［Abstract］ For the past few years, a complete theory and twenty different procedures have been developed for natural orifice specimen extraction surgery (NOSES). However, ensuring aseptic and tumor-free procedure in NOSES remains to be a controversial topic. Based on the clinical practice experience of the author’s centre, combined with domestic and foreign literature reports, this paper reviews the issues related to the standardized aseptic and tumor-free procedure in NOSES, in order to provide reference for the clinical practice of NOSES.

目前,直肠低位前切除术已经成为直肠癌应用最为广泛的术式.吻合口瘘是直肠癌术后最常见的并发症之一,而预防性造口曾被认为可以降低其发生风险,临床上有滥用之势.越来越多的证据表明回肠预防性造口弊大于利,它会增加患者的身心及经济负担.本文就预防性造口的"理论依据"以及回肠预防性造口利与弊进行阐述,同时从卫生经济学、国家医保政策及人文关怀层面提出了一些思考与建议.

目的:探讨经自然腔道取标本手术(natural orifice specimen extraction surgery,NOSES)的安全性,并比较3种取标术式在直肠癌治疗中的近期疗效和远期预后.方法:回顾性分析接受腹腔镜NOSES的Ⅰ～Ⅲ期直肠癌患者的临床资料.直肠NOSES手术包括外翻切除式、拉出切除式和切除拖出式3种.比较3种取标本方式的术后并发症、5年无病生存期(disease-free survival,DFS)、5年局部复发率(local recurrence rate,LRR)和5年远处转移率(distant metastasis rate,DMR)等指标.结果:本研究共有268例直肠癌患者符合入组标准,包括83例外翻切除式,75例拉出切除式,110例切除拖出式.肿瘤位置与手术方式的选择具有显著相关性,术后全部患者的并发症发生率为12.3％,其中外翻切除组为18.1％,高于拉出切除组(13.3％)和切除拖出组(7.3％),P=0.073.全部患者5年DFS、LRR及DMR分别是85.0％、4.2％和11.0％.切除拖出组患者5年DFS高于其他两组,外翻切除组患者5年LRR要高于其他两组,而5年DMR在外翻切除组中最低,差异均无统计学意义.结论:直肠癌NOSES 3种术式具有良好安全性和肿瘤学预后,肿瘤位置是选择手术方式的决定因素.

Objective To study the short-term outcomes of laparoscopic right hemicolectomy with transvaginal specimen extraction without abdominal incisions(CRC-NOSES Ⅷ A) for radical resection of colon cancer comparing with laparoscopic right hemicolectomy with transabdominal specimen extraction. Methods Clinical data of the patients with complete laparoscopic right hemicolectomy including 29 cases in transvaginal group and 29 cases in transabdominal group were collected. Comparision between two groups was done for preoperative clinical features, intraoperative indexes, post-operative complications, female sexual function score to charify the impact of the two methods of specimen removal on patients. Results There were no significant differences in intraoperative blood loss, fever and bleeding after operation, intestinal obstruction, anastomotic leakage and other postoperative complications between two groups. Compared with transabdominal group, operative time prolonged [(151.52±33.73) min vs. (179.59±47.02) min, P=0.012 0] and postoperative hospital stay decreased (7.14 d vs. 6.07 d, P=0.013 0) in transvaginal group. The female sexual activity recovered more quickly with less discomfort caused by the scar in transvaginal group and there was no statistical difference in postoperative female sexual function score between two groups. Conclusions CRC-NOSES Ⅷ A could be safe and feasible when compared with conventional laparoscopic hemicolectomy with transabdominal specimen extraction for radical resection of colon cancer. The patients in transvaginal group had less sensation of scars and faster recovery of sexual activity.

结直肠癌在我国发病率逐年升高,严重威胁人们生命健康,造成了沉重的社会经济负担.众多国家的实践经验表明,采取有效的结直肠癌筛查策略能够降低结直肠癌的疾病负担,然而我国人群结直肠癌筛查项目覆盖尚不广泛,方法不统一,有待形成完善的国家结直肠癌筛查体系.本文结合国内外最新指南、共识,阐述国内外结直肠癌筛查的研究现状,探讨常用的结直肠癌筛查方法,并对我国结直肠癌筛查的发展提出了展望,以期未来能够建立具有我国特色的结直肠癌筛查策略.

目的 探讨腹部无辅助切口经造口取标本的直肠癌前切除术(造口借道NOSES手术)的安全性及有效性.方法 回顾性分析2016年1月至2019年12月于中国医学科学院北京协和医学院肿瘤医院结直肠外科接受造口借道NOSES手术的134例患者临床资料,总结造口借道NOSES手术、造口还纳手术的操作要点、临床效果,以及随访情况.结果 134例患者均顺利完成造口借道NOSES手术,无中转开腹病例.中位手术时间169.0(138.5,210.8)min,中位出血量30(20,50)mL,中位右下腹切口长度4.5(4.0,5.0)cm,中位肿瘤大小4(3,5)cm,术后可视中位切口长度1.2(1.2,2.0)cm,中位术后肛门排气时间2(2,3)d,术后第1天中位疼痛评分3(3,3)分,术后第2天中位疼痛评分2(2,2)分,术后第3天中位疼痛评分1(1,1)分,中位术后住院时间7(6,8)d.截至2019年12月,共113例患者完成还纳手术,还纳中位间隔时间215(149,284)d,中位手术时间79(63,97)min,中位出血量20(10,20)mL,中位切口长度6(6,8)cm,中位术后肛门排气时间3(2,3)d,术后第1天中位疼痛评分3(3,3)分,术后第2天中位疼痛评分2(1,3)分,术后第3天中位疼痛评分1(1,2)分,中位术后住院时间6(5,7)d.造口借道NOSES手术并发症:吻合口狭窄3例,肠梗阻2例,吻合口漏1例,腹腔感染1例.造口相关并发症:粪水性皮炎23例,造口旁疝5例,造口凹陷1例.术后1个月内无二次住院患者及死亡病例.二次还纳手术并发症:切口感染3例,吻合口出血1例.随访发现肝转移3例,肺转移1例,未见局部复发,未见发生腹腔种植及切口种植.结论 造口借道NOSES手术安全可行,术中巧妙借用腹壁预防性造口的切口完成标本的取出及抵钉座的置入,可降低NOSES手术难度,易操作、方便推广,该术式在保肛手术中有良好的应用价值.