摘要结直肠癌是我国常见的恶性肿瘤,患者就诊时多已为晚期或局部晚期.由于肿瘤瘤体巨大,侵犯邻近脏器,多个脏器受累,临床处理有一定困难.部分外科医生面对晚期结直肠癌时选择放弃手术.但事实上,多学科综合治疗能使晚期或局部晚期患者获得相对好的治疗结果,不应该轻易放弃合理的外科手术.对于肿瘤巨大但没有远处转移、有多脏器受累的患者,直接手术切除困难,可以考虑进行术前的辅助治疗.外科手术原则是在能够达到R0切除的基础上,尽量保留脏器的功能,进行合理的区域淋巴结清扫.常见的局部晚期结直肠癌手术包括:(1)右半结肠癌侵及十二指肠:需先从结肠右后侧、肿瘤左侧以及肿瘤上方幽门下3个方向游离结肠,暴露并评估肿瘤和十二指肠的关系;肿瘤实际上侵犯十二指肠的范围可能很小.(2)脾区结肠癌侵及胰尾及脾门:确定行联合脏器切除,不要分离肿瘤和脾脏的"粘连";从降结肠部位开始操作更容易找到界限.(3)巨大乙状结直肠癌侵及膀胱:侵犯往往发生在膀胱底,手术时先评估膀胱三角是否受累,不要首先分离直肠和膀胱的"粘连".(4)直肠癌侵及骶骨:骶骨S3以下的侵犯是可以切除的;游离直肠近端肠管至与骶骨相连部分以上,离断直肠,近端行永久性造口,骶骨做"工"字形切口,预计切除线切除骶骨.(5)直肠癌侵犯子宫、附件、阴道及男性前列腺精囊腺:常见于低位直肠癌.一侧卵巢受累应联合切除双侧附件;阴道受累应连同阴道一并切除;前列腺受累可以实施前列腺的部分切除.总体而言,面对相对复杂的、晚期或局部晚期结直肠癌患者,临床外科医生仍需怀抱积极处理、迎难而上的热情,在多学科团队诊治的支持下,不能轻易放弃手术,从而为患者争取更多生存的机会!

abstractsColorectal cancer, a malignant tumor arising from the colon or rectum, is a common cancer in China, with most patients diagnosed at the advanced stage or locally advanced stage. Large tumor size results in the invasion of adjacent organs and the multiple organ involvement, which poses certain challenges for clinical treatment. When facing advanced stage colorectal cancer, some surgeons do not consider surgery, a reasonable option. However, in fact, multi-disciplinary treatment can achieve relatively good treatment outcomes in patients with advanced stage or locally advanced stage colorectal cancer. Therefore, reasonable surgery should not be hastily abandoned. For patients with large tumors without distant metastases but with multiple organ involvement, directly surgical resection is difficult, therefore, preoperative adjuvant therapy can be considered. The basic principle of surgical treatment is to accomplish maximum protection of organ functions and to perform reasonable regional lymph node dissection on the basis of achieving R0 resection. Common surgical procedures for locally advanced colorectal cancer are as follows:(1)Right-sided colon cancer with duodenal invasion: first, the colon must be freed from three directions, namely the right posterior surface of the colon, the left side of the tumor, and the upper side of the tumor inferior to the pylorus, so as to expose and assess the spatial relationship between the tumor and the duodenum; the actual tumor invasion depth in the duodenum may be shallow. (2)Splenic flexure colon cancer with invasion of the cauda pancreatis and hilum lienis: multivisceral resection must be performed without separating the attachment between the tumor and spleen. The tumor border can be found more easily through manipulations starting from the descending colon.(3) Giant sigmoid colorectal cancer with bladder invasion:invasion usually occurs at the bladder fundus. Therefore, during surgery, the attachment between the rectum and the bladder must not be separated first, but instead, an assessment must be made to determine if the bladder trigone is involved. (4)Rectal cancer with invasion of the sacrum:sacral invasion below S3 can be resected. The proximal end of the rectum to the point where it joins the sacrum is freed, and the rectum is severed. A permanent colostomy is made at the proximal end, while a h-shaped incision is made in the sacrum. The sacrum is then resected along pre-determined resection lines.(5)Rectal cancer with invasion of the uterus, adnexa, vagina, or prostate and seminal vesicles: it is usually observed in low rectal cancer. For unilateral ovarian involvement, combined resection of the bilateral adnexa should be performed. For vaginal involvement, combined resection of the vagina should be performed. For prostatic involvement, partial resection of the prostate can be performed. In general, when facing relatively complicated advanced or locally advanced colorectal cancer, clinical surgeons must adopt a positive attitude and strive zealously against the odds. With the support of multi-disciplinary treatment, the option of surgery must not be hastily abandoned in order to increase the survival chances of patients.