为保肛手术做决策依据

正确认识盆腔的构造与内括约肌、外括约肌组合的肛门控制功能,为科学保肛手术做决策依据

第一节  正确认识超低位直肠癌的保肛风险,了解低位直肠癌周边人体器官结构,做慎重的科学保肛决策。

要说清楚这个问题,首先要从直肠功能和盆腔的结构和附近的人体功能器官说起,因为人的盆腔是v字型的,盆腔和直肠的相对位置和形状,就像一个向下的箭头↓的形状,1竖是直肠,v字就是盆腔底和盆腔两侧的形状了。

而肛门向上约2公分是外括约肌和肛提肌,负责肛门的开关功能,由大脑控制,而肛门向上约2-4公分是内括约肌,是负责自动探测肛管和直肠大便的存储和到达情况,探测肠子是要排气放屁还是排便,给大脑和外括约肌、肛提肌提示肠子要排便或者要排气了,让人们有时间选择放屁的环境放屁,找到方便的厕所排便。

而负责低位直肠周边淋巴功能的淋巴管、淋巴结系统,是有别于其它的肠段的淋巴管系统都是半字型的横向和向上延伸分布状态,而是木字型的呈横向与向下生长延伸状态的,淋巴管在这个位置收集淋巴液之后再汇入盆底的大淋巴管再向上做淋巴液回流。

也就是说,5-6公分以下的超低位直肠癌患者,怀疑被侵犯的淋巴系统因为其向下生长的结构,其实还低于距离肛门5公分,更加接近骶前淋巴结和髂内、髂血管旁的淋巴结和周边林立的功能器官;所以这个位置的超低位直肠癌患者,术前核磁报告有如下描述之一或多种描述者:肿瘤局部突破浆膜层,周边脂肪模糊、脂肪间隙不清的;直肠周围可见血管侵犯的;肿瘤侵犯输精管、前列腺的,或与上述器官分界不清的;肿瘤累及内括约肌的;累及肛提肌的;周边有数个淋巴结肿大的,或者累及骶骨及骶前淋巴结肿大强化的、左右侧髂血管旁淋巴结肿大强化的;侵犯输卵管或与子宫后壁粘连或者分界不清的;侵犯某种妇科器官的。术前核磁报告上有上述任何一种描述的患者,基本属于3b-3c期超低位直肠癌;除了一定要到省肿瘤医院以上专业肿瘤医院诊疗之外,还要克服强烈的保肛愿望,面对现实接受肠癌外科专家的建议,果断的做术前放化疗辅助治疗之后切除肛门,做永久造口以达到彻底根治肠癌目的,科学治疗才能免除日后复发转移的后患,毕竟保命比保肛重要,永久造口用习惯了,与常人无异,不妨碍工作、生活和社交。

第二节  3期超低位直肠癌要果断的放弃保肛,术前新辅助放化疗之后切除肛门,做永久造口,保命比保肛重要!!2期以下的超低位直肠癌才有机会稳妥保肛。

这个位置的肠癌患者,专业的医生看到肿瘤已经出肠侵犯周边的复杂情况时,一般都会建议患者不要保肛,而6年群经验见过不少因为年纪轻保肛意志强烈的患者,在几个专业肿瘤医院强烈要求医生做保肛手术,专业医生都不肯帮他(她)做保肛手术之后,自己寻找到不专业的医院和不专业的医生勉为其难的为他(她)做保肛手术,基本不够一年最多两年就发现复发转移的个案比比皆是,后悔莫及。

肿瘤位置越低距离肛门越近,直肠肿瘤越靠近盆腔两壁和盆腔低、周围临近的盆腔两壁淋巴结、骶骨、子宫、输卵管、前列腺、输精管、盆腔底等被侵犯的概率越高,盆腔底部和直肠底部肠段的狭窄三角地带一般被脂肪所填满,(特别以身体肥胖者为甚)低位直肠癌患者,医生要在那个非常狭窄的盆腔底部三角区域内动刀,在周边功能器官林立的环境里,就是肿瘤术前核磁报告显示肿瘤不出肠,周边见不到明显侵犯的病灶,只是理论上肿瘤不出肠也可以通过遍布于肠壁深肌层的淋巴管出肠,周边脂肪有可能被侵犯的2期患者,做这种超低位直肠癌手术,医生要在这个周边功能器官林立,又被脂肪包裹着的狭窄区域动刀,医生根本就不可能干净的切除全部可能被侵犯的病灶,又能够保证周边功能器官不被误切,是非常的考验医生的手术水平和经验深浅的高难度手术,这类2-3a期的患者术后还得做放疗补救以消灭没有被医生切除的怀疑病灶,才能够妥当的治好这种超低位的直肠癌,这种手术一般全国地级市三甲医院的肿瘤科和肛肠科医生做不好这种超低位保肛手术,3b-3c期就更不用说了,或严肃点说,他们没有资格和能力做好这种超低位直肠癌保肛手术!!!

第三节  距离肛门6公分以下的超低位直肠癌患者,术前或术后一定要配合好放疗医生做放疗,低位直肠癌放疗效果非常好。

所以,一切6公分以下低位的直肠癌患者,放疗医生都会假定患者有怀疑被侵犯的组织或功能器官被癌细胞侵犯而没有被手术切除,都必须做放疗去补救——所以低位直肠癌患者,除了一定要去专业的肿瘤医院找专家手术之外,术前、术后一定要配合放疗医生做好放疗治疗!

也就是说,直肠癌病灶位置越低位,肿瘤那段直肠就越靠近盆腔底部和盆腔两侧,肠外脂肪和淋巴结和周围功能器官,受到侵犯的概率也就越高,也只能够靠术后放疗才能够彻底消灭干净直肠周边手术无法切干净而残存的癌细胞。低位肿瘤的肠外可能侵犯病灶或残留癌细胞,因为低位直肠癌距离肛门很近,放疗医生从肛门位置对准病灶做放疗,也特别敏感,所以低位直肠癌必须做放疗,也特别适合做放疗,放疗的效果也非常好。距离肛门6公分以下的患者千万不要跟医生讨价还价放疗不放疗和放疗强度的问题,术前术后好好配合医生做足放疗治疗,认真学习后面的放疗期间护理知识,你就能够顺利的完成对于低位直肠癌患者来说,非常重要的放疗治疗!

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