1、大肠癌的治疗The treatment of colorectal carcinoma徐 为徐州医学院临床学院 外科教研室,大肠癌的治疗原则,手术治疗为主 其他治疗为辅的综合治疗,结肠癌根治性手术The radical dissection of colonic carcinoma,切除范围,癌肿所在肠袢相关肠系膜区域淋巴结,Ca,Ca,癌肿所在肠袢,相关肠系膜,适应证,盲肠癌升结肠癌结肠肝曲癌,切除范围,横结肠右半升结肠盲肠回肠末段,右半结肠切除术The resection of right side colon,用于横结肠癌,切除范围,肝曲脾曲结肠相应系膜胃结肠韧带的 相应淋巴结组,横结肠
2、癌切除术The resection of transverse colon,结肠脾曲癌降结肠癌,切除范围,横结肠左半降结肠部分或全部乙状结肠,左半结肠切除术 Resection of lift side colon,适应证,切除范围,切除范围取决于乙状结肠长短和肿瘤的部位,降结肠 +乙状结肠乙状结肠 +部分直肠 +部分降结肠,用于乙状结肠癌,乙状结肠癌根治切除术The radical dissection of sigmoid cancer,直肠癌局部切除术Local resection of rectal cancer,适用证,早期瘤体较小局限于粘膜或粘膜下层分化程度高,手术方式,经肛局部切
3、除术骶后经路局部切除术,Local ProceduresCandidates:Tumours less than 10 cm from the dentate lineThe lesions should be mobile on digital examination,less than 5 cm in diameter and of favourable differentiationLocal resection should be limited to T1 and T2 tumours.Not with lymph node metastasis,腹会阴联合直肠癌根治术(Miles手
4、术),适用范围:腹膜返折以下直肠癌,乙状结肠远段全部直肠肠系膜下动脉及其区域淋巴结全直肠系膜肛提肌坐骨直肠窝内脂肪肛管肛门周围约5cm直径皮肤皮下组织全部肛门括约肌,切除范围,Miles procedure,Rectal cancer located abdominal retating level,local intestinal wall enhanced,we can see the obvious shrinking tumor in postoperative sample,Hepatic metastasis cancer resection,Greyish white area:
5、 cancer,cancer,Oringinal cancer hepatic metastasis resection,Metastasis hepatic cancer,Colic cancer ( oringinal cancer ),Resection after of the tuomr minim- ized by interventional treatment,Total mesorectum excisionThe mesorectum consists of fatty tissue surrounding the rectum and contains the lymph
6、aticsdeposits of tumour within the mesorectum up to 3 cm distal to the main tumour. Total mesorectal excision has reduced local recurrence (less than 10%),经腹直肠癌切除术(Dixon手术),适用于距齿线5厘米以上的直肠癌,原则,远切端距癌肿下缘3厘米以上确保根治性切除,缺点:,根治的彻底性差术后近期排便控制性差,优点:去瘤保肛 提高生活质量,Although the management of colonic malignancies ha
7、s not altered greatly in recent years this is not true of rectal cancer,Distal Micrometastasis of The Rectal cancer The abnormal retrograde spread of rectal cancer ist common only that the lymphatic vessels of along the inferior mesenteric artery are blocked Distal intramural spread seldom exceeds a
8、 few millimetres and distal lymphatic spread is rare,超低位直肠癌的概念低位直肠癌:5 肿瘤下缘距肛缘1cm者110例4例复发 (World J Surg.1992,16:848857) 薛红千等:87例6复发(消化外科,2001,3(1):5253)李德川等:15例无1例复发(肿瘤研究与临床,2003;15(4):242244)冯基业等96例5例复发(中华医学研究杂志,2003;3(3):216218)我们19982000年54例 到目前为止仅2例局部复发,超低位直肠癌保肛手术的可行性研究排便节制功能的研究殷波等390例:恢复预感便意:23
9、个月恢复控制能力:56个月(34次/天)我们的经验:68个月恢复控制能力,Hartmann手术,适用证,全身情况差 不能耐受根治性手术急性梗阻 不宜行Dixon手术,手术方式,直肠癌切除近端造瘘远端封闭,优点:创伤小 能耐受 有还瘘的可能缺点:需造瘘 二次手术 根治性差,急性梗阻大肠癌的治疗 The treatment for acute obstructive colorectal cancer,一般处理原则胃肠减压纠正水 电解质 酸 碱失衡早期手术,右侧结肠癌伴梗阻的处理,病情许可 一期切除 回结肠吻合情况较差 先作盲肠造口 二期切除肿瘤肿瘤不能切除 行回肠横结肠侧侧吻合 或切断末端回肠行
10、远端回肠造口 近端回肠横结肠端侧吻合,左侧结肠癌伴梗阻的手术,一般在梗阻部位近端行横结肠造口 在肠道准备充分的情况下行二期手术根治肿瘤不能切除者 行姑息性结肠造口,晚期直肠癌并梗阻的手术,行乙状结肠双腔造口再行放疗可使部分病人获得再次手术切除的机会,大肠癌术前肠道准备 The prepare of intestinal tract for preoperative colorectal cancer,结肠完全空虚安全迅速不用抗生素肠道细菌数减少不影响水电平衡对肿瘤刺激小病人痛苦小 价廉,肠道准备的要求,肠道准备方法,肠道排空:口服复方聚乙二醇电解质散法、口服甘露醇法;口服泻剂法。不用清洁灌肠法
11、肠道抗生素的使用:术前一天用:甲硝唑 0.4g , tid ; 新霉素 1.0g , bid.不建议三天肠道准备法。,口服甘露醇肠道准备法,术前晚口服5%10%甘露醇优点:方法较简单 准备可靠缺点:肠道内产气 使用电刀时可引起爆炸 年老体弱 心功能差及有梗阻者慎用,大肠癌的化疗The chemotherapy of colorectal cancer,奥沙利铂100mg/m2 , 亚叶酸钙200mg/m2, iv d1 FOLFOX6方案:随后5-Fu 2.43.6g/m2,持续48h 每两周重复,共1012疗程,MAYO方案:是5-FU和CF的配伍,常用化疗方案,XELOX方案:奥沙利铂和Xeloda联合用药,新辅助放化疗,新辅助化疗(术前化疗) 肿瘤降期 切除率 复发率 FOLFOX6方案或MAYO方案24疗程 适用于、期结直肠癌新辅助放化疗 新辅助化疗+新辅助放疗 适用于中低位、中晚期直肠癌 2Gy/次、5次/周、总量46GY,其他治疗,基因治疗靶向治疗免疫治疗,液氮冷冻射频消融激光凝固,思考题1大肠癌的治疗原则直肠癌保肛手术的指征直肠癌局部切除的适应证全直肠系膜切除术在治疗直肠癌中的意义Miles手术Dixon手术,思考题2伴有急性梗阻的左右半大肠癌 外科处理方式的异同点肠道准备的要求口服甘露醇肠道准备的优缺点新辅助放化疗的适应证,Thank you,Thank you,