Nghiên cứu phẫu thuật nội soi cắt trực tràng kết hợp xạ trị ngắn ngày trước mổ điều trị ung thư biểu mô tuyến trực tràng tt tiếng anh

M INISTRY OF EDUCATION AND TRAININGM INISTRY OF DEFENCE 108 IN STITU TE OF C LINI C A L MEDI C A L AN D P HA R MAC EU TI CA L SCI EN C ES NGUYEN TO HOAI RESEARCH ON RECTAL RESECTION LAPAROSCOPY COMBINED PREOPERATIVE SHORT-COURSE RADIATION TO TREAT RECTAL CARCINOMA Speciality: Gastrointestinal Surgery Code: 62720125 ABSTRACT OF MEDICAL PHD THESIS Ha Noi – 2020 THE THESIS WAS DONE IN:108 INSTITUTE OF CLINICAL MEDICA L AND PHA RMACEUTICAL SCIENCES Supervisor: Ass.Prof.PhD Trieu Trieu Duong Ass.Prof PhD Le Ngoc Ha Reviewer: This thesis w ill be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year 2020 The thesis can be found at: National Library of Vietnam Library of 108 Institute of Clinica l Medica l and Pharmaceutical Sciences INTRODUCTION Rectal cancer is a fairly common disease in the world and is on the rise in developing countries According to Globocan statistics, in 2018 there were 704,376 cases of cancer, accounting for 3.9% of cancer diseases, of which 310,394 patients died, accounting for 3.2% of the total cancer deaths In the world, there have been many studies on preoperativeshort-course radiation combined with total mesorectal excision to treat rectal cancer.Studies show that the regimen has a short duration of treatment, low treatment costs and is easy to apply while effectively reducing local recurrence rates by about 50% compared to the simple surgery group and the effectiveness of oncology to the equivalent of long-course Summary of studies in Vietnam, many previous studies on rectal cancer have not been indicated for neoadjuvant treatment The current prevailing treatment before surgery is long-term radiation therapy, the total time of wa iting for surgery to be prolonged, expensive and difficult for patients to follow the regimen Based on the advantages of preoperative short-course radiationsuch as short treatment time, low cost of treatment, ease of application and advantages of laparoscopic surgery with the desire to improve the quality and reduce the recurrence rate in the treatment of rectal cancer We perform this study to: Describe the stage of disease in patients with rectal carcinoma who received preoperative short-course radiation Evaluate the results of laparoscopic surgery combined with preoperative short-course radiation to treat rectal carcinoma CONTRIBUTIONS OF THE THESIS This is the first thesis in Vietnam that fully describes the stage of disease and the results of laparoscopic rectal excision combined short-course preoperative radiationtreatment rectal carcinoma - Stage of the disease: The stage of pre-surgery disease according to MRI meets stage II, III respectively 16.4% and 83.6%, according to the CT stage II, III respectively are 12.9% and 87, first% The stage of postoperative disease stage I, II, III was respectively 14.3%, 64.3% and 21.4% - Surgical results:LAR procedure was 74.3%, APR procedure was 25.7% Ileostomy rate was 53.8% Intraoperative complication was 5.7%, serious postoperative complication was 12,1% Mean operative time was 134.1 ± 32.4 minutes Mean postoperative time was 10,7±4,6 days Complete and nearly complete mesorectum were 63.6% and 36.4% respectively Mean distal resection margin was 24.5 ± 13.6 mm Distal margin with negative was 98.0% Circumferential resection margin with negative was 98.5% Overall survival and disease-free survival were 26.7 ± 9.6 months and 25.2 ± 10.9 months respectively Recurrence rate was 12.1% Late toxicity of the preoperative radiotherapy common grade was 12.9% The above-mentioned contributions are realistic and practical, provide another option for surgeons in their treatment of rectal cancer The research has provided new contributions, confirms the safety, feasibility and efficacy in reducing complication rates and ensuring oncologica l principles of laparoscopic rectal excision combined short-course radiation in treating rectal cancer STRUCTURE OF THE THESIS The thesis consists of 113 pages: 2-page questions, 33-page overview, 19-page research objects and methods, 27-page research results, 32-page discussion, 2-page conclusions, 1-page request Research works, 34 tables, charts, 18 images 113 references, of which 13 are in Vietnamese and 100 are in foreign languages Chapter OVERVIEW 1.1 Rectal anatomy 1.1.1 Rectum The rectum is the continuation of the sigma colon to the anal canal, about 12 to 15 cm long In women, the anterior of rectum is associated with the posterior vaginal and cervical wall In men, rectum is located behind the bladder, vas deferens, seminal ves icles and prostate gland 1.1.2 Atery The blood supply enters the rectum posteriorly The upper rectum is supplied by the superior rectal artery (SRA), a branch of the inferior mesenteric artery (IMA) The middle and lower rectum are supplied by the middle rectal artery and inferior rectal artery, respectively, which branch from the anterior division of the internal iliac artery and/or the pudendal artery 1.1.3 Venous and lymphatic drainage The pathways for the lymphatic and venous drainage of the rectum are cephalad and lateral.The lymphatic drainage of the upper two-thirds of the rectum is along the pathway of the superior hemorrhoidal vein, cephalad to the inferior mesenteric nodes, and the paraaortic nodes The lymphatic drainage of the lower third of the rectum is cephalad as well as lateral along the middle hemorrhoidal vessels to the internal iliac nodes There are no communications between the inferior mesenteric and internal iliac lymphatics In women, lymphatic drainage above the dentate line also includes the posterior wall of the vagina and reproductive organs Below the dentate line, the drainage is along the inferior rectal lymphatics to the superior inguinal nodes and along the pathway of the inferior rectal artery 1.1.4 Nerve All branches of the pelvic region are located between the peritoneum and inner pelvis The nerve branches may be damaged or severed during rectal removal 1.1.5 Mesorectum The fascia propria is an extension of the pelvic fascia and encloses the rectum, adipose tissue, blood, and lymphatic vessels It is more pronounced laterally and posteriorly and forms the lateral ligaments of the rectum In 25 percent of patients, the lateral ligaments contain branches of the middle rectal artery and venous plexus The rectum is not suspended by a true mesentery (ie, two layers of peritoneum that suspend an organ) The "mesorectum" is perirectal areolar tissue that is thicker posteriorly and contains the terminal branches of the inferior mesenteric artery 1.2 Pathology 1.2.1 Macroscopic Rectal cancer consists of main types : fungating/polypoid, ulcerfungating/ulceroinfiltrative, infiltrative 1.2.2.Microscopic According to Halminton: 98% are adenocarcinoma Less common are lymphoma (1.3%), carcinoid (0.4%) and connective carcinoma (0.3%) 1.3 Diagnosis 1.3.1 Clinical The first common symptom is a bloody stool Another symptom of UTTT is natural anal bleeding or defecation Rectal examination in addition to determining the location and size of the tumor, can also assess the invasion of the tumor, and also check nearby organs such as sphincter, prostate, vagina 1.3.2 Subclinical 1.3.2.1 Colonoscopy Colonoscopy is the most accurate diagnostic method for colorectal cancer Proctoscopy can accurately determine the distance between the distal tumor margin, the top of the anorectal ring, and the dentate line.It also allows the tumor biopsy to be performed 1.3.2.2 Imaging Valuable imaging diagnostics help assess local tumor lesions and metastases help to indicate treatment - Local imaging may include preoperative CT scan, MRI or endoscopic ultrasound For some early stage adenomas (cT1) there is a risk of lymph node metastasis (0,05 >0,05 >0,05 >0,05 Conclusion: - The APR group did not have any recurrence cases, the LAR group had recurrent cases, accounting for 16.3% This difference is not statistically significant with p> 0.05 18 - Considering the relationship between local recurrence and CEA, tumor size and stage found no significant difference (p> 0.05) Fig 3.4 Overall survival Conclusion:The overall survival rates after 1, and years were 97.1%, 95.7% and 95.7%, respectively Fig 3.7 Disease-free survival 19 Conclusion: The disease-free survival ratesafter 1, and years were 92.9%, 91.4% and 88.6% respectively Chapter DISCUSSION 4.1 Characte ristics The study showed that the mean age of patients was 59.6 ± 10.48 years This result is similar to other authors Understanding gender, the statistics of domestic and foreign authors show that men meet more often (about 60-70%) The results showed that male patients accounted for 62.9% CEA is commonly used in colorectal cancer Research by several authors shows that a high CEA at the time of diagnosis has an adverse effect on the survival time independent of the tumor stage If this indicator decreases after surgery is associated with increased disease-free survival CEA levels> ng / ml at the time prior to radiotherapy were associated with poor tumor response Concentrations of CEA