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复发性结肠癌再手术的指征和时机
傅传刚(上海第二军医大学长海医院200433)
结肠癌术后再手术的患者通常包括两部分病人，一类是肿瘤局部晚期，已经在其它医院进行了手术，由于各种原因没能对原发肿瘤进行根治性切除，或仅单纯行剖腹探查、简单的结肠造口或短路手术等；另一类是结肠癌根治性切除术后复发的患者。无论是哪一类病人是否能够或需要再次手术，再次手术的时机以及手术方式的把握等均较为复杂。处理的好．可以明显延长患者的生存时问，减轻患者的疼痛，否则不仅增加患者的痛苦和花费，而且常常加速肿瘤的生长，缩短病人的生存时间。对于结肠癌术后复发的定义。大体可以分为两类：—类将结肠癌术后所有脏器再次出现与原发癌相关的再发均包括在复发的范畴中，包括肝脏、肺、骨骼等的转移以及局部的复发等；另一类则特指初次手术范围内的再发，而其它脏器的相关再发则包括在转移的范围内。本文所指复发指此类患者。
结肠癌术后复发根据部位可分为：吻合口复发、结节性复发、腹腔内复发以及混合型复发。吻合口复发指肿瘤复发位于吻合口及其附近的肠壁，可向腔内、腔外生长，伴有或不伴有周围组织浸润。多因术前灌肠、术中挤压导致肠腔内癌细胞脱落，种植于吻合口或其附近的黏膜或肿瘤两端肠管切除长度不够。切缘有癌细胞残留引起。结节性复发指腹腔内孤立的结节样复发．由于初次手术结肠系膜切除不足或腹腔内转移淋 巴结清扫不够引起。腹腔内复发是指腹腔内浆膜表面的肿瘤复发，常为多发性或弥漫性．由于原发肿瘤已经穿透浆膜或术中癌细胞散落于腹腔、盆腔引起。混合型复发指局部及肝、肺等组织同时复发。在Ⅱ、m期结肠癌根治性手术患者中约有30—40％的患者术后发生复发。其中仅约 10％一21％的可以再次进行根治性切除。
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