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1.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1137-1143, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874529

RESUMO

Objective: To explore the technical characteristics and short-term clinical efficacy of robotic-assisted intersphincteric resection (ISR) for patients with low rectal cancer. Methods: A retrospective cohort study was used. Inclusion criteria: (1) rigid colonoscopy showed lower margin of the tumor ≤5 cm from the anal verge; (2) preoperative rectal MRI or endorectal ultrasound revealed staging T1-2, or T3 patients receiving concurrent chemoradiotherapy; (3) patients less than 70 years old with good function of anal sphincter before surgery; (4) no synchronous multiple primary carcinoma, and no distant metastasis; (5) the method of operation was agreed by the patient. Exclusion criteria: (1) T4 stage tumors; (2) sphincter dysfunction before operation; (3) recurrent tumors; (4) lower edge of tumors beyond the dentate line; (5) death due to non-rectal cancer during follow-up and unsatisfactory follow-up data. The clinical data of 21 patients with low rectal cancer meeting inclusion criteria undergoing robotic-assisted ISR at our department from January 2015 to June 2018 were collected. Parameters during and after operation were observed. Anorectal manometry was performed at 3, 6, and 12 months after the operation, and anal function was evaluated at 3, 6, and 12 months after the closure of the stoma by Kirwan classification and Wexner fecal incontinence score. The key steps of the operation are as follows: according to the principle of total mesorectal excision, the robot continued to enter into the levator ani hiatusdistally, and dissectin the sphincter space; according to the scope of sphincter resection, ISRwas divided into partial ISR, subtotal ISR, and total ISR; subtotal and total ISR usually needed to be combined with transanal pathway. The reconstruction of digestive tract was performed by double stapler anastomosis under laparoscope orhand-sewnanastomosis under direct vision, and preventive ileostomy was completed in the right lower abdomen. Results: Of 21 patients, 13 were male and 8 were female with mean age of (57.5±16.3) years. All the patients successfully completed the operation without conversion to laparotomy. Fourteen cases (66.7%) adopted partial ISR through complete transabdominal approach, 6 cases (28.6%) adopted the subtotal ISR through combined transabdominal and transanal approachs, and 1 case (4.8%) adopted the total ISR through the combined transabdominal and transanal approachs. The total operation time was (213.1±56.3) minutes, including (27.3±5.4) minutes for mechanical arm installation and (175.7±51.6) minutes for robotic operation. The amount of intraoperative hemorrhage was (62.8±23.2) ml, and no blood transfusion was performed in any patient. All patients underwent prophylactic ileostomy, and the stoma was closed 3-6 months after the operation. Except one case of anastomotic leakage, all other stomas were closed successfully. The postoperative hospitalization time was (7.6±2.2) days, and time to fluid intake was (3.3±0.9) days. One case of anastomotic leakage, one case of anastomotic stenosis, one case of inflammatory external hemorrhoids and one case of urinary retention occurred after surgery,and all of them were cured by conservative treatment. The mean diameter of tumors was (2.9±1.2) cm, and the number of harvested lymph node was 12.8 ± 3.3. In the whole group, the circumcision margin was negative, the proximal margin was (12.2 ± 2.1) cm, the distal margin was (1.1 ± 0.4) with all negative, and the R0 resection rate was 100%. The results of anorectal manometry showed that the preoperative rest pressure, rectal maximum squeeze pressure, initial sensory volume and maximum tolerated volume were (45.19±8.46) mmHg, (128.18±18.80) mmHg, (44.33±10.11) ml and (119.00±19.28) ml, respectively;these parameters reduced significantly 3 months after operation and they were (23.44±5.54) mmHg, (93.72±12.15) mmHg, (17.72±5.32) ml and (70.44±10.9) ml, respectively. The differences were statistically significant (all P<0.001). The resting pressure and the rectal maximum squeeze pressure returned to preoperative levels 12 months after operation, which were (39.33±6.64) mmHg and (120.58±16.47) mmHg, respectively (both P>0.05), while the initial sensory volume and the maximum tolerated volume failed to reach the preoperative state, which were (30.67±7.45) ml and (92.25±10.32) ml, respectively (both P<0.05). The patients were followed up for (22.1±10.6) months without local recurrence and distant metastasis. Eighteen patients were evaluated for anal function: Kirwan classification was grade I for 6 cases, grade II for 7 cases, grade III for 4 cases, and grade IV for 1 case; Wexner incontinence score was 8.6±0.8; 14 cases had good defecation control. Conclusion: The clinical efficacy of ISR with Da Vinci robot in the treatment of low rectal cancer is satisfactory.


Assuntos
Protectomia/métodos , Neoplasias Retais/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Canal Anal/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1165-1169, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874533

RESUMO

Objective: To compare the efficacy and safety of two procedures in the treatment of hemorrhoid: the procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection (STARR). Methods: A retrospective cohort research was conducted. Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively, while those had other anorectal diseases, emergency surgery, inflammatory bowel disease, tumor and incomplete clinical data were excluded. PPH was performed in 129 patients and STARR was performed in 134 patients. PPH procedure: a circular purse 2-0 string suture was made at 4 cm above the dentate line; in accordance with the standard protocol, the PPH circular stapling devicewas introduced; the suture was closed, and a pull-through followed; the traction was continued; the stapler was fired; the prolapsed mucosa and submucosa were removed. STARR procedure: 3-5 needles were sutured in the anterior rectal mucosa, protecting the posterior wall mucosa; with the help of a finger the PPH stapler was inserted into the vaginal lumen; the sutures were hooked from both sides of the stapler to maintain traction; according to the disease condition, the suturewas tightened appropriately; stapler was screwed and activated; the anterior wall mucosa was removed; the joint of the both ends of anastomosis was cut; the posterior wall mucosa was removed as well. The short-term efficacy, surgical safety and prognosis of the two groups were compared. Results: There were 67 males (51.9%) in the PPH group and 57 (42.5%) males in the STARR group. The median age of the two groups was 51.0 (22.0, 80.0) years and 49.0 (24.0, 74.0) years, respectively. There were no significant differences in the baseline data between the two groups (all P>0.05). No significant differences in the intraoperative bleeding, length of hospital stay, postoperative analgesic drug use, postoperative bleeding, postoperative infection, etc. were found between two groups (all P>0.05). As compared to PPH group, STAAR group had longer operation time and higher hospitalization cost with significant differences [(44.0±19.3) minutes vs. (26.3±8.5) minutes, t=9.701, P=0.001; (11 047±473) yuan vs. (7674±309) yuan, t=32.826, P=0.001]. One case in STAAR group developed rectovaginal fistula. The median follow-up period of the whole group was 40 (33, 52) months. A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up. The 3-year disease-relapse rate was 0 in STARR group and 4.2% in PPH group (P=0.042). Conclusion: STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid, but attention should be paid to the development of complications.


Assuntos
Hemorroidas/cirurgia , Protectomia/métodos , Prolapso Retal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Canal Anal , Feminino , Hemorroidas/classificação , Hemorroidas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Prolapso Retal/complicações , Reto/cirurgia , Estudos Retrospectivos , Grampeamento Cirúrgico , Resultado do Tratamento , Adulto Jovem
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1170-1176, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874534

RESUMO

Objective: To evaluate the quality of life after Altemeier and Delorme procedures for rectal prolapse patients. Methods: A retrospective cohort study was performed. Clinical data of patients with full-thickness rectal prolapse undergoing surgical treatment in the Sixth Affiliated Hospital, Sun Yat-sen University from February 2013 to January 2018 were retrospectively analyzed. Patients who had no preoperative imaging data, who suffered from internal rectal intussusception, or who did not undergo Altemeier and Delorme operations were excluded. Sixty-seven patients were enrolled, including 32 males with median age of 20.5 (13, 34) years and 35 females with median age of 65.0 (50, 77) years. According to different procedures, patients were divided into the Altemeier group (48 cases) and the Delorme group (19 cases), who received standard Altemeier and Delorme operations respectively. The maximal prolapse length of preoperative squat position, the Longo constipation score, Wexner incontinence score, EQ-5D-5L score, postoperative complications and recurrence rate were analyzed and compared between two groups. Results: The maximal prolapse length of preoperative squat position in Altemeier group and Delorme group was (7.3±3.3) cm and (4.9±2.1) cm respectively with significant difference (t=2.907, P=0.005). The operations in both groups were successfully completed. The operation time and postoperative hospital stay of Altemeier group were longer than those of Delorme group [(112.3±47.0) minutes vs. (80.7±35.4) minutes, t=2.637, P=0.010; (11.3±5.0) days vs. (8.6±3.0) days, t=2.177, P=0.033]. The median follow-up period was 26 (13, 45) months. In the last follow-up, compared to pre-operation, the Longo constipation score [9.0 (6.0, 14.0) vs 4.0 (1.0, 6.5), Z=-4.989, P<0.001], Wexner incontinence score [0 (0, 5.5) vs. 0 (0, 2.0), Z=-3.325, P<0.001] and EQ-5D-5L score [45.0 (40.0, 57.5) vs. 80.0 (70.0, 87.5), Z=-5.587, P<0.001] were all improved obviously in the Altemeier group, meanwhile Longo constipation score [6.0 (5.0, 14.0) vs. 3.0 (1.0, 7.0), Z=-2.186, P=0.029], Wexner incontinence score [0 (0, 12.0) vs. 0 (0, 4.0), Z=-2.325, P=0.020] and EQ-5D-5L score [50.0 (35.0, 60.0) vs. 75.0 (65.0, 90.0), Z=-3.360, P=0.001] in the Delorme group were all improved obviously as well. The postoperative morbidity of complication between the two groups was not significantly different [10/48 (20.8%) vs. 4/19 (21.1%), χ(2)=0.049, P=0.826]. Sixteen patients (28.0%) relapsed after operation, including 10 patients in the Altemeier group and 6 patients in the Delorme group, without statistically significant difference (P=0.134). Conclusions: Both the Altemeier and Delorme procedures are effective treatments for rectal prolapse, which can improve the postoperative quality of life. Delorme procedure has the advantages of shorter operation time and faster postoperative recovery in patients with mild prolapse.


Assuntos
Prolapso Retal/cirurgia , Adolescente , Adulto , Idoso , Colectomia/métodos , Colo Sigmoide/cirurgia , Feminino , Humanos , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Protectomia/métodos , Qualidade de Vida , Reto/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
4.
Surg Clin North Am ; 99(6): 1151-1162, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676054

RESUMO

Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.


Assuntos
Doença de Crohn/terapia , Fístula Intestinal/cirurgia , Doenças Retais/terapia , Terapia Combinada , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Feminino , Humanos , Fístula Intestinal/etiologia , Fístula Intestinal/fisiopatologia , Masculino , Protectomia/efeitos adversos , Protectomia/métodos , Prognóstico , Doenças Retais/diagnóstico , Doenças Retais/etiologia , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
5.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 920-925, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630487

RESUMO

The theory of membrane surgery actually holds the same concepts as that of traditional cancer surgery, which believes that tumor spread is regarded as an isotropic process but the tumor is confined by the block of the membrane. Therefore, the radical resection can be achieved by complete mesentery excision along the membrane plane. The surgical practice derived from these conceptions is extended excision and lays emphasis on tumor-free margins. But the theory is controversial in the view of the existence of mesorectal fascial envelope and the feasibility of complete excision of mesorectum along the "holy plane". Based on ontogenetic anatomy, the compartment theory suggeststhat tumor spread is not isotropic, and it is locally confined within the ontogenetic compartment derived from a common primordium for a relatively long phase during their natural course. Local tumor is suppressed by the boundary instead of fascia. The anatomical territory developing from each anlage primordium may be separated morphologically. Consequently, ontogenetic compartment theory states that optimal local control of cancer is achieved by whole compartment resection, irrespective of margin width. The compartment model of tumor spread provides explanations for total mesorectal excision (TME) which excises the complete rectum compartment including the rectum and its surrounding vascular and ligamentous mesenteries. The compartment theory may set up the new principles for surgical tumor treatment, namely the resection of the tumor bearing compartment rather than target organ.


Assuntos
Mesentério/patologia , Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Colectomia/métodos , Colectomia/normas , Fáscia/patologia , Humanos , Margens de Excisão , Mesocolo/patologia , Mesocolo/cirurgia , Invasividade Neoplásica , Metástase Neoplásica , Protectomia/normas , Reto/anatomia & histologia , Reto/patologia
6.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 943-948, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630491

RESUMO

The neurovascular bundle (NVB) starts at the lateral angle of the seminal vesicle (the initial part), passes posterolateral of the prostate gland (the main part), and ends at the cavernous body of the penis (the cavernous part). In low rectal surgery, different transabdominal and transanal perspectives result in different NVB injury risks. In the perspective of transabdominal operation, the separation between the initial part of NVB and Denonvilliers fascia and the anatomical variation of the two lateral sides of Denonvilliers fascia increases the risk of NVB injury, and conformation separation may take into account the convenience of separationand the protection of NVB. In the perspective of transanal operation, when separating the main part with NVB and mesorectum, the perspective of the transanal, unidirection traction and excessive dissection increase the risk of NVB main exposure. Clear anatomical identification helps the protection of NVB in the transanal operation. At present, the medical evidence on the difference of NVB injury in different perspectives of transabdominal and transanal approach is still in need of relevant clinical researches.


Assuntos
Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Colectomia/métodos , Dissecação , Fáscia/anatomia & histologia , Humanos , Masculino , Mesentério/anatomia & histologia , Mesentério/irrigação sanguínea , Mesentério/inervação , Neoplasias Retais/patologia , Reto/anatomia & histologia , Reto/irrigação sanguínea , Reto/inervação
7.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 949-954, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630492

RESUMO

Objective: To perform an anatomical observation on the extension of the mesocolon to the mesorectum and the continuity of the fasciae lining the abdomen and pelvis, in order to clarify the appropriate surgical plane of total mesorectal excision. Methods: This is an descriptive study. The operation videos of 61 cases (28 males, 33 females, median age of 61) were collected. All the patients underwent laparoscopic colorectal surgery from January 2018 to December 2018 in Yangpu Hospital, including low anterior resection for rectal cancer in 25 cases, left hemicolectomy for descending colon cancer in 15 cases, and subtotal resection of the colon for intractable constipation in 21 cases. Among these 21 constipation patients, 8 received additional modified Duhamel surgeries. Gross anatomy was performed on 24 adult cadavers provided by Department of Anatomy, Shanghai Jiaotong University School of Medicine, including 23 formalin-fixed and 1 fresh cadaver (12 males, 12 females). Sixty-one patients and 24 cadavers had no previous abdominal or pelvic surgical history. The anatomy and extension of fasciae related to descending colon, sigmoid colon and rectum, especially the morphology of Toldt fascia, and the continuities of mesocolon and mesorectum were observed carefully. The distribution characteristics of the fasciae and anatomical landmarks during laparoscopic surgery were recorded and described. Results: The anatomical study on 24 cadavers showed that visceral fascia was the densest connective tissue in the pelvic, posterolateral to the rectum, and stretched as a hammock to lift all pelvic organs. Among 61 patients undergoing laparoscopic surgery, 36 (59.0%) needed to free the left colon during operation, and Toldt fascia in the descending colon segment presented as potential, avascular and extensible loose connective tissue plane between the mesocolon and posterior Gerota fascia; 33 (54.1%) needed to free the rectum during operation, and Toldt fascia extended downward to pelvis as loose connective tissue between the fascia propria of the rectum and visceral fascia; the fascia propria of the rectum exposed completely in 32 (32/33, 97.0%) cases, which ran downward and fused with visceral fascia at the level of the fourth sacral vertebra. The anatomy of 24 cadavers also showed that fascia propria of the rectum fused with visceral fascia at the level of Waldeyer fascia. The fusion line of these two fasciae was supposed to be the extension of Waldeyer fascia. There were two avascular planes behind the rectum: one between the fascia propria of the rectum and visceral fascia, and the other between the visceral fascia and parietal fascia. In 8 constipation cases undergoing laparoscopic subtotal colon resection plus modified Duhamel operation, both mesocolon and mesorectum needed to be mobilized. It was obvious that the mesocolon of descending colon extended and became the mesocolon of sigmoid colon, and ran further into the pelvic and became the mesorectum. The colon fascia of descending colon served as the natural boundary of mesocolon extended downward as the fascia of sigmoid colon and the fascia propria of the rectum, respectively. Toldt fascia locating between mesocolon of descending colon and Gerota fascia extended to pelvis as the 'presacral space' between the fascia propria of the rectum and visceral fascia. Gerota fascia in descending colon segment extended as urogenital fascia in sigmoid colon segment and visceral fascia in the pelvis, respectively. In the cadaver anatomy study, the visceral fascia served as a corridor carrying the hypogastric nerve, and ureter was observed in 23 (23/24, 95.8%) cases. The visceral fascia passed from posterior to anterior lateral of rectum, fusing with Denonvilliers fascia in a fan shape. The pelvic plexus located exactly external to the junction of visceral fascia and Denonvilliers fascia. Pelvic splanchnic nerves went through the parietal fascia toward to the inferolateral of the pelvic plexus. Conclusion: Fascia propria of the rectum and the visceral pelvic fascia are two independent layers of fascia, and the TME surgical plane is between the fascia propria of the rectum and visceral pelvic fascia instead of between the visceral and the parietal pelvic fascia.


Assuntos
Fáscia/anatomia & histologia , Mesentério/anatomia & histologia , Pelve/anatomia & histologia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/anatomia & histologia , Abdome/anatomia & histologia , Cadáver , Colectomia/métodos , Feminino , Humanos , Laparoscopia , Masculino , Mesocolo/anatomia & histologia , Pessoa de Meia-Idade
8.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 961-965, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630494

RESUMO

Objective: To introduce a new technique of protective ostomy using the specimen extraction auxiliary incision following laparoscopic low anterior resection for rectal cancer, and to compare the pros and cons of loop ileostomy (LI) and loop transverse colostomy (LTC). Methods: A retrospective cohort study was performed. The data of patients who underwent laparoscopic low anterior resection for rectal cancer and ostomy using the auxiliary incision in Peking Union Medical College Hospital from January 2010 to December 2017 were retrospectively analyzed. Inclusion criteria: (1) patient underwent neoadjuvant chemoradiotherapy before operation; (2) patient was classified as tumor stage II or III; (3) patient was followed up and underwent stoma closure at our center; (4) ostomy was performed through specimen extraction incision. Patients with multiple gastrointestinal carcinomas or inflammatory bowel disease were excluded. Two hundred and eight patients were included in the study and divided into the LI group (n=86) and LTC group (n=122). The operation parameters and postoperative complications were compared between the two groups. Results: There were 135 males and 73 females (1.85∶1.00). Mean age of the 208 patients was (59.6±11.6) years (range 29-85 years). There were no significant differences between LI and LTC groups in baseline data (all P>0.05). All of the patients completed surgery successfully. The severe complication rate after ostomy was 2.9% (6/208). In the fecal diversion period, LI group showed significantly faster defecation [(1.6±1.0) days vs. (2.2±1.9) days, t=-2.918, P=0.004] and lower incidence of parastomal hernia [8.1% (7/86) vs. 19.7% (24/122), χ(2)=5.290, P=0.021], but higher incidence of peristomal dermatitis [18.6% (16/86) vs. 4.9% (6/122), χ(2)=9.990, P=0.002] as compared to LTC group. The incidence of renal insufficiency was lower in LTC group, though the difference was not significant [4.9% (6/122) vs. 10.5% (9/86), χ(2)=2.320, P=0.128]. The severe complication rate after stoma closure was 1.9% (4/208). In the stoma closure period, a significantly higher incidence of wound infection was noted in LTC group [18.0% (22/122) vs. 4.7% (4/86), χ(2)=8.258, P=0.004]. There were no significant differences between the two groups in the incidence of anastomotic leakage, stenosis, and incisional hernia (all P>0.05). All complications were improved after treatment. Conclusions: Both LI and LTC through auxiliary incision following laparoscopic low anterior resection for rectal cancer are safe and feasible. LTC is an optional method for those patients with sensitive skin.


Assuntos
Colostomia , Ileostomia , Protectomia/métodos , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ferida Cirúrgica
9.
Rev Col Bras Cir ; 46(4): e20192171, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31644719

RESUMO

OBJECTIVE: to evaluate the influence of the splenic flexure mobilization for the main surgical outcomes of patients submitted to resection of sigmoid and rectal cancer. METHODS: we searched the MEDLINE, Cochrane Central Register of Controlled Trials and LILACS, using the terms "splenic flexure mobilization", "colorectal surgery", "rectal cancer", "anterior resection", "sigmoid colon cancer", and "sigmoid resection". The main outcome was anastomotic dehiscence. Other outcomes analyzed were mortality, bleeding, infection and general complications. We estimated the effect sizes by grouping data from six case-control studies (1,433 patients) published until January 2018. RESULTS: our meta-analysis showed that patients undergoing complete mobilization of the splenic flexure had a higher risk of anastomotic dehiscence (RR=2.27, 95%CI: 1.22-4.23) compared with those not submitted to this procedure. There was no difference between the groups in terms of mortality, bleeding, infection and general complications. CONCLUSION: splenic flexure mobilization is associated with a higher risk of anastomotic dehiscence in resections of sigmoid and rectal cancer. This surgical maneuver should be used with caution in the surgical management of sigmoid or rectal cancers.


Assuntos
Colectomia/métodos , Protectomia/métodos , Neoplasias Retais/cirurgia , Neoplasias do Colo Sigmoide/cirurgia , Colectomia/efeitos adversos , Humanos , Complicações Pós-Operatórias , Protectomia/efeitos adversos , Resultado do Tratamento
10.
Khirurgiia (Mosk) ; (8. Vyp. 2): 6-15, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31502588

RESUMO

AIM: To optimize the indications for laparoscopic surgery in patients with locally advanced and prognostically unfavorable rectal cancer after neoadjuvant chemoradiotherapy. MATERIAL AND METHODS: 226 patients with locally advanced rectal cancer underwent combination therapy in A.F. Tsyba Medical Radiological Research Centre in 2003-2016. The patients were divided into two subgroups, depending on the surgical approach. The main group included 55 patients who underwent laparoscopic resections, and the control group included 171 patients - for conventional approach. RESULTS: In the subgroup of patients who underwent laparoscopic resections 42 (76.3%) organ preservation surgery were performed more often in comparison with the control subgroup 74 (43,2%) (p<0.0001). There were no significant differences in the incidence of intraoperative complications in both subgroups. The incidence of postoperative complications was lower in the laparoscopic approach group in comparison with the control group 12 (21.8%) patients and 62 (36.3%), respectively (p=0.0493). Data for local recurrence and dissemination of the process after surgery was not received. CONCLUSION: According to the main clinical and morphological features, laparoscopic resections may be an alternative, and in many cases even superior approach in comparison with the conventional surgery.


Assuntos
Protectomia/métodos , Neoplasias Retais/cirurgia , Quimiorradioterapia Adjuvante , Humanos , Laparoscopia , Terapia Neoadjuvante , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/patologia , Neoplasias Retais/radioterapia , Resultado do Tratamento
11.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(8): 724-728, 2019 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-31422609

RESUMO

Whether the transanal total mesorectal resection (taTME) techniques increase the risk of anastomotic failure is inconclusive. This paper discusses the anastomotic problems of taTME from different aspects including anatomical factors and technical characteristics. In terms of the anatomic and physiological characteristics of the lower rectum, the Hiatal ligament and the density of the perirectal space is a disadvantage to the anastomosis of taTME, while the prolapse of the rectum may be a beneficial factor. Due to the unique technical characteristics of taTME, the main reason affecting its anastomosis at present is that the caudal space at the distal end is not sufficiently mobilized, especially for male and lower anastomosis. In addition, stapled anastomosis at the level of anorectal ring may cause more problems, while manual anastomosis at the lower level may bring better results.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Protectomia/efeitos adversos , Protectomia/métodos , Reto/cirurgia , Canal Anal/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Masculino , Mesentério/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle
12.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(8): 781-785, 2019 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-31422618

RESUMO

Objective: To evaluate the feasibility and safety of transanal lateral lymph node dissection for mid-low rectal cancer. Methods: A descriptive case series research method was used. Clinical and pathological data of 5 mid-low rectal cancer patients who underwent transanal lateral lymph node dissection at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from November 2018 to May 2019 were retrospectively collected and analyzed. Of 5 cases, 4 were male and 1 was female with mean age of (43.2±13.2) years and mean body mass index of (21.2±2.6) kg/m(2); the mean diameter of tumor was (3.2±2.4) cm; the mean distance between tumor and anus was (6.3±2.5) cm; 3 received preoperative neoadjuvant chemotherapy. In preoperative TNM staging, 2 cases were T3N1M0, 1 was T3cN2aM0, 1 was T3cN2bM0, and 1 was T2N1M0. All the patients had no intestinal obstruction before operation. Surgical methods: (1) total mesorectal excision: using general transanal and transabdominal methods to mobilize and resect total mesorectum, and dissect No.252, No.253 lymph nodes; (2) transanal lateral lymph node dissection: dissect the adipose lymphoid tissue on the surface of the iliococcygeal muscle, the coccygeal muscle, and the obturator muscle (the No.283 lymph nodes) upward, and dissect No.263d and No.263p lymph nodes with fat tissue sequentially till the bifurcation of the internal and external iliac artery; (3) take out the specimen from anus, and make anastomosis between proximal colon and anal canal. Intraoperative and postoperative variables was observed. Results: All the 5 patients completed surgery successfully, and no patient needed to convert to open approach. The mean operative time was (295.6±97.7) minutes, and the median intraoperative blood loss was 70 (50-500) ml. The mean length of specimen was (12.9±3.0) cm, and the mean number of harvested lymph node was 30.4±9.9. The positive lateral lymph nodes were founder in 4 patients. The median distance between tumor and distal resection margin was 1.5 (1.2-8.0) cm. The resection margin in all the patients was negative. The mean time to postoperative flatus was (4.2±1.6) days, the mean postoperative spontaneous urination was (3.0±1.9) days, time to drainage tube removal was (5.6±1.9) days, and the mean postoperative hospital stay was (9.4±2.1) days. The postoperative TNM staging by pathology was 1 case with T1N0M0, 1 with T2N1M0, 1 with T3N2bM0, and 2 with T3N2M0. Five patients were moderately differentiated adenocarcinoma. Only 1 patient developed postoperative abdominal bleeding, who was healed after conservative treatment. The other 4 patients did not develop any perioperative complications, such as incision infection, presacral abscess, pelvic abscess, anastomotic leakage, or anastomotic stricture. Four patients underwent postoperative chemotherapy. All the patients were followed up for 2 to 28 weeks after surgery and they all felt well. The patients with stoma had fluent bowel. Conclusions: Transanal lateral lymph node dissection is feasible and safe in the treatment of mid-low rectal cancer, which can achieve the purpose of extended radical resection of mid-low movement rectal cancer. Moreover, this procedure is a new method to treat rectal cancer patients with lateral lymph node metastasis.


Assuntos
Adenocarcinoma/cirurgia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Protectomia/métodos , Neoplasias Retais/cirurgia , Adenocarcinoma/patologia , Adulto , Canal Anal/cirurgia , Anastomose Cirúrgica , Colo/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Laparoscopia , Linfonodos/cirurgia , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Estudos Retrospectivos
14.
Khirurgiia (Mosk) ; (8): 53-58, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31464275

RESUMO

OBJECTIVE: To evaluate the influence of reinforcement of staple line of colorectal anastomosis on the incidence of leakage. MATERIAL AND METHODS: A systematic review was performed in accordance with the PRISMA recommendations. Statistical analysis was carried out in the Review Manager 5.3 software. RESULTS: This trial included four original articles published in 2011-2018. There were 493 patients. Reinforcement of anastomosis was made in 232 (47%) cases, colorectal anastomosis was not reinforced in 261 (53%) patients. Anastomotic leakage rate was 5.6 and 11.1% in both groups, respectively (OR 0.55, CI 0.13-2.33; p=0.42). Transabdominal reinforcement reduced leakage rate by 10.2% (OR 0.18, CI 0.06-0.55; p=0.002) while transanal reinforcement was ineffective (OR 1.66, CI 0.38-7.19; p=0,5). Incidence of preventive stoma was similar (OR 0.3, CI 0.07-1.22; p=0.09), but it was possible to abandon preventive stoma in 18% of cases after anastomotic reinforcement. CONCLUSION: A small number of studies dedicated to anastomosis reinforcement resulted controversial data.


Assuntos
Anastomose Cirúrgica/métodos , Fístula Anastomótica/prevenção & controle , Colo/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Humanos , Grampeamento Cirúrgico/efeitos adversos , Grampeamento Cirúrgico/métodos
15.
Dis Colon Rectum ; 62(9): 1055-1062, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318766

RESUMO

BACKGROUND: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision. OBJECTIVE: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer. DESIGN: This study is a retrospective review. SETTINGS: Patients treated by University of Minnesota-affiliated physicians, 1994 to 2014, were selected. PATIENTS: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up. INTERVENTIONS: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence. RESULTS: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed. LIMITATIONS: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available. CONCLUSIONS: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979. CÁNCERES RECTALES T1 EXTIRPADOS LOCALMENTE: NECESIDAD DE PROTOCOLOS DE VIGILANCIA ESPECIALIZADOS: La escisión local de los cánceres de recto T1 ayuda a evitar una cirugía mayor, pero la frecuencia y el patrón de recurrencia pueden ser diferentes a los de los pacientes tratados con escisión mesorectal total. OBJETIVO: Evaluar el patrón, la frecuencia y los medios de detección de recidiva en una cohorte de pacientes con cáncer de recto T1 extirpado localmente bajo un régimen de seguimiento especifico. DISEÑO:: Revisión retrospectiva. AJUSTES: Pacientes tratados por hospitales afiliados a la Universidad de Minnesota, 1994-2014 PACIENTES:: Pacientes con cáncer de recto T1 confirmado patológicamente, tratados con escisión local y con al menos 3 meses de seguimiento. INTERVENCIONES: Extirpación local del cáncer de recto T1, con un seguimiento multimodal incluyendo examen físico, antígeno carcinoembrionario (CEA), TC, ecografía endorrectal y proctoscopia. PRINCIPALES MEDIDAS DE RESULTADO: Presencia de recurrencia local y medios de detección de recurrencia. RESULTADOS: Un total de 114 pacientes cumplieron con los criterios de inclusión. La tasa de recurrencia local fue del 11,4% y la tasa de metástasis a distancia fue del 2,6%. Las recurrencias locales se presentaron hasta 7 años después de la escisión local. De los 14 pacientes con recurrencia, 10 de las recurrencias se detectaron por ultrasonido y / o proctoscopia en lugar de los métodos tradicionales de vigilancia, como CEA o imágenes. De estos diez pacientes, cuatro tenían una cicatriz aparente en la proctoscopia y el ultrasonido solo reveló hallazgos relacionados con tumores malignos recurrentes. En una ecografía se demostró malignidad recurrente, pero no se realizó proctoscopia concurrente. LIMITACIONES: Revisión retrospectiva; estudio realizado en una institución donde se dispone fácilmente de ultrasonido endorrectal CONCLUSIONES:: Los cánceres de recto T1 extirpados localmente deben tener una vigilancia específica distinta de los cánceres en etapa I tratados con TME. El régimen de seguimiento deberá de extender más allá del intervalo tradicional de 5 años de vigilancia. También se debe considerar la posibilidad de realizar una ecografía o una resonancia magnética (IRM) además de la sigmoidoscopía flexible o la proctoscopía. Vea el Resumen del video en http://links.lww.com/DCR/A979.


Assuntos
Adenocarcinoma/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Estadiamento de Neoplasias , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/diagnóstico por imagem , Adenocarcinoma/diagnóstico , Endossonografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Proctoscopia , Neoplasias Retais/diagnóstico , Reto/cirurgia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
16.
BMC Surg ; 19(1): 79, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277628

RESUMO

BACKGROUND: Aim of this study was to evaluate functional outcomes of transanal total mesorectal excision (TaTME) in comparison to conventional laparoscopic approach (LaTME) in terms of low anterior resection syndrome (LARS). METHODS: Forty-six patients who underwent total mesorectal excision for low rectal cancer between 2013 and 2017 were enrolled. Primary outcome was the severity of faecal incontinence, assessed both before the treatment and 6 months after ileostomy reversal. LARS score and Jorge-Wexner scale were utilized to analyze its severity. RESULTS: Twenty (87%) from TaTME and 21 (91%) from LaTME group developed LARS postoperatively. There were no significant differences between groups in terms of LARS occurrence (p = 0.63) and severity. The median Wexner score was comparable in both groups (8 [IQR: 4-12] vs 7 [3-11], p = 0.83). Univariate analysis revealed that postoperative complications were a risk factor for LARS development (p = 0.02). Perioperative outcomes, including operative time, blood loss and intraoperative adverse events did not differ significantly between groups either. Five TaTME patients developed postoperative complications, while there were morbidity 6 cases in LaTME group. Quality of mesorectal excision was comparable with 20 and 19 complete cases in TaTME and LaTME groups, respectively. CONCLUSIONS: TaTME provided comparable outcomes in terms of functional outcomes in comparison to LaTME for total mesorectal excision in low rectal cancers. Having said that, LARS prevalence is still high and requires further evaluation of the technique.


Assuntos
Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Protectomia/efeitos adversos , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/efeitos adversos , Idoso , Feminino , Humanos , Ileostomia , Incidência , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Protectomia/métodos , Recuperação de Função Fisiológica , Neoplasias Retais/patologia , Estudos Retrospectivos , Síndrome , Resultado do Tratamento
17.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 507-513, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238630

RESUMO

Neoadjuvant chemoradiotherapy plus total mesorectal excision (TME) is the standard care for locally advanced middle-low rectal cancer. Some patients could benefit from neoadjuvant chemoradiotherapy to achieve clinical complete response (cCR). Therefore, in recent years, for patients with cCR after neoadjuvant therapy, the "watch and wait" strategy has been widely recommended by their doctors to let them enter "waiting period" without surgery, so that the quality of life is improved. However, the "watch and wait" strategy also has many practical problems that have not been resolved. Firstly, the diagnostic criteria for cCR and pathologic complete response (pCR) are not uniform and different significantly. Secondly, some cCR patients have found tumor regrowth and subsequently underwent salvage surgery during the "watch and wait" period. Thirdly, there is no clinical consensus on the adjuvant therapy for patients during the "watch and wait" period. Fourthly, the role of surgery in patients with cCR is controversial. Finally, we need to accumulate more clinical evidence to confirm whether the "watch and wait" strategy can be selected immediately after achieving cCR for rectal cancer. At the same time, we should find novel molecular markers that can predict the efficacy of chemoradiotherapy. Only rational choice of "watch and wait" strategy will allow more patients with rectal cancer to benefit from chemoradiotherapy.


Assuntos
Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Protectomia/métodos , Neoplasias Retais/terapia , Terapia Combinada , Humanos , Mesentério/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Qualidade de Vida , Neoplasias Retais/patologia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
18.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 527-533, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238633

RESUMO

Neoadjuvant chemoradiotherapy is the current standard of care for locally advanced rectal cancer. However, this modality is facing more and more challenges. The research progress on this issue around the world can be summarized into three aspects. The first is to increase the intensity of treatment to obtain better tumor regression, such as adding a second drug during the neoadjuvant chemoradiotherapy, prolonging the interval and receiving sufficient chemotherapy before surgery. Current research data are not sufficient to support strategies for adding drugs or receiving sufficient chemotherapy before surgery, but it may be worth looking forward to adding irinotecan during neoadjuvant chemoradiotherapy, and an appropriate extension of the interval before surgery may also be a good option. Secondly, we can reduce the intensity of treatment to improve the quality of life of patients with a non-inferior clinical outcome, such as non-surgical approach, local excision rather than total mesorectal excision and removal of preoperative radiotherapy. The data of the International Watch & Wait Database (IWWD) suggest that patients with a Watch & Wait strategy have similar long-term survival outcomes as those who have undergone surgery and have pathologic complete response, meanwhile the data are still inadequate to support using local excision instead of total mesorectal excision, or removal of preoperative radiotherapy strategies. Finally, to achieve a precise individual treatment, some potential biomarkers are investigated via genomics, metabolomics and radiomics. But so far, there is no recognized biomarker for clinical treatment in the field of neoadjuvant therapy for rectal cancer. This article summarizes the clinical research progress of locally advanced rectal cancer in recent years from the above three aspects.


Assuntos
Quimiorradioterapia Adjuvante/normas , Terapia Neoadjuvante/normas , Neoplasias Retais/terapia , Quimiorradioterapia Adjuvante/métodos , Terapia Combinada , Humanos , Mesentério/cirurgia , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Protectomia/métodos , Qualidade de Vida , Radioterapia Adjuvante , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
19.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 566-572, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238636

RESUMO

Objective: To evaluate the effect of preservation of left colic artery (LCA) on postoperative anastomotic leakage in patients with rectal cancer after neoadjuvant therapy. Methods: A retrospective cohort study was conducted to collect data of rectal cancer patients at Department of Gastrointestinal Surgery of Fujian Cancer Hospital from September 2014 to August 2017. Inclusion criteria: (1) age of 18 to 79 years; (2) rectal adenocarcinoma confirmed by postoperative pathology; (3) patients without preoperative serious cardiovascular and cerebrovascular disease receiving preoperative neoadjuvant radiotherapy or chemoradiotherapy; (4) laparoscopic-assisted anterior rectal resection and distal ileostomy were performed simultaneously; (5) complete clinical data. Exclusion criteria: patients with extensive abdominal metastasis, or distant organ metastasis during operation, and combined organ resection. According to whether LCA was retained during operation, the patients were divided into two groups, then the intraoperative and postoperative clinical outcomes were compared. Moreover, univariate analysis and multivariate logistic regression were used to analyze risk factors of postoperative anastomotic leakage. Results: A total of 125 patients were included in this study, including 56 patients in the retained LCA group and 69 patients in the non-retained LCA group. Differences in baseline data, such as gender, age, diabetes mellitus, body mass index, hemoglobin, distance between tumor and anal margin, maximum diameter of tumor, preoperative neoadjuvant therapy, and ypTNM stage, between retained LCA group and non-retained LCA group were not statistically significant (all P>0.05), indicating that two groups were comparable. Meanwhile there were no significant differences in operation time, intraoperative blood loss, total number of lymph node harvested, number of harvested lymph node at the root of inferior mesenteric artery, circumferential margin, anastomotic bleeding, or postoperative hospital stay between two groups (all P>0.05). Thirteen patients in the non-retained LCA group (18.8%) developed postoperative anastomotic leakage, including 7 cases of grade A, 5 cases of grade B and 1 case of grade C, while in the retained LCA group, only 5.4% (3/56) of patients developed postoperative anastomotic leakage, including 1 case of grade A and 2 cases of grade B without case of grade C, whose difference was statistically significant (U=1674.500, P=0.028). Univariate analysis showed that preoperative hemoglobin <120 g/L and non-retained LCA were associated with postoperative anastomotic leakage (both P<0.05). Multivariate analysis cofirmed that preoperative hemoglobin < 120 g/L (OR=3.508, 95% CI: 1.158 to 10.628, P=0.017) and non-retained LCA (OR=4.065, 95%CI: 1.074 to 15.388, P=0.031) were independent risk factors for postoperative anastomotic leakage. Median follow-up time was 31 months (16 to 51 months), and no long-term complication was found. Local recurrence and distant metastasis were found in 1 case (1.8%) and 7 case (12.5%) in the retained LCA group, while those were found in 2 cases (2.9%) and 5 cases (7.2%) respectively, in the non-retained LCA group, whose differences were not statistically significant (P=1.000, P=0.321 respectively). Conclusion: Preservation of left colic artery not only can ensure radical lymph node dissection efficacy under the condition of similar operation time and blood loss, but also can effectively reduce the incidence of postoperative anastomotic leakage for rectal cancer patients after neoadjuvant therapy.


Assuntos
Adenocarcinoma/cirurgia , Fístula Anastomótica/etiologia , Artéria Mesentérica Inferior/cirurgia , Protectomia/efeitos adversos , Neoplasias Retais/cirurgia , Reto/irrigação sanguínea , Quimiorradioterapia Adjuvante/efeitos adversos , Humanos , Terapia Neoadjuvante/efeitos adversos , Protectomia/métodos , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos
20.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 594-596, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238639

RESUMO

Colorectal cancer is one of the most common malignant tumors worldwide. Surgical resection is the most important and decisive method in the treatment of rectal cancer. Total mesorectal excision (TME) has greatly reduced the local recurrence rate of middle and low rectal cancer. However, local recurrence and distant metastasis remain the leading cause of death in patients with rectal cancer. 5-fluorouracil (5-FU)-based neoadjuvant chemoradiotherapy has been widely accepted in locally advanced rectal cancer and was recommended by various clinical practice guidelines as the standard treatment option. Tumors often achieve satisfactory reduced stage after neoadjuvant radiotherapy, and some patients even achieve pathological complete regression, which brings much controversies to the choice of adjuvant chemotherapy. This article intends to introduce evidence-based evidences for adjuvant chemotherapy for rectal cancer, impact of current neoadjuvant models on choice of adjuvant chemotherapy strategies, controversies and considerations for adjuvant chemotherapy in the context of neoadjuvant radiotherapy.


Assuntos
Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Protectomia/métodos , Neoplasias Retais/terapia , Intervalo Livre de Doença , Humanos , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Retais/patologia
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