循證醫(yī)學(xué)實(shí)踐匯報(bào)

1、循證醫(yī)學(xué)實(shí)踐匯報(bào),成員：匯報(bào)：,王某，男，71歲，永寧縣人，農(nóng)民，回族。 主訴：肛門憋脹感進(jìn)行性加重4月。 現(xiàn)病史：患者自述4月前開始無明顯誘因出現(xiàn)肛門憋脹感，無肛門疼痛，偶有里急后重感，無腹痛腹脹，無便血便細(xì)，無惡心嘔吐，大便次數(shù)逐漸從1天1次變?yōu)?天3~4次，大便性狀無改變，自行口服和外用類治痔瘡藥，效果無好轉(zhuǎn)。10天前到永寧縣醫(yī)院做肛門指檢后未作治療，隔日就診于五醫(yī)院行直腸鏡檢查，考慮直腸腫瘤。為

2、求進(jìn)一步診治，于10月19日來門診就診并收住我院結(jié)直腸外科。自發(fā)病以來，患者飲食睡眠精神尚可，小便正常，體重下降5kg左右。 既往史：30年前因顱骨骨折行外科手術(shù)，否認(rèn)冠心病、糖尿病、高血壓病史，無輸血史和過敏史，否認(rèn)傳染病史。 體格檢查：視診肛門外形正常，觸診下腹正中有壓痛，肛門括約肌張力及緊張度正常。肛門指診距肛門緣2cm處有一3×4cm大小的腫塊，活動(dòng)度差，質(zhì)韌、占據(jù)腸腔體積1/2。指套退

3、出時(shí)無血，肛周觸痛陰性。 診斷：直腸中分化腺癌。,循證問題構(gòu)建,英語檢索策略：Colorectal Cancer OR Large Intestine Cancer OR Colonic Neoplasm OR Rectal neoplasm AND Surgery AND laparoscopy AND RCT,,1,經(jīng)過初篩，閱讀文獻(xiàn)摘要、全文等過程，共收集6篇符合標(biāo)準(zhǔn)的文獻(xiàn)。,納入標(biāo)準(zhǔn)：（1）原始資料為已公開發(fā)表的

4、文獻(xiàn)；（2）研究對(duì)象為病理學(xué)診斷的結(jié)直腸癌患者；（3）文獻(xiàn)類型為前瞻性隨機(jī)對(duì)照研究；（4）干預(yù)方式為L(zhǎng)S與OS比較，包括右半結(jié)腸切術(shù)、左半結(jié)腸切除術(shù)、乙狀結(jié)腸切除術(shù)、腹會(huì)陰聯(lián)合切除術(shù)、直腸前切除術(shù)等，LS為全腹腔鏡手術(shù)或腹腔鏡輔助手術(shù)；（5）原始文獻(xiàn)中有患者特征、并發(fā)癥，明確的隨訪截尾時(shí)的計(jì)數(shù)或計(jì)量資料等；（6）近5年發(fā)表的研究。  排除標(biāo)準(zhǔn)：（1）研究對(duì)象包括結(jié)直腸良性疾病，結(jié)直腸癌存在遠(yuǎn)處轉(zhuǎn)移或周圍器侵襲；（

5、2）研究目的不是比較LS和OS的臨床療效以及動(dòng)物實(shí)驗(yàn)和細(xì)胞實(shí)驗(yàn)；（3）未提供具體數(shù)據(jù)；（4）重復(fù)發(fā)表；（5）統(tǒng)計(jì)學(xué)分析違反處理意向原則。,2,3,4,5,6,中文文獻(xiàn)：經(jīng)過與之前相同的初篩，閱讀文獻(xiàn)摘要、全文等過程，共收集2篇符合標(biāo)準(zhǔn)的文獻(xiàn)。分別列出文獻(xiàn)結(jié)果：,臨床指南：檢索PubMed及中國(guó)生物醫(yī)學(xué)文獻(xiàn)數(shù)據(jù)庫(kù)，共檢出1個(gè)相關(guān)指南：,Background The laparoscopic approach is increasingly

6、 applied in colorectal surgery. Although laparoscopic sur-gery in colon cancer has been proved to be safe and fea-sible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncolog

7、-ical outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be ef?cacious, but indications and limitations are not clearly de?ned. Therefore, the European Associ

8、ation for Endoscopic Surgery (EAES) has developed this clinical practice guideline.Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The

9、expert panel constituted for a consensus development conference in May 2010. Thereafter, there commendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consens

10、us process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (mid-and low-) rectal cancer

11、 is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital sta

12、y are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dis

13、section may impair genitourinary and sexual function after rectal resection, like in open surgery. Conclusions Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most

14、 level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in

15、 comparison with the open approach.,結(jié)果：腹腔鏡手術(shù)治療腹膜外（中，低）直腸癌是可行的并且被廣泛接受。腹腔鏡方法必須提供與開放手術(shù)相同質(zhì)量的手術(shù)標(biāo)本。腹腔鏡方法可以略微改善腸道功能，手術(shù)部位感染，疼痛和住院時(shí)間等短期結(jié)果。腹腔鏡直腸癌切除術(shù)在無病生存率，總體生存率或局部復(fù)發(fā)方面并不遜于開放性。像開放手術(shù)一樣，腹腔鏡下盆腔夾層可能會(huì)影響直腸切除后的泌尿生殖系統(tǒng)和性功能。結(jié)論：在最佳條件下，可推薦腹腔鏡

16、手術(shù)治療中，低位直腸癌。盡管如此，大多數(shù)1級(jí)證據(jù)仍然是結(jié)腸癌手術(shù)而不是直腸癌。正在等待大型隨機(jī)試驗(yàn)即將出現(xiàn)的結(jié)果，以加強(qiáng)證據(jù)，以改善短期結(jié)果和與開放方法相比的長(zhǎng)期結(jié)果。,所檢出的6篇英文文獻(xiàn)中，前五篇為原始研究證據(jù)，均采用的隨機(jī)對(duì)照實(shí)驗(yàn)，達(dá)Ⅰb級(jí)論證強(qiáng)度；第六篇為二次研究證據(jù)，但其真實(shí)性較低，且為同質(zhì)性隊(duì)列研究的系統(tǒng)綜述，論證強(qiáng)度為Ⅱa級(jí)。 所檢出的2篇中文文獻(xiàn)均采用回顧性隊(duì)列研究，論證強(qiáng)度為Ⅱ級(jí)。 目

17、前基于循證醫(yī)學(xué)基礎(chǔ)上建立起來的臨床實(shí)踐指南是指導(dǎo)臨床實(shí)踐的最佳證據(jù)，為Ⅰa級(jí)。,將所得證據(jù)結(jié)果告訴患者家屬：本例老年男性患者完全滿足腹腔鏡下直腸癌根治性切除術(shù)的條件，可以選用腹腔鏡手術(shù)。相比開腹手術(shù)，腹腔鏡方法可以略微改善腸道功能，手術(shù)部位感染，疼痛和住院時(shí)間等短期結(jié)果。腹腔鏡直腸癌切除術(shù)在無病生存率，總體生存率或局部復(fù)發(fā)方面并不遜于開放性，像開放手術(shù)一樣，腹腔鏡下盆腔夾層可能會(huì)影響直腸切除后的泌尿生殖系統(tǒng)和性功能。