅡ~Ⅲ型AEG患者DFS的因素包括：TNM分期（Ⅱ期：HR=2.789，95%CI：1.210~6.428，P=0.016；Ⅲ期：HR=10.721，95%CI：4.709~24.411，P<0.001）、辅助化疗（HR=0.640，95%CI：0.432~0.946，P=0.025）和NPS（NPS-1：HR=1.703，95%CI：1.043~2.782，P=0.033；NPS-2：HR=3.124，95%CI：1.722~5.666，P<0.001）。t-ROC分析显示：与SIS、CONUT和PNI等评分系统相比，NPS在预测SiewertⅡ~Ⅲ型AEG患者OS及DFS方面均更准确。 结论 NPS与年龄和TNM分期相关，是可切除SiewertⅡ~Ⅲ型AEG的独立预后因素，且在预测生存方面价值优于SIS、CONUT和PNI等评分系统。 Objective To evaluate the clinical value of preoperative Naples prognostic scores (NPS) in patients with resectable Siewert type II-III esophagogastric junction adenocarcinoma (AEG). Methods In this retrospective observational study we collected and analyzed relevant data of patients with Siewert Type II-III AEG treated in the Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital from January 2014 to December 2018. NPS were calculated using preoperative albumin concentration, total cholesterol concentration, neutrophil/lymphocyte ratio, and lymphocyte/monocyte ratio and used to allocate patients into three groups: NTS-0 (0 points), NTS-1 (1-2 points) and NTS-2 (3-4 points). Kaplan–Meier was used to calculate disease-free survival (DFS) and overall survival (OS) in each NPS group and the log-rank test to compare these groups. Univariate and multivariate survival analyes were performed using the Cox regression model. Time-dependent receiver operating characteristic curves were constructed to compare the relationships between four commonly used tools for evaluating inflammatory responses and nutritional status:NPS, systemic inflammatory response scores, nutrient control status (CONUT), and prognostic nutrition index (PNI). Results The study cohort comprised 221 patients with AEG of median age 63.0 (36.0–87.0) years. There were 190 men (86.0%) and 31 women (14.0%). As to pTNM stage, 47 patients (21.3%) had Stage I disease, 68 (30.8%) Stage II, and 106 (48.0%) Stage III. One hundred and forty-seven patients (66.5%) had Siewert Type II disease and 74 (33.5%) Siewert type III. There were 45 patients (20.4%) in the NPS-0, 142 (64.2%) in the NPS-1 and 34 (15.4%) in the NPS-2 groups. Higher NPS scores were significantly associated with older patients (χ²=5.056, P=0.027) and higher TNM stages (H=5.204,P<0.001). The median follow-up was 39 (6-105) months 16 patients (7.2%) were lost to follow-up. The median OS in the NPS-0, NPS-1, and NPS-2 groups were 78.4, 63.1, and 37.0 months, respectively these differences are statistically significant (P=0.021). Univariate and multivariate Cox regression analysis identified the following as independently and significantly associated with OS in patients with Siewert Type II-III: TNM stage (Stage II: HR=2.182, 95%CI: 1.227-3.878, P=0.008 Stage III: HR=3.534, 95%CI: 1.380-6.654, P<0.001), tumor differentiation (G3: HR=1.995, 95%CI: 1.141-3.488,P=0.015), vascular invasion (HR=2.172, 95%CI: 1.403-3.363, P<0.001), adjuvant chemotherapy (HR=0.326, 95%CI: 0.200-0.531,P<0.001), NPS (NPS-1: HR=2.331, 95%CI: 1.371-3.964,P=0.002 NPS-2: HR=2.494, 95%CI: 1.165-5.341, P=0.019), SIS group (NPS-1: HR=2.170, 95%CI: 1.244-3.784, P=0.006 NPS-2: HR=2.291, 95%CI: 1.052–4.986, P=0.037), and CONUT (HR=1.597, 95% CI: 1.187-2.149, P=0.038). The median DFS in the NPS-0, NPS-1, and NPS-2 groups was 68.6, 52.5, and 28.3 months, respectively these differences are statistically significant (P=0.009). Univariate and multivariate Cox regression analysis identified the following as independently and significantly associated with DFS in patients with Siewert Type II-III AEG: TNM stage (StageⅡ: HR=2.789, 95%CI:1.210-6.428, P=0.016 Stage III: HR=10.721, 95%CI:4.709-24.411, P<0.001), adjuvant chemotherapy (HR=0.640, 95% CI: 0.432-0.946,P=0.025), and NPS (NPS-1: HR=1.703, 95%CI: 1.043-2.782, P=0.033 NPS-2: HR=3.124, 95%CI:1.722-5.666, P<0.001). Time-dependent receiver operating characteristic curves showed that NPS was more accurate in predicting OS and DFS in patients with Siewert Type II-III AEG than were systemic inflammatory response scores, CONUT, or PNI scores. Conclusion NPS is associated with age and TNM stage, is an independent prognostic factor in patients who have undergone resection of Siewert type II-III AEG, and is better than SIS, CONUT, or PNI in predicting survival.

    食管胃结合部腺癌预后那不勒斯预后评分全身炎症评分营养控制状态预后营养指数

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    中低位直肠癌新辅助放疗前后肛门功能的比较：单中心回顾性观察性研究

    孙振王智凤孙曦羽徐徕...
    63-68页
    查看更多>>摘要：目的 比较中低位直肠癌患者放疗前后的肛门测压资料，探讨新辅助放疗对肛门功能的影响。 方法 本研究采用回顾性观察性研究方法，收集2020年6月至2023年4月期间，北京协和医院基本外科结直肠专业组直肠癌前瞻性登记数据库中具有新辅助放疗前后肛门直肠压力测定数据的中低位直肠癌患者临床资料，观察指标包括患者临床病理资料以及新辅助放疗前后患者肛门直肠压力测定结果，并使用logistic回归分析确定与肛门直肠测压指标发生显著改变的有关因素。 结果 对45例中低位直肠癌患者进行分析。其中男性32例（71.1%），女性13例（28.9%）；年龄为（60±11）岁；体质指数（BMI）为（23.4±3.7）kg/m2。肿瘤距肛缘距离为（5.4±1.5）cm，MRI T分期（mrT）3~4期患者有41例（81.1%），MRI N分期（mrN）阳性患者有40例（88.9%），肿瘤最大径中位数为3.4（2.9~4.5）cm，环周比中位数为66.0（45.5~75.0）%。新辅助放疗后患者的最大静息压有降低的趋势［（55.3±32.0）mmHg比（48.0±28.5）mmHg，t=1.930，P=0.060］，但差异无统计学意义；最大缩榨压无明显变化。新辅助放疗后患者各时期感觉阈值均降低，其中感觉阈值的最大耐受量降低具有统计学意义［66.0（49.0，88.0）ml比52.0（39.0，73.5）ml，Z=-2.481，P=0.013］。logistic回归分析结果提示，mrN降期与最大静息压的降低有关（OR=6.533，95%CI：1.254~34.051，P=0.026），未发现与感觉阈值的最大耐受量降低有关的因素。 结论 新辅助放疗会导致直肠癌患者肛门功能损伤，使得肛门静息压降低和排便敏感性增高，此外mrN降期与最大静息压的降低有关。 Objective The aim of this study was to evaluate the impact of neoadjuvant radiotherapy on anorectal function of patients with mid-low rectal cancer by means of high-resolution anorectal manometry. Methods A retrospective observational study was conducted. Information on patients with mid-low rectal cancer was collected from the prospective registry database of Rectal Cancer at Peking Union Medical College Hospital (PUMCH) from June 2020 to April 2023. Anorectal functions were detected using three-dimensional high-resolution manometry system. Logistic regression analysis was performed to identify the factors associated with the changed anorectal manometry. Results A total of 45 patients with mid-low rectal cancer were included in the study. Thirty-two (71.1%) patients were male, 13 (28.9%) patients were female. The mean age was 60±11 years, and the mean BMI was 23.4±3.7 kg/m2. The mean distance between the lower edge of the tumor and the anal verge was 5.4±1.5 cm. The median size of the tumor was 3.4 (2.9-4.5) cm, and the median circumferential extent of the tumor was 66.0 (45.5-75.0) %. 41 (81.1%) patients were MRI T3-4 and 40 (88.9%) patients were MRI N positive. The resting pressure has a decreasing trend after neoadjuvant radiotherapy (55.3±32.0 mmHg vs. 48.0±28.5 mmHg, t=1.930, P=0.060). There was no significant change in maximum squeezing and the length of the high-pressure zone after neoadjuvant radiotherapy. All volumes describing rectal sensitivity (first sensation, desire to defecate, and maximum tolerance) were lower after neoadjuvant radiotherapy. And maximum tolerance was significantly lower (66.0 [49.0,88.0] ml vs. 52.0 [39.0,73.5] ml,Z=-2.481,P=0.013). Univariate analysis demonstrated that the downstage of N-stage was associated with the decrease in maximum tolerance (OR=6.533, 95%CI:1.254-34.051, P=0.026). Conclusion Neoadjuvant radiotherapy damages anorectal function by decreasing the resting pressure and rectal sensory threshold of patients. The N-stage downstaging was associated with a decrease in maximum tolerance.

    直肠肿瘤新辅助放疗肛门功能肛门直肠测压

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    腹腔镜直肠癌前切除术后低位前切除综合征的发生率和症状学分析

    王璋邵胜利刘鹭卢麒亦...
    69-74页
    查看更多>>摘要：目的 探究腹腔镜直肠癌前切除术后低位前切除综合征（LARS）及其症状随时间变化的趋势。 方法 本研究采用回顾性队列研究的方法。回顾性纳入2010年1月1日至2020年12月31日期间，在华中科技大学同济医学院附属同济医院接受腹腔镜直肠癌前切除的原发性直肠（腺）癌患者，所有患者病历资料完整，术后3、6、9、12和18个月时间点的随访资料齐全。共1 454例患者纳入本研究，年龄≤65岁1 094例（75.2%），女性597例（41.1%）。吻合口距肛缘的距离为0~5 cm者1 040例（71.5%），新辅助治疗患者86例（5.9%）。所有患者均完成汉化版LARS评分问卷表并记录术后3、6、9、12和18个月时LARS的发生率及其具体症状的情况，并综合既往文献报道和临床经验，对吻合口位置、术前新辅助治疗、术后辅助治疗、有无预防性造口等可能影响重度LARS的相关亚组行进一步分析。 结果 1 454例患者术后3、6、9、12和18个月时，LARS的发生率分别为78.5%（1 142/1 454）、71.4%（1 038/1 454）、55.0%（799/1 454）、45.7%（664/1 454）和45.7%（664/1 454），整体差异有统计学意义（χ2=546.180，P<0.001），但12个月后趋于稳定（P>0.05）。与术后3个月相比，术后12个月时LARS的症状谱中排气失禁［1.7%（24/1 454）比33.9%（493/1 454）］，液体大便失禁［3.9%（56/1 454）比41.9%（609/1 454）］，大便频率增加［79.6%（1 158/1 454）比95.9%（1 395/1 454）］，大便簇集［74.4%（1 081/1 454）比92.9%（1 351/1 454）］，排便急迫［46.5%（676/1 454）比78.7%（1 144/1 454）］的发生率均有缓解（均P<0.05），而12个月以后稳定（均P>0.05）。随着术后时间的延长，重度LARS发生率在不同吻合口位置、术前新辅助治疗、术后辅助治疗、有无预防性造口等亚组中均呈下降趋势（均P<0.001），并在术后12个月时达到稳定（均P>0.05）。 结论 术后1年内，LARS及其具体症状情况随时间增长呈逐渐改善趋势，但超过1年后趋于稳定。大便频率增加和簇集是最主要的肠道功能异常表现，术后改善缓慢。 Objective This study aims to explore the temporal trend of Low Anterior Resection Syndrome (LARS) and its symptoms after laparoscopic anterior resection for rectal cancer. Methods A retrospective cohort study design was employed. The study included primary rectal (adenocarcinoma) cancer patients who underwent laparoscopic anterior resection at Tongji Hospital, Huazhong University of Science and Technology, between January 1, 2010, and December 31, 2020. Complete medical records and follow-up data at 3, 6, 9, 12, and 18 months postoperatively were available for all patients. A total of 1454 patients were included, of whom 1094 (75.2%) were aged ≤65 years, and 597 (41.1%) were females. Among them, 1040 cases (71.5%) had an anastomosis-to-anus distance of 0-5cm, and 86 cases (5.9%) received neoadjuvant treatment. All patients completed the Chinese version of the LARS questionnaire and their LARS occurrence and specific symptom information were recorded at 3, 6, 9, 12, and 18 months postoperatively. Considering past literature and clinical experience, further subgroup analyses were performed to explore the potential impact factors on severe LARS, including anastomosis level, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and the presence of preventive stoma. Results The occurrence rates of LARS at 3, 6, 9, 12, and 18 months postoperatively were 78.5% (1142/1454), 71.4% (1038/1454), 55.0% (799/1454), 45.7% (664/1454), and 45.7% (664/1454), respectively (χ2=546.180, P<0.001). No statistically significant difference was observed between the 12-month and 18-month time points (P>0.05). When compared with the symptoms at 3 months, the occurrence rates of gas incontinence [1.7% (24/1454) vs. 33.9% (493/1454)], liquid stool incontinence [3.9% (56/1454) vs. 41.9% (609/1454)], increased stool frequency [79.6% (1158/1454) vs. 95.9% (1395/1454)], stool clustering [74.3% (1081/1454) vs. 92.9% (1351/1454)], and stool urgency [46.5% (676/1454) vs. 78.7% (1144/1454)] in the LARS symptom spectrum were significantly alleviated at 12 months (allP<0.05) and remained stable beyond 12 months (allP>0.05). With the extension of postoperative time, the incidence rates of severe LARS exhibited a decreasing trend in different subgroups, of anastomosis level, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and the presence of preventive stoma, and reached stability at 12 months postoperatively (allP>0.05). Conclusion LARS and its specific symptom profile showed a trend of gradual improvement over time up to 1 year postoperatively, and stabilized after more than 1 year. Increased stool frequency and stool clustering are the most common features of abnormal bowel dys function, which improve slowly after surgery.

    直肠肿瘤低位前切除综合征发生率症状学

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    肛管腺癌合并侵及外阴的肛周Paget病一例

    李干斌石维坤张宁林国乐...
    75-76页
    查看更多>>摘要：肛周Paget病分原发性和继发性，因其部位隐匿、症状缺乏特异性常被漏诊，多点深层穿刺联合免疫组化检查有助于肛周Paget病的诊断与鉴别诊断，根治性手术是主要治疗手段。本中心借鉴直肠癌的新辅助治疗模式，诊疗1例肛管腺癌合并侵及外阴的肛周Paget病，取得较好疗效。

    肛管腺癌肛周Paget病手术新辅助治疗

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