晚期大肠癌的外科治疗学习教案

1、会计学1晚期晚期(wnq)大肠癌的外科治疗大肠癌的外科治疗第一页，共25页。第1页/共25页第二页，共25页。第2页/共25页第三页，共25页。微创技术采用特殊器械缩小手术创伤范围，减少(jinsho)应激损伤控制采用特殊手术方案缩小手术创伤程度，减轻应激外科快速康复理念采用一系列措施，减少(jinsho)应激程度，促进康复第3页/共25页第四页，共25页。腹腔镜(laparoscopy)经肛门(gngmn)内窥镜下微创手术( transanal endoscopic microsurgery,TEM) 腹腔镜-内镜“双镜”联合手术(Laparoscopic in combination wi

2、th transanal endoscopic microsurgery) 经自然腔道内镜手术(natural orifice transluminal endoscopic surgery, NOTES) 经脐单孔腹腔镜技术(transumbilical laparoendoscopic single site surgery,TU-LESS)机器人手术(robotic surgery)微创技术微创技术(jsh)第4页/共25页第五页，共25页。腹腔镜对大肠良性病变及晚期大肠癌的姑息性切除或短路手术的微创疗效已基本得到肯定，并广泛应用，但对非晚期大肠癌的腹腔镜肠切除术，是否能达到(d do)

3、根治目的尚有较多争议。腹腔镜腹腔镜第5页/共25页第六页，共25页。TEM兼备了内镜、腹腔镜和显微手术的优点 TEM主要适应于距肛门4-20cm范围内的腺瘤或早期(zoq)直肠癌 如对不愿或不能耐受经腹根治性手术的高龄或高手术风险病人的姑息性手术及有广泛转移病人的局部控制。 第6页/共25页第七页，共25页。 固定固定(gdng)(gdng)支撑支撑架架(adjustable holder)(adjustable holder) 直肠镜手术直肠镜手术(shush)(shush)鞘鞘 （operating rectoscope)operating rectoscope) 工作工作(gngzu)(

4、gngzu)附件附件 （working attachmentworking attachment）双目立体视镜单目镜第7页/共25页第八页，共25页。经肛门(gngmn)内窥镜下微创手术（TEM）我们(w men)的经验：Local Resection for Rectal Tumors: Comparative Study of Transanal Endoscopic rosurgery versus Conventional Transanal Excision - The Experience in China. Yi H, Yong-Gang H, Mou-Bin L, Ya-Jie

5、 Z, Lu Y, Jin X, Jian-Wen L.Hepatogastroenterology. 2012 Apr 25;59(120). 第8页/共25页第九页，共25页。腹腔镜-内镜“双镜”联合(linh)技术按传统腔镜技术行直肠或乙状结肠癌切除术大多数肿瘤能经镜筒从肛门拖出，避免腹部切口双镜操作时腹腔与直肠内压力保持稳定，视野(shy)暴露清晰，可精确定位肿瘤下切缘，允许腹腔内及肛门内同时操作第9页/共25页第十页，共25页。完成完成(wn chng)TME(wn chng)TME后，经肛门取出标后，经肛门取出标本本第10页/共25页第十一页，共25页。关闭远端残端后，完成关闭远端

6、残端后，完成(wn (wn chng)chng)吻合吻合第11页/共25页第十二页，共25页。乙结肠肿瘤，腔镜下荷包乙结肠肿瘤，腔镜下荷包(h bo)(h bo)缝合并放置缝合并放置抵钉座抵钉座第12页/共25页第十三页，共25页。术后腹部术后腹部(f b)(f b)无切口无切口第13页/共25页第十四页，共25页。2012年年CSCO年会年会(ninhu)北京北京 腹腔镜腹腔镜- -内镜内镜“双镜双镜”联合联合(linh)(linh)技术技术 术后腹部(f b)无切口第14页/共25页第十五页，共25页。腹腔镜腹腔镜- -内镜内镜“双镜双镜”联合联合(linh)(linh)技术技术我们(w

7、men)的经验：Total laparoscopic sigmoid and rectal surgery in combination with transanal endocopic microsurgery: a preliminary evaluation in China. Han Y, He YG, Zhang HB, Lv KZ, Zhang YJ, Lin MB, Yin L.Surg Endosc. 2012 Jul 18. 第15页/共25页第十六页，共25页。第16页/共25页第十七页，共25页。快速康复外科(Fast-Track Surgery，FTS) 主要包括快速通

8、道麻醉、微创技术、最佳镇痛技术及强有力的术后护理(如术后早期进食、运动(yndng)等，其宗旨是为患者提供最优质的服务、最大的益处和最少的损伤。 现代肿瘤外科快速康复现代肿瘤外科快速康复(kngf)理念理念第17页/共25页第十八页，共25页。将微创技术与FTS共同应用于肿瘤治疗，可以降低患者术后炎症反应(fnyng)及免疫损伤，减轻患者的疼痛，有利于术后肺、心、肾、肠道等多器官功能的恢复，缩短术后住院时间，进而达到快速恢复的目的，为进一步的治疗打下基础。微创技术与快速康复理念微创技术与快速康复理念(l nin)联联合应用合应用第18页/共25页第十九页，共25页。外科在晚期肿瘤治疗外科在晚期

9、肿瘤治疗(zhlio)中角色的中角色的演变演变现代(xindi)肿瘤治疗已经从单一依靠外科过渡到多学科参与的综合治疗 。外科医生应该熟悉肿瘤治疗的各种手段：手术可以提高肿瘤治疗的局部和区域控制率；化疗、放疗、内分泌治疗、生物基因治疗和分子靶向治疗等可进一步减少复发和死亡，提高患者生存率；基因芯片、基因组学、蛋白质组学以及临床预后指标检测，有助于辅助治疗的选择和判断预后，也为肿瘤的分子研究提供了更直观、更精确的工具。第19页/共25页第二十页，共25页。晚期(wnq)大肠癌的化疗第20页/共25页第二十一页，共25页。1.Lin M, Gu J, Eng C, Ellis LM, Hildebr

10、andt MA, Lin J, Huang M, Calin GA, Wang D, Dubois RN, Hawk ET, Wu X.Genetic polymorphisms in MicroRNA-related genes as predictors of clinical outcomes in colorectal adenocarcinoma patients. Clin Cancer Res. 2012 15;18(14):3982-91. (SCI 7.742)2.Lin M, Eng C, Hawk ET, Huang M, Lin J, Gu J, Ellis LM, W

11、u X. Identification of polymorphisms in ultraconserved elements associated with clinical outcomes in locally advanced colorectal adenocarcinoma. Cancer. 2012 15;118(24):6188-98. (SCI 4.771)3.Lin M, Eng C, Hawk ET, Huang M, Greisinger AJ, Gu J, Ellis LM, Wu X, Lin J. Genetic variants within ultracons

12、erved elements and susceptibility to right- and left-sided colorectal adenocarcinoma. Carcinogenesis. 2012;33(4):841-7. (SCI 5.702)4. Lin M, Stewart DJ, Spitz MR, Hildebrandt MA, Lu C, Lin J, Gu J, Huang M, Lippman SM, Wu X.Genetic variations in the transforming growth factor-beta pathway as predict

13、ors of survival in advanced non-small cell lung cancer. Carcinogenesis. 2011;32(7):1050-6. (SCI 5.702)第21页/共25页第二十二页，共25页。Macedo LT, da Costa Lima AB, Sasse AD. Addition of bevacizumab to first-line chemotherapy in advanced colorectal cancer: a systematic review and meta-analysis, with emphasis on c

14、hemotherapy subgroups.BMC Cancer. 2012 12:89.Bevacizumab in colorectal cancer was studied initially in the metastatic setting, and was approved by US FDA in 2004, based on a survival benefit noted in the AVF2107 trial with irinotecan, 5-fluorouracil and leucovorin (IFL) regimen. The increment in OS

15、occurred only for irinotecan-based regimens (HR = 0.78; 95% CI: 0.68-0.89; P = 0.0002) and no oxaliplatinbased treatments presented statistically significant data.第22页/共25页第二十三页，共25页。The Medical Research Council (MRC) COIN trial has not confirmed a benefit of addition of cetuximab to oxaliplatin-bas

16、ed chemotherapy in first-line treatment of patients with advanced colorectal cancer. No benefit in progression-free or overall survival in KRAS wild-type patients was observed. The multicenterCRYSTAL trial showed that HR for progression-free survival among patients with wild-typeKRAS tumors was 0.68 (95% CI, 0.50 to 0.94), in favor of the cetuximabFOLFIRI group.Timothy S Maughan, Richard A Adams, Christopher G Smith, et al.Addition of cetuximab to oxaliplatin-based first-line combination chemotherapy for treatment of advanced colorectal cancer: results of the randomised phase 3 MRC COI