第六節(jié)結(jié)腸癌（SIXTHCOLONCANCER）第六節(jié)結(jié)腸癌結(jié)腸癌（結(jié)腸癌）是胃腸道中常見的惡性腫瘤，以41歲發(fā)病率高在我國65。近20年來尤其在大城市，發(fā)病率明顯上升，且有結(jié)腸癌多于直腸癌的趨勢。從病因看半數(shù)以上來自腺瘤癌變，從形態(tài)學(xué)上可見到增生、腺瘤及癌變各階段（圖4013）以及相應(yīng)的染色體改變。隨分子生物學(xué)技術(shù)的發(fā)展，同時(shí)存在的分子事件基因表達(dá)亦漸被認(rèn)識，從中明確癌的發(fā)生發(fā)展是一個(gè)多步驟、多階段及多基因參與的細(xì)胞遺傳性疾病。大腸癌時(shí)從細(xì)胞向癌變演進(jìn)，從腺瘤一癌序列約經(jīng)歷1015年，在此癌變過程中，遺傳突變包括癌基因激活（KRAS、CMYC、EGFR）、抑癌基因失活（APC、DCC，P53）、錯(cuò)配修復(fù)基因突變（HMSHI，何梁何利，PMS1，PMS2，GTBP）及基因過度表姨發(fā)減一FF一尹1E）所日馬所有目APCKRAS基因DCCP53NM23MMR染色體改變?nèi)ゼ谆鵐MR5Q12Q18Q17Q突變?nèi)笔蛔兺蛔內(nèi)笔蛔內(nèi)笔笔蛔儓D4013大腸癌變過程模式圖（錯(cuò)配修復(fù)基因）HMSH2、HMLH1、創(chuàng)新1創(chuàng)新2達(dá)（COX2，CD44V）OAPC基因失活致雜合性缺失，APC/汗連環(huán)通路啟動促成腺瘤進(jìn)程；錯(cuò)配修復(fù)基因突變致基因不穩(wěn)定，可出現(xiàn)遺傳性非息肉病結(jié)腸癌（遺傳性非息肉性結(jié)腸癌，HNPCC）綜合征。結(jié)腸癌病因雖未明確，但其相關(guān)的高危因素漸被認(rèn)識，如過多的動物脂肪及動物蛋白飲食，缺乏新鮮蔬菜及纖維素食品；缺乏適度的體力活動。遺傳易感性在結(jié)腸癌的發(fā)病中也具有重要地位，如遺傳性非息肉性結(jié)腸癌的錯(cuò)配修復(fù)基因突變攜帶的家族成員，應(yīng)視為結(jié)腸癌的一組高危人群。有些病如家族性腸息肉病，已被公認(rèn)為癌前期疾病；結(jié)腸腺瘤、潰瘍性結(jié)腸炎以及結(jié)腸血吸蟲病肉芽腫，與結(jié)腸癌的發(fā)生有較密切的關(guān)系。病理與分型根據(jù)腫瘤的大體形態(tài)可區(qū)分為1。腫塊型（圖4014）腫瘤向腸腔內(nèi)生長，好發(fā)于右側(cè)結(jié)腸，特別是盲腸。2。浸潤型（圖4015）沿腸壁浸潤，容易引起腸腔狹窄和腸梗阻，多發(fā)生于左側(cè)結(jié)腸。3。潰瘍型（圖4016）其特點(diǎn)是向腸壁深層生長并向周圍浸潤，是結(jié)腸癌常見類型。圖4014腫塊型結(jié)腸癌顯微鏡下組織學(xué)分類較常見的為腺癌占結(jié)腸癌的大多數(shù)粘液癌預(yù)后較腺。癌差。未分化癌易侵人小血管和淋巴管，預(yù)后最差。臨床病理分期分期目的在于了解腫瘤發(fā)展過程，指導(dǎo)擬定治療方案及估計(jì)預(yù)后。國M際一般仍沿用改良的公爵分期及UICCTNM分期法提出的。根據(jù)我國對公爵法的補(bǔ)充，分為癌僅限于腸壁內(nèi)為公爵穿透腸壁侵人期。漿膜或/及漿膜外，但無淋巴結(jié)轉(zhuǎn)移者為B期。有淋巴結(jié)轉(zhuǎn)移者為C期，其中淋巴結(jié)轉(zhuǎn)移僅限于癌腫附近如結(jié)腸壁及結(jié)腸旁淋巴結(jié)者為C1期；轉(zhuǎn)移至系膜和系膜根部淋巴結(jié)者為C期。已有遠(yuǎn)處轉(zhuǎn)移或腹腔轉(zhuǎn)移，或廣泛侵及鄰近臟器無法切除者為1之期。TNM分期法T代表原發(fā)腫瘤，TX為無法估計(jì)原發(fā)腫瘤。無原發(fā)腫瘤證據(jù)為來；原位癌為T；G；腫瘤侵及粘膜肌層與粘膜下層為T1；侵及固有肌層為TZ；穿透肌層至漿膜下為T3；PENETRATINGDIRTPERITONEUMORINVASIONOFOTHERORGANSORTISSUESIST4NWASREGIONALLYMPHNODE,N,ANDNOLYMPHNODECOULDBEESTIMATEDNOLYMPHNODEMETASTASISWASNOLYMPHNODEMETASTASISWAS13ONEWASN,ANDTHEOTHER4ANDMORETHAN4LYMPHNODESWERENZOMFORDISTANTMETASTASIS,DISTANTMETASTASISCANNOTBEESTIMATEDFORMXNODISTANTMETASTASISTODISTANTMETASTASISFORALLQUACKM,TNMSTAGINGCOMPAREDWITHDUKESSTAGINGISSHOWNINTABLE4010TABLE401COMPARISONOFTNMSTAGINGWITHDUKESSTAGINGTNMSTAGINGDUKESSTAGINGNCTISTITZPLUSHOIANYTN,NZANYTNMCOLONCANCERISMAINLYLYMPHATICMETASTASIS,FIRSTTOTHECOLONWALLANDTHECOLONLYMPHNODE,ANDTHENTOTHEMESENTERICVASCULARAROUNDANDINTESTINALMESENTERICLYMPHNODEHEMATOGENOUSMETASTASISISMORECOMMONINTHELIVER,FOLLOWEDBYLUNG,BONE,ETCCOLONCANCERCANALSOBEDIRECTLYINFILTRATEDINTOTHEVICINITYORGANSUCHASTHESIGMOIDCOLON,BLADDER,UTERUS,OFTENINVADEURETERTRANSVERSECOLONCANCERCANINVADETHESTOMACHWALL,ANDEVENFORMTHEINTERIOREXFOLIATEDCANCERCELLSCANALSOBETRANSFERREDINPERITONEALIMPLANTSTHECLINICALMANIFESTATIONOFCRCISTHATITUSUALLYHASNOSPECIALSYMPTOMSINTHEEARLYSTAGEOFDEVELOPMENTTHEMAINSYMPTOMSAREFOLLOWINGSYMPTOMS1THECHANGEOFDEFECATIONHABITANDFECALCHARACTERISUSUALLYTHEEARLIESTSYMPTOMMOSTOFTHEMWEREINCREASEDDEFECATIONFREQUENCYANDABDOMENCONTAININGBLOOD,PUS,ORMUCUSINTHESTOOLTHEABDOMINALPAINISONEOFTHE2EARLYSYMPTOMS,OFTENPERSISTENTPAINPOSITIONINGISNOTCLEAR,ORONLYFORABDOMINALDISCOMFORTORABDOMINALDISTENSIONOFTHEABDOMENANDTHEPRESENCEOFINTESTINALOBSTRUCTIONAREAGGRAVATEDBYABDOMINALPAINORPAROXYSMALANGINA3,THEABDOMINALMASSISMOSTLYTUMORBODYITSELF,ANDSOMETIMESMAYBEOBSTRUCTIONINTHEPROXIMALGUTCAVITYFECALACCUMULATIONMOSTOFTHELUMPSAREHARD,NODULARASFORTHETRANSVERSEANDSIGMOIDCOLONCANCERCANHAVECERTAINACTIVITYIFTHECANCERPENETRATESTHECONCURRENTINFECTION,THETUMORISSOLIDDEFINITEANDMARKEDTENDERNESS4,INTESTINALOBSTRUCTIONSYMPTOMSAREGENERALLYCOLONCANCERINTHEMIDDLEANDLATESYMPTOMS,MOSTLYCHRONIC,INCOMPLETEINTESTINALOBSTRUCTION,THELORDTHESYMPTOMSAREBLOATINGANDCONSTIPATIONABDOMINALPAINORPAROXYSMALANGINAWHENACOMPLETEOBSTRUCTIONOCCURS,THESYMPTOMSAREEXACERBATEDLEFTCOLONCANCERCANSOMETIMESBEACUTEANDCOMPLETECOLONICOBSTRUCTIONISTHEFIRSTSYMPTOMBERELUCTANTTOLEAVEDIPINTHEFRAGRANCE,LOOKFORWARDTOL5,SYSTEMICSYMPTOMSDUETOCHRONICBLEEDING,CANCERULCERATION,INFECTION,TOXINSABSORPTION,ETC,PATIENTSCANAPPEARANEMIAANDDISAPPEARLEAN,WEAK,LOWHEAT,ETCTHEDISEASEMAYOCCURLATEHEPATOMEGALY,JAUNDICE,EDEMA,ASCITES,RECTALTUMOR,SUPRACLAVICULARCONCAVELYMPHNODEENLARGEMENTANDCACHEXIABECAUSEOFTHEPATHOLOGICALTYPEANDLOCATIONOFTHECANCER,THECLINICALMANIFESTATIONSAREDIFFERENTINGENERAL,RIGHTCOLONCANCERISCHARACTERIZEDBYSYSTEMICSYMPTOMS,ANEMIA,ABDOMINALMASSWERETHEMAINMANIFESTATIONSOFLEFTCOLONCANCERWITHINTESTINALOBSTRUCTION,CONSTIPATION,DIARRHEA,HEMATOCHEZIAANDOTHERSYMPTOMSTHEEARLYSYMPTOMSOFCOLONCANCERARENOTOBVIOUSANDEASILYOVERLOOKEDANYPERSONWHOISOVER40YEARSOFAGEANDANYOFTHEFOLLOWINGSHALLBELISTEDASHIGHRISKPOPULATIONOILEVELRELATIVESWITHCOLORECTALCANCERHISTORYTHEHISTORYOFCANCERORINTESTINALADENOMASORPOLYPSHISTORYTHEFECALOCCULTBLOODTESTTESTPOSITIVETHEFOLLOWINGFIVEPERFORMANCETHANTWOITEMSMUCOUSBLOODYSTOOL,CHRONICDIARRHEA,CHRONICCONSTIPATION,CHRONICAPPENDICITISHISTORYANDHISTORYOFTRAUMAINTHISGROUP,THEHIGHRISKGROUPUNDERWENTFIBERCOLONOSCOPYORXRAYBARIUMENEMAORBARIUMGASDOUBLECONTRASTITISNOTDIFFICULTTOMAKEADEFINITEDIAGNOSISTYPEBULTRASONOGRAPHYANDCTSCANWEREPERFORMEDTOUNDERSTANDABDOMINALMASSESANDENLARGEDLYMPHNODESANDTODETECTTHELIVERWHETHERTHEREAREANYTRANSFERSANDSOONAREHELPFULSERUMCARCINOEMBRYONICANTIGENCEAVALUESWEREAPPROXIMATELY60HIGHERINBOWELTHANINNORMALCOLONCANCERPATIENTS,HOWEVERTHEOPPOSITESEXISNOTHIGHFORPOSTOPERATIVEJUDGMENT,PROGNOSISANDRECURRENCE,THEREWILLBESOMEHELPTHEPRINCIPLEOFTREATMENTISCOMPREHENSIVETREATMENTBASEDONSURGICALRESECTION1RADICALRESECTIONOFCOLONCANCERSHOULDINCLUDETHEBOWELMIXANDITSMESENTERYANDREGIONALLYMPHNODESOFTHECARCINOMA1RIGHTHEMICOLECTOMYFORTHECECUMANDASCENDINGCOLON,HEPATICFLEXUREOFCOLONCANCERTHECECUMANDASCENDINGCOLONCANCERRESECTION,INCLUDINGRIGHTTRANSVERSECOLON,ASCENDINGCOLONANDCECUM,INCLUDINGSOME1520CMTERMINALILEUMFIGURE4017,FORTHEENDORENDTOSIDEANASTOMOSISOFILEUMANDCOLONFORTHECANCEROFTHEHEPATICFLEXUREOFTHECOLON,ITMUSTBEEXCISEDINADDITIONTOTHEABOVERANGETHELYMPHNODESOFTHECOLONANDGASTROOMENTALRIGHTARTERYGROUPFIGURE4017RIGHTHALFCOLONRESECTIONRANGE2THETRANSVERSECOLONRESECTIONFIGURE4018SUITABLEFORTRANSVERSECOLONCANCERINCLUDESRESECTIONOFTHEHEPATICFLEXUREOFTHECOLONANDSPLENICFLEXUREANDTHEGASTROCOLICLIGAMENTOFLYMPHNODEFORASCENDINGANDDESCENDINGCOLONICANASTOMOSISIFTHETENSIONATBOTHENDSISTOOLARGETOKISSTOGETHER,TRANSVERSECOLONRESECTIONOFTHELEFTSIDEOFTHEDESCENDINGCOLON,ASCENDINGCOLON,SIGMOIDCOLONANASTOMOSISFOR3LEFTHEMICOLECTOMYSUITABLEFORCOLON,SPLENICFLEXUREANDDESCENDINGCOLONCANCERTHEEXTENTOFRESECTIONINCLUDINGTRANSVERSECOLON,LEFTHALFTHEBOWELISRESECTED,ANDPARTIALORALLSIGMOIDCOLONFIG4019ISREMOVEDACCORDINGTOTHELOCATIONOFTHEDESCENDINGCOLON,ANDTHENTHECOLONORTHECOLONISREMOVEDENDTOENDANASTOMOSISOFINTESTINEANDRECTUM4RADICALRESECTIONOFSIGMOIDCOLONCANCERSHOULDBEDONEACCORDINGTOTHELENGTHOFSIGMOIDCOLONANDTHELOCATIONOFTHECANCERTHEENTIRESIGMOIDCOLONANDALLTHEDESCENDINGCOLONWERERESECTED,ORTHEWHOLESIGMOIDCOLON,PARTOFTHEDESCENDINGCOLONANDPARTOFTHERECTUMWEREREMOVED,ANDTHECOLONWASREMOVEDFORTIETHCHAPTERSA,FIGURE4018COLONRESECTIONFIGURE4019LEFTHALFCOLECTOMYRANGEANASTOMOSISOFRECTUMFIGURE402002COLORECTALCANCERASSOCIATEDWITHACUTEINTESTINALOBSTRUCTIONSURGERYSHOULDBECARRIEDOUTINGASTROINTESTINALREDUCTIONPRESSURE,CORRECTWATERANDELECTROLYTEDISTURBANCES,ANDACIDBASEIMBALANCEAFTERPROPERPREPARATION,EARLYSURGERYRIGHTCOLONCANCERISRESECTIONOFRIGHTCOLONFORPRIMARYILEUMANASTOMOSISIFTHEPATIENTISNOTALLOWED,HEWILLHAVEACOLOSTOMYFIRSTTORELIEVETHEOBSTRUCTIONTHETWOSTAGERADICALRESECTIONWASPERFORMEDIFTHECANCERCANNOTBEREMOVED,THEDISTALILEUMCANBESEVERED,INTHECUTENDILEOTRANSVERSOENDTOSIDEANASTOMOSIS,THEDISTALTERMINALILEUMPROXIMALCOLOSTOMYLEFTWHENCOLONCANCERISCOMPLICATEDWITHACUTEINTESTINALOBSTRUCTION,ITSHOULDBEDONEINTHEPROXIMALPARTOFTHEOBSTRUCTIONTRANSVERSOSTOMY,FULLYPREPAREDININTESTINALCONDITIONS,THENTHETWOSTAGEOPERATIONFORROOTTHERAPEUTICRESECTIONIFTHETUMORCANNOTBEREMOVED,THENPALLIATIVECOLOSTOMYWILLBEPERFORMEDINTHESPECIFICOPERATIONOFCOLONCANCERRESECTION,THETUMORSHOULDBELOCATEDFIRSTTHEPROXIMALBOWELWITHGAUZETIEDTOPREVENTCANCERCELLSINTHEINTESTINALCAVITYEXPANSIONLOOSEPLANTINGTHEBLOODVESSELSARETHENLIGATEDTOPREVENTMETASTASISOFTHECANCERCELLSANANTICANCERDRUG,SUCHAS5FU,ISTHENREMOVEDWITHINTESTINALRESECTIONFIGURE4020EXTENTOFRESECTIONOFSIGMOIDCOLONCANBEDILUTEDINTHECLOSEDLUMENOFTHEINTESTINECOLONCANCERSURGERYUSUALLYREQUIRESADEQUATEBOWELPREPARATION,ANDBOWELPREPARATIONISPRIMARILYTHEEVACUATIONOFINTESTINALTRACTANDPROPERINTESTINALANTIBIOTICSAPPLICATIONINTESTINALEMPTYINGTHEREAREMANYMETHODS,AND1224HOURSBEFORETHEOPERATION,THECOMPOUNDPOLYETHYLENEGLYCOLELECTROLYTEPOWDER2000ISTAKENORALLY3000MLORORALMANNITOLALSOTHEDAYBEFORESURGERY,ORALLAXATIVES,SUCHASCASTOROILANDSENNAORMAGNESIUMSULFATELIQUIDETCUNLESSTHEREISASUSPECTEDINTESTINALOBSTRUCTION,THEREISASMALLBOWELCLEANSINGMETHODFORREPEATEDCLEANSINGENEMATHEMAKINGOFINTESTINALANTIBIOTICSUSAGEROUTINEUSEOFMETRONIDAZOLE,04G,THREETIMESADAY,NEOMYCIN1G,TWOTIMESADAY,ONEDAYBEFORESURGERYNOTRECOMMENDEDBOW