查看更多>>摘要：目的 探讨多层螺旋CT显示腹腔游离气体位置及弥散程度与急性消化道穿孔部位及大小的关系。 方法 本研究采用描述性病例系列研究方法。分析南方医院普通外科2022年1—9月期间，33例经手术证实的消化道穿孔患者（阑尾穿孔除外）的腹部CT图像，将腹腔游离气体位置分为5个部位，即膈下、肝门、中腹壁、肠系膜间和盆腔。按手术探查结果，将33例患者分为上消化道穿孔组（23例）和下消化道穿孔组（10例），分析不同位置的腹腔游离气体与消化道穿孔部位的关系。另外，通过观察腹腔内游离气体的弥散程度，建立两个分析模型，利用受试者工作特征（ROC）曲线分析两种模型与消化道穿孔大小的关系。 结果 上消化道穿孔组中，有91.3%（21/23）可观察到肝门部游离气体，高于下消化道穿孔组（5/10），差异有统计学意义（P=0.016）；而下消化道穿孔组中，有8/10可观察到肠系膜间游离气体，高于上消化道穿孔组（8.7%，2/23），差异有统计学意义（P<0.010）。肝门部游离气体诊断上消化道穿孔的灵敏度为84.8%，特异度为71.4%；肠系膜间游离气体诊断下消化道穿孔的灵敏度为80.0%，特异度为91.3%。两组观察到膈下、中腹壁和盆腔游离气体的差异无统计学意义（均P>0.05）。ROC曲线显示，当腹腔内出现4个或以上部位游离气体时，穿孔直径最佳截断值为2 cm，对应灵敏度为66.7%，特异度为100%；提示穿孔直径>2 cm时，腹腔游离气体高度弥散。当腹腔内出现3个或以上部位游离气体时，穿孔直径最佳截断值为1 cm，对应灵敏度为91.7%，特异度为76.2%；提示穿孔直径<1 cm时，腹腔游离气体相对局限。 结论 腹腔游离气体五分法可帮助诊断急性消化道穿孔的定位和大小。 Objective To evaluate the relationships between the location and extent of diffusion of free intraperitoneal air by multi-slice spiral CT (MSCT) and between the location and size of acute gastrointestinal perforation. Methods This was a descriptive case series. We examined abdominal CT images of 33 patients who were treated for intraoperatively confirmed gastrointestinal perforation (excluding appendiceal perforation) in the Department of General Surgery, Nanfang Hospital between January and September 2022. We identified five locations of intraperitoneal air: the subphrenic space, hepatic portal space, mid-abdominal wall, mesenteric space, and pelvic cavity. We allocated the 33 patients to an upper gastrointestinal perforation (n=23) and lower gastrointestinal perforation group (n=10) base on intraoperative findings and analyzed the relationships between the locations of free gas and of gastrointestinal perforation. Additionally, we established two models for analyzing the extent of diffusion of free gas in the abdominal cavity and constructed receiver operating characteristic (ROC) curves to analyze the relationships between the two models and the size of the gastrointestinal perforation. Results In the upper gastrointestinal perforation group, free gas was located around the hepatic portal area in 91.3% (21/23) of patients: this is a significantly greater proportion than that found in the lower gastrointestinal perforation group (5/10) (P=0.016). In contrast, free gas was located in the mesenteric interspace in 8/10 patients in the lower gastrointestinal perforation group this is a significantly greater proportion than was found in the upper gastrointestinal perforation group (8.7%, 2/23) (P<0.010). The sensitivity of diagnosis of upper gastrointestinal perforation base on the presence of hepatic portal free gas was 84.8% and the specificity 71.4%. Further, the sensitivity of diagnosis of lower gastrointestinal perforation base on the presence of mesenteric interspace free gas was 80.0% and the specificity 91.3%. The rates of presence of free gas in the subdiaphragmatic area, mid-abdominal wall, and pelvic cavity did not differ significantly between the two groups (allP>0.05). Receiver operating characteristic curves showed that when free gas was present in four or more of the studied locations in the abdominal cavity, the optimal cutoff for perforation diameter was 2 cm, the corresponding sensitivity 66.7%, and the specificity 100%, suggesting that abdominal free gas diffuses extensively when the diameter of the perforation is >2 cm. Another model revealed that when free gas is present in three or more of the studied locations, the optimal cutoff for perforation diameter is 1 cm, corresponding to a sensitivity of 91.7% and specificity of 76.2% suggesting that free gas is relatively confined in the abdominal cavity when the diameter of the perforation is <1 cm. Conclusion Identifying which of five locations in the abdominal cavity contains free intraperitoneal air by examining MSCT images can be used to assist in the diagnosis of the location and size of acute gastrointestinal perforations.
查看更多>>摘要：目的 探讨腹腔镜下双离断-双吻合器技术联合直肠外翻体外切除术（LDER）在低位直肠癌保肛治疗中的应用价值。 方法 LDER法适应证：（1）年龄18~70岁；（2）肿瘤下缘距离肛缘4~5 cm；（3）原发肿瘤直径≤3 cm；（4）cTNM分期T1~2N1~2M0；（5）“困难骨盆”（坐骨结节间径<10 cm或体质指数>25 kg/m2）；（6）患者保留肛门括约肌意愿强烈；（7）术前未接受放化疗或免疫及靶向治疗；（8）术前影像资料未发现侧方淋巴结肿大；（9）既往无肛肠手术史；（10）基础情况良好、可耐受手术的患者。禁忌证：（1）既往曾罹患消化道恶性肿瘤或现罹患非消化道恶性肿瘤；（2）术前肛门功能差（Wexner评分≥10分）、排便失禁者。其手术关键步骤如下：内外括约肌间游离直肠远端，腹腔镜下线型切割闭合器离断肿瘤之近端直肠，再将远端直肠经肛门翻转拖出，离断肿瘤之远端直肠，手工全层缝合加固残端，残端回纳入盆腔后，腹腔镜监视下采用双吻合器技术行结肠直肠端端吻合。本文采用描述性病例系列研究方法，回顾性分析2020年1月至2022年12月期间，河南省人民医院采用LDER治疗的12例T1~2期低位直肠癌患者的术中术后资料和随访数据，观察其疗效。 结果 12例患者均顺利完成LDER，均保留肛门，无中转开腹或手术方式变更。中位手术时间272（155~320）min，中位出血量100（50~200）ml，手术中肛门括约肌保留率100%，均未行预防性造口，所有患者均进行R0切除，术后中位住院时间为9（7~15）d，3例患者出现术后发热（Clavien-DindoⅠ级），无术后吻合口漏或围手术期死亡者。12例患者中位随访12（6~36）个月，术后6个月中位Wexner评分8（5~14）分，随访期间无肿瘤复发转移。 结论 腹腔镜下双离断-双吻合器技术联合直肠外翻体外切除术治疗低位直肠癌安全可行的。 Objectives To investigate the application value of laparoscopic double stapler firings and double stapling technique combined with rectal eversion and total extra-abdominal resection (LDER) in the anal preservation treatment of low rectal cancer. Methods Inclusion criteria: (1) age was 18-70 (2) the distance of the lower tumor edge from the anal verge was 4-5 cm (3) primary tumor with a diameter ≤3 cm (4) preoperative staging of T1~2N1~2M0 (5) "difficult pelvis", defined as ischial tuberosity diameter<10 cm or body mass index>25 kg/m2 (6) patients with strong intention for sphincter preservation (7) no preoperative treatment (e.g., chemotherapy, radiotherapy, molecular targeted therapy, or immunotherapy) (8) no lateral lymph node enlargement (9) no previous anorectal surgery (10) patients with good basic condition who could tolerate surgery. Exclusion criteria: (1) previously suffered from malignant tumors of the digestive tract or currently suffering from malignant tumors out of the digestive tract (2) patients with preoperative anal dysfunction (Wexner score ≥ 10), or fecal incontinence. The specific surgical steps are as follows: the distal end of the rectum was dissected to the level of the interspace between internal and external sphincters of anal canal. Five centimeters proximal to the tumor, the mesorectum was ligated, and a liner stapler was used to transect the rectum. The distal rectum with the tumor were then everted and extracted through the anus. The rectum was transected 0.5-1.0 cm distal to the tumor with a linear stapler. Full thickness suture was used to reinforce the stump of the rectum, which was then brought back into the pelvic cavity. Finally, an end-to-end anastomosis between the colon and the rectum was performed. A retrospective descriptive study was performed of the clinical and pathological data of 12 patients with T1-T2 stage low rectal cancer treated with LDER at Henan Provincial People's Hospital from January 2020 to December 2022. Results All 12 patients successfully completed LDER with sphincter preservation, without conversion to open surgery or changes in surgical approach. The median surgical time was 272 (155-320) minutes, with a median bleeding volume of 100 (50-200) mL. No protective stoma was performed, and all patients received R0 resection. The average hospital stay was 9 (7-15) days. There were no postoperative anastomotic leakage or perioperative deaths. All 12 patients received postoperative follow-up, with a median follow-up of 12 months (6-36 months) and a Wexner score of 8 (5-14) at 6 months postoperatively. There was no tumor recurrence or metastasis during the follow-up period. Conclusions LDER is safe and effective for the treatment of low rectal cancer.
查看更多>>摘要：近年来，结直肠癌（CRC）在诊疗方面取得长足进步，但目前标准治疗方案仍存在诸多不足，因此亟需更有效的生物标志物，用于患者的个性化治疗。循环肿瘤DNA（ctDNA）检测作为一种动态、非侵入性的液体活检方法，克服了组织活检在检测肿瘤异质性和分子演变中的不足。多项研究证据表明，ctDNA在复发风险分层、指导治疗决策和早期复发监测等方面展现出巨大前景。此外，ctDNA的应用还可提高临床研究的效率和药物开发。然而，ctDNA检测前变量和分析过程的标准化尚未统一，其技术成本也较高昂，这些均限制了其推广应用。本文总结了关于ctDNA在CRC临床管理中的现有证据，并提出了其局限性和改进策略。 Despite the great progress in the treatment of colorectal cancer (CRC), the current standard treatment protocols still have many limitations, and there is an urgent need for more effective biomarkers for personalized patient treatment. Circulating tumor DNA (ctDNA), as a dynamic, non-invasive liquid biopsy approach, overcomes the limitations of tissue biopsy in detecting tumor heterogeneity and molecular evolution. Current evidence from several studies suggests that ctDNA shows great promise in stratifying recurrence risk, guiding treatment decisions, and monitoring early recurrence. In addition, ctDNA can improve the efficiency of clinical research and drug development. However, the lack of standardisation of pre-ctDNA test variables and analysis procedures and the high technical costs limit its promotion and development. In this review, we summarize the available evidence on ctDNA in the clinical management of CRC and present its limitations and strategies for improvement.
查看更多>>摘要：肝脏是直肠癌最常见的转移部位，伴有可切除肝转移患者的生存较好。盆腔放疗已成为直肠癌伴肝转移多学科管理的组成部分。对于伴有不可切除肝转移患者，针对原发灶的姑息放疗能减少出血、梗阻等风险进而改善生活质量。对于伴有可切除肝转移患者，盆腔放疗可有效降低局部复发率、使部分患者免于手术而提高生活质量、甚至提高患者总生存率。目前，对于直肠癌伴肝转移患者盆腔放疗的标准化治疗模式没有达成共识，在如何筛选放疗获益人群、优化多学科协作以及放疗方案（长程放疗比短程放疗）、器官保留等方面成为研究热点。本文对近年来盆腔放疗在直肠癌伴肝转移中的研究进展作一综述，为直肠癌伴肝转移患者个体化盆腔放疗提供思路。 Hepatic metastasis is the most common in rectal cancer, and patients with resectable hepatic metastasis have better survival. Pelvic radiotherapy has become a key component of multidisciplinary management of rectal cancer with hepatic metastasis. For patients with unresectable hepatic metastasis, palliative radiotherapy to the primary lesion can reduce the risk of bleeding and obstruction and thus improve the quality of life. For patients with resectable hepatic metastasis, pelvic radiotherapy can effectively reduce the local recurrence rate, help some patients avoid surgery and improve their quality of life, and even improve the overall survival. At present, there is no consensus on the standardized treatment mode of pelvic radiotherapy for rectal cancer patients with hepatic metastasis, and it has become a hotspot for research on how to select the population benefiting from radiotherapy, how to optimize multidisciplinary collaboration and radiotherapy plans (long-course radiotherapy versus short-course radiotherapy) and how to preserve organs. This article reviews the research progress in pelvic radiotherapy for rectal cancer with hepatic metastasis in recent years, and provides ideas for individualized pelvic radiotherapy for rectal cancer with hepatic metastasis.
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