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首页 腹腔镜结直肠癌的治疗进展ppt演示课件

腹腔镜结直肠癌的治疗进展ppt演示课件.ppt

腹腔镜结直肠癌的治疗进展ppt演示课件

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2018-10-22 0人阅读 举报 0 0 暂无简介

简介:本文档为《腹腔镜结直肠癌的治疗进展ppt演示课件ppt》,可适用于医药卫生领域

腹腔镜辅助结直肠癌根治术CompanyLogo主要内容HuashanHospitalHaoHankunCompanyLogo腹腔镜发展史HuashanHospitalHaoHankunCompanyLogo年Flower和Jacobs行腹腔镜乙状结肠切除术年Kokerling首次施行腹腔镜Miles手术年Watanabe日本首例腹腔镜结肠手术年Leahy首次报告手助腹腔镜手术年香港郭宝贤完成亚洲首例乙状结肠手术年上海郑民华完成内地首例乙状结肠手术腹腔镜结直肠手术发展HuashanHospitalHaoHankunCompanyLogo腹腔镜面临的质疑Lancet():SubcutaneousmetastasesafterlaparoscopiccolectomyBerendsFJ,KazemierG,BonjerHJ,LangeJFBrJSurg():AbdominalwallmetastasesfollowinglaparoscopyNdukaCC,MonsonJR,MenziesGowN,DarziABrJSurg():AbdominalwallmetastasesfollowinglaparoscopyPrasadA,AveryC,FoleyRJHuashanHospitalHaoHankunCompanyLogo腹腔镜医生迎接挑战COST(ClinicalOutcomesofSurgicalTherapy)COLOR(COloncancerLaparoscopicorOpenResection)CLASICC(ConventionalversusLaparoscopicAssistedSurgeryInColorectalCancer)HuashanHospitalHaoHankunCompanyLogo腹腔镜与结肠癌COST的结果NEnglJMed:HuashanHospitalHaoHankunConclusionsInthismultiinstitutionalstudy,theratesofrecurrentcancerweresimilarafterlaparoscopicallyassistedcolectomyandopencolectomy,suggestingthatthelaparoscopicapproachisanacceptablealternativetoopensurgeryforcoloncancerCompanyLogo腹腔镜与结肠癌COLOR的结果LessbloodlossRadicalityofresectionnotdifferEarlierrecoveryofbowelfunctionFeweranalgesicsShorterhospitalstayMorbidityandmortalitydaysaftercolectomydidnotdifferConclusion:Laparoscopicsurgerycanbeusedforsafeandradicalresectionofcancerintheright,left,andsigmoidcolonLancetOncol:ndashHuashanHospitalHaoHankunCompanyLogoASCRSPracticeParameters()LaparoscopicandopencolectomyachieveequivalentoncologicaloutcomesforlocalizedcoloncancerTheuseofthelaparoscopicapproachshouldbebasedonthesurgeonrsquosdocumentedexperienceinlaparoscopicsurgeryaswellasonpatientandtumorspecificfactorsGradeofRecommendation:ADisColonRectum:ndashHuashanHospitalHaoHankunCompanyLogoNCCN指南的变化拒绝:费用昂贵术后恢复时间与开腹手术没有区别且缺乏相关生存数据不推荐临床常规使用。部分接受:①要求术者具有丰富的腹腔镜手术经验②无直肠或远端结肠肿瘤③无远处转移、无梗阻或穿孔、无腹腔粘连④要求术者对腹腔全面探查⑤较小的肿瘤术前需要定位。HuashanHospitalHaoHankun医学百事通在线医生咨询CompanyLogoNCCN指南的变化HuashanHospitalHaoHankunCompanyLogo腹腔镜结直肠手术的主要适应证和禁忌证适应证:腹腔镜手术适应证与传统开腹手术相似。包括结肠良恶性肿瘤、炎性疾病、多发性息肉等相对手术禁忌:肿瘤直径大于cm或和与周围组织广泛侵润腹部严重粘连、重度肥胖者、大肠癌的急症手术(如急性梗阻、穿孔等)心肺功能不良者禁忌证:全身情况不良虽经术前治疗仍不能纠正者有严重心肺肝肾疾患不能耐受手术随着腹腔镜手术技术和器械的发展以及麻醉和全身支持水平的提高腹腔镜手术适应证将进一步扩大和发展。HuashanHospitalHaoHankunCompanyLogo操作准备之体位选择充分利用地球引力方便术者操作头高脚低位头低脚高位分腿位左倾、右倾HuashanHospitalHaoHankunCompanyLogo操作准备之Trocar的放置第一穿刺孔往往选择在脐部减少对腹部血管、神经和腹直肌的损伤腹部正中位置,便于术者观察腹壁最薄处脐部穿刺切口更加隐蔽符合美学要求其余穿刺孔按手术种类和手术方式决定一般是三到四个选择原则便于操作打结、牵引、吸引互不干扰统筹兼顾放置引流、切开、美观HuashanHospitalHaoHankun医学百事通网络会诊wwwbstcomCompanyLogo操作准备之气腹的建立在第一穿刺孔气腹针直视下小切口可视穿刺器气腹压力~kPa或~mmHg)HuashanHospitalHaoHankunCompanyLogo手术操作分离技术电刀分离:)凝固血管和切断组织)电钩、电铲等超声刀分离:)切断mm以下血管(蛋白质变性))多用途:切割、止血、分离、抓持等HuashanHospitalHaoHankunCompanyLogo手术操作结扎技术夹闭法:可吸收夹不可吸收夹圈套器打结法体内打结体外打结HuashanHospitalHaoHankunCompanyLogo手术视频HuashanHospitalHaoHankunCompanyLogo腹腔镜与直肠癌技术上是否可行?肿瘤学是否安全?是否有优势?HuashanHospitalHaoHankunCompanyLogo腹腔镜与低位直肠癌(历史与现实)年LeroyJ完成首例腹腔镜TMELaparoscopicsurgeryispreferredinthesettingofaclinicaltrialNCCNGuidelinesVersion(Rectal)HuashanHospitalHaoHankunCompanyLogo腹腔镜与低位直肠癌(ASCRS现状)CurrentevidenceindicatesthatlaparoscopicTMEcanbeperformedwithequivalentoncologicaloutcomesincomparisonwithopenTMEwhenperformedbyexperiencedlaparoscopicsurgeonspossessingthenecessarytechnicalexpertiseGradeofRecommendation:Strongrecommendationbasedonmoderatequalityevidence,BDisColonRectum:ndashCompanyLogo腹腔镜直肠癌手术的循证医学依据Conclusions:Accordingtotheseresults,laparoscopicsurgeryisthebestoptionforthesurgicaltreatmentofrectalcancer,withsimilarratesoflocalrecurrenceandsurvivalSurgEndosc():ndashHuashanHospitalHaoHankunCompanyLogo腹腔镜直肠癌手术的循证医学依据Todate,thehighestlevelofevidenceforthebenefitsofthelaparoscopicapproachcomesfromtheCLASICCtrialCLASICC:TheMedicalResearchCouncilConventionalversusLaparoscopicAssistedSurgeryInColorectalCancertrial()NCCNGuidelinesVersionRectalCancerHuashanHospitalHaoHankunCompanyLogoFiveyearfollowupofCLASICCtrialBritishJournalofSurgery:ndashNodifferenceswerefoundbetweenlaparoscopicallyassistedandopensurgeryintermsofoverallsurvival,diseasefreesurvival,andlocalanddistantrecurrenceTheyearanalysesconfirmtheoncologicalsafetyoflaparoscopicsurgeryforbothcolonicandrectalcancerHuashanHospitalHaoHankunCompanyLogoLongtermfollowupofCLASICCtrialBritishJournalofSurgery:ndashTherewerenostatisticallysignificantdifferencesbetweenopenandlaparoscopicgroupsinoverallsurvivalLongtermresultscontinuetosupporttheuseoflaparoscopicsurgeryforbothcolonicandrectalcancerHuashanHospitalHaoHankunCompanyLogo腹腔镜直肠癌根治术HuashanHospitalHaoHankunCompanyLogoIMA处理细节IMA低位结扎高位结扎?低位结扎理由:生存率与高位相当高位结扎理由:更高的淋巴结检出率、更准确的分期利于降低张力尤其是低位直肠前切理论上更好的预后并不增加手术风险和时间高位清扫、低位结扎美国结直肠外科医师协会()totheleveloftheoriginofthesuperiorrectalarteryHuashanHospitalHaoHankunDisColonRectum:ndashCompanyLogoTME指征Miles的贡献()Heald的贡献()TME的指征直肠中和下的肿瘤,无论行低位前切除术(LAR)还是腹会阴联合切除术(APR),均应采用全直肠系膜切除技术(TME)。TSME、PME对于直肠上的肿瘤,可根据肿瘤情况进行系膜的切除,但要保证远切缘距肿瘤cm以上。HuashanHospitalHaoHankunCompanyLogoDistalresectionmarginsHuashanHospitalHaoHankunCompanyLogoNCCN关于下切缘要求对于超低位直肠癌(cm)cm的阴性下切缘是可以接受的但必须送冰冻证实。HuashanHospitalHaoHankunCompanyLogoASCRS关于下切缘HuashanHospitalHaoHankunDisColonRectum:ndashAcmdistalmuralmarginisadequateformostrectalcancerswhencombinedwithaTMEForcancerslocatedatorbelowthemesorectalmargin,acmdistalmuralmarginisacceptableGradeofRecommendation:Strongrecommendationbasedonmoderatequalityevidence,BCompanyLogo植物神经保护HuashanHospitalHaoHankunCompanyLogo植物神经保护HuashanHospitalHaoHankun医学百事通咨询医师CompanyLogo植物神经保护HuashanHospitalHaoHankunCompanyLogo植物神经保护HuashanHospitalHaoHankunCompanyLogo植物神经保护HuashanHospitalHaoHankunCompanyLogo肿瘤学原则:充分的切缘功能学原则:良好的括约肌功能医生的选择:技术难度、潜在风险患者的选择:充分的医患沟通LAR,ISRorAPRHuashanHospitalHaoHankunCompanyLogoLARorISRLAR指征:肿瘤下缘距离齿状线大于cm无括约肌和周围脏器侵犯双吻合器ISR指征:肿瘤下缘距离齿状线小于cm肿瘤下缘距离括约肌间沟大于cm无外括约肌或提肛肌侵犯HuashanHospitalHaoHankunCompanyLogo括约肌间切除(ISR)括约肌间切除(intersphinctericresection,ISR)最早()由Schiessel等详细描述提高保肛率获得更确切的下切缘潜在的劣势:增加手术并发症局部复发控便功能损害BrJSurgSep():HuashanHospitalHaoHankunCompanyLogoISR评价DisColonRectum:ndashIntersphinctericresectionisavaluableprocedureforsphinctersavingrectalsurgeryWeshowedthatthistechniquehassatisfactorylongtermresultsinfunctionalandoncologicrespectsHuashanHospitalHaoHankunCompanyLogoISR评价OncologicaloutcomesafterISRforlowrectalcancerareacceptable,withdiverse,oftenimperfectfunctionalresultsThesedatawillaidtheclinicianwhencounsellingpatientsconsideringanISRformanagementoflowrectalcancerBritishJournalofSurgery:ndashHuashanHospitalHaoHankunCompanyLogoISR分类DisColonRectum:HuashanHospitalHaoHankunCompanyLogo选择ISR需谨慎肿瘤分期基础括约肌功能是否需要辅助放疗患者性别以及年龄患者主观意愿HuashanHospitalHaoHankunCompanyLogoAPR指征APR适用于肿瘤侵犯外括约肌或提肛肌或可能导致肛门失禁的保肛术。HuashanHospitalHaoHankunCompanyLogo直肠癌手术原则肿瘤学良好的结果良好的功能保护不要盲目保肛HuashanHospitalHaoHankunCompanyLogo手术视频HuashanHospitalHaoHankun复旦大学附属华山医院蒿汉坤haohankungmailcom

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