The thesis determines the value of multi-sequence computerized tomography in the diagnosis of rectal cancer undergoing radical surgery. Evaluate the results of laparoscopic surgery for radical treatment of rectal cancer. Invite you to refer to the thesis to understand the content of the study.
Trang 1Rectal cancer is a common cancer of the digestive tract, a common disease in the world, especially in developed countries. According to the World Health Organization (2003), it is estimated that each year, around 572,100 people have colorectal cancer (in which colorectal cancer accounts for the most rate). In Vietnam, the rectal cancer is ranked the fifth after the bronchial, stomach, liver, and breast cancers.
As noted by the Hanoi Cancer Society (2002), nearly 15,000 new cases are diagnosed each year with the rate of 13.1/100000 people and about
7000 deaths
To achieve high effectiveness in the treatment, computerized tomography, magnetic resonance imaging have been used to diagnose the disease and the level of organ invasion, lymph node metastasis in rectal cancer Although MRI is increasingly proving superiority, multidisciplinary computed tomography is still valuable in the diagnosis
of rectal cancer, especially for the diagnosis of distant metastases, as well as the popularity of medical facilities. local, easy to carry, time taken. Thus, the strategy of treating rectal cancer for each patient is formulated more completely and accurately, with higher treatment efficiency. In the treatment of rectal cancer, surgery plays an important role, other treatments such as radiation and immunochemicals have an auxiliary role. Radical surgery in the treatment of rectal cancer is the destination of all surgeons in the treatment of cancer in general and rectal cancer in particular. Radical surgery can be done with classic open surgery or laparoscopic surgery In order to contribute to perfecting the method of diagnosis and treatment of rectal cancer, we have conducted research on this topic with two objectives:
1. Determining the values of multithreaded computer tomography in the diagnosis of rectal cancer.
2 Evaluating the results of radical laparoscopic surgery treatment of rectal cancer.
1 New contributions of the thesis
The dissertation has gained new results and contributed more to the specialization
Trang 2Indicates the diagnostic value of multithreaded computer tomography with rectal cancer In particular, the degree of invasive diagnosis has an accuracy of 88.197.4% with sensitivity of 2095.8%, specificity of 80.0100%. Diagnosis of lymph node metastasis has the accuracy of 63.576.2%, sensitivity of 48.7100%, specificity of 67.594.7%. Diagnosis of the disease stage has the accuracy of 63.598.3%.Reporting the results of laparoscopic surgery for radical treatment
of rectal cancer applied at Viet Duc University Hospital: No death after surgery, early complications after surgery 8.5%, average hospitalization time 8.4 ± 3.5 days. Recurrence rate of 15%, death of 9.3% (after 247 months)
The followup results showed that the overall survival rate was 43.8 months, the average without disease was an average of 42.5 months. The sequelae of sexual disorders are 14.0%. The thesis also analyzes in depth the relationship between the degree of damage of rectal cancer and the extra time after surgery. Which has determined the extent of invasive tumor is an independent prognostic factor of the extra lifetime
The thesis has contributed to further clarify the diagnostic value of rectal cancer lesions of multithreaded computer tomography and the results of radical laparoscopic surgery treatment of rectal cancer
2 The thesis structure
The thesis consists of 138 pages, including: Introduction (2 pages); Chapter 1: Literature Overview (36 pages); Chapter 2: Research subjects and methods (20 pages); Chapter 3: Results (42 pages); Chapter 4: Discussion (36 pages); Conclusion: (2 pages), The thesis has 50 data tables, 20 charts; 13 photos; 122 references (46 Vietnamese documents,
76 English documents), appendices, research form, patient list.
CHAPTER 1. LITERATURE OVERVIEW
1.4. CT ANATOMICAL CHARACTERISTICS OF RECTUM AND PELVIS
For computerized rectal tomography, the patient is cleared of stool with enemas or indented 11.5 liters of fluid into the colorectal. Helical technique from diaphragm arch to edge of anus with thin cutting
Trang 3thickness on axial, reconstructed on two (sagital) and horizontal (coronal) planes.
1.4.1. Rectal position and structure
* Rectal position: On the sagial plane it is possible to locate the
rectum by measuring the distance from the anus. Rectal 1/3 section on anal margin 1015cm, 1/3 median between anal margin 5 10cm, low segment 5cm anal margin. On the horizontal plane (axial), the rectum looks like a round tube with a diameter of 35cm. The wall of the rectum is about 36 mm thick
* On a horizontal plane (axial):
Between men and women have similar or different images depending on the location of computer tomography, in men with seminal vesicles, prostate, In women with uterus, vagina. There are 3 basic cutting positions
Indications for laparoscopic surgery for rectal cancer are not limited with age but need to fully evaluate respiratory and circulatory function. Location and number of trocar: 46 trocar depending on the habits of the surgeon. The amount of blood lost during surgery ranges from 30 60ml. The overall complication rate is 5 18%
Trang 4of open surgery confirming the feasibility of laparoscopic surgery. Postoperative results between hand and machine connection showed no difference in complications or deaths.
1.6. SITUATION OF LAPAROSCOPIC SURGERY FOR RECTAL CANCER TREATMENT IN THE WORLD AND IN VIETNAM1.6.1. In the world
In the world, there have been many studies on laparoscopic rectal cancer surgery compared and compared with open surgery for many good results. Zhou G et al. (2004) compared rectal cancer patients undergoing laparoscopic surgery (82 patients) and open surgery (89 patients) found that laparoscopic surgery had the amount of blood loss (20 ml: 5–120 ml) less than open surgery (92 ml: 50–200ml), p <0.05.Wang YW et al (2015) paired analysis (laparoscopic surgery of 106 patients; open surgery: 106 patients) found the surgery time (180.8 ± 47.8 minutes compared to 172.1 ± 49, 2 minutes), the number of removable lymph nodes (12.9 ± 6.9 compared to 12.9 ± 5.4) and postoperative pathological characteristics of the two groups were not statistically significant ( p> 0.05). Baek JH et al. (2015) studied 230 patients with 5year diseasefree survival time of rectal cancer patients 83% (laparoscopic surgery) and 74.6% (open surgery), ( p> 0.05). 1.6.2. In Vietnam
In Vietnam, laparoscopic surgery has been used since 1992 at Cho Ray Hospital. Currently, rectal cancer laparoscopic surgery has been carried out in many hospitals such as Viet Duc University Hospital, National Cancer Hospital, Military Hospital 103, Hue Central Hospital
Nguyen Hoang Bac et al. (2010) retrospectively examine 482 rectal cancer surgery patients at Ho Chi Minh City University of Medicine and Pharmacy Hospital to see 329 cases of rectal segmentectomy and 19 posterior colonoscopy. subject, 134 surgery Miles. There are 21 cases of open surgery. Two patients had damage to the ureter, 22 patients (6%) had a rectal fistula, and three patients had early bowel obstruction after Miles surgery. Average hospitalization time of 6.9 days
Pham Van Binh (2017) studied 53 patients on 1/3 of rectal cancer who had surgery to cut the colorectal segment and connected the
Trang 5machine, the average surgery time was 136.7 34.5 minutes (Internal surgery soi 171.8 45.7 minutes; open surgery: 124 17.2 minutes). The average hospitalization time after surgery is 10.2 2.6 days. The total extra life of 3 years is 85.1%.
CHAPTER 2RESEARCH SUBJECTS AND METHDS
2.1. RESEARCH SUBJECTS
Including rectal cancer patients who underwent radical laparoscopic surgery at VietnamGermany Hospital from June 2013 to June 2015
2.1.1. Criteria for selecting patients
The patient was diagnosed with a lower rectal cancer tumors less than 15cm from the edge of the anus
2.2.2. Research variables
All information was collected by questionnaires through sample cases, direct patient visits, multithreaded computer tomography, tumor invasion assessment, GPB comparison and evaluation of surgical results. including:
Trang 6to the division of Thoeni in 2 stages: localized tumor in rectum wall, invasive tumor
2.2.2.3. Anatomy results after surgery
* Macrobody: Postoperative tumors were assessed for macrobody
lesions in terms of location, size, shape, and properties; Cut a slice at the 2cm invasive position to assess the degree of rectal wall invasion. Lymph nodes are analyzed for evaluation: location, size, number
2.2.2.6 Early results after laparoscopic radical surgery for rectal cancer
Death after surgery Complications after surgery: intraabdominal bleeding; peritonitis; Postoperative urinary retention; infection of the abdominal incision; infection of the episiotomy
Trang 7incision; artificial anal prolapse, artificial anal lag; splitting of abdominal wall; early bowel obstruction after surgery Time to return to peristalsis, bladder sonde withdrawal time after surgery, hospitalization time after surgery: in days.
CHAPTER 3RESEARCH RESULTS
r of Rate (%) Number of Rate (%) Number of Rate (%)
Trang 8 Male account for 54.2%, female is 45.8%. The male to female ratio is 1.19.
Trang 9 Of the 118 patients with rectal carcinoma, the majority had moderate degree of differentiation (73.7%), 16.1% with high grade and 10.2% with poor differentiation.
Trang 10 Number of lymph nodes: 67.8% of cases without lymph node metastases (N0); 23.7% of cases metastases from 1 to 3 lymph nodes (N1); only 8.5% of metastases ≥4 lymph nodes (N2)
Locations of lymph node metastasis: lymph nodes around the rectum (18.6%), anterior lymph nodes (2.5%), mesenteric lymph nodes (11.0%)
Table 3.8. Stage of rectal cancer disease on anatomical pathology
Number
of patients
Classified by Duckes: Dukes A period is 25.4%; Dukes B is 39.8% and Dukes C is 32.2%
Trang 11Rate(%)
T3: Wall thickening and invading of surrounding
Trang 12 On computerized tomography, the average thickness of rectal wall is 2.14 4.27mm; The height of the average tumor is 4.72 4.54mm.
The majority of patients have tumor size compared to the rectum from 1/4 to 1/2 (23.7%), 1/2 to 3/4 (38.1%) and> 3/4 of the circumference (28.8%); tumor size is less than 1/4 circumference and difficult to assess, accounting for low percentage (7.6% and 1.7%)
The extent of tumor invasion (T): highest in T3 (72.9%), followed by T2 (18.6%), T1 and T4 accounted for low rate (4.2% and 3.4 %). There is 1 case (0.8%) of T stage not identified
Table 3.11. Compare the degree of invasive cancer of rectum through computerized tomography with pathology
81.8%
910.5%
125.0%
2823.7%
Trang 139.1% 81.4% 25.0% 61.9%
4.5%
78.1%
250.0%
108.5%
100.0%
5100.0%
22100.0%
86100.0%
4100.0%
118100.0%
Comparing the invasion of colorectal cancer through multithreaded computer tomography with GPB found the highest proportion of diagnosed matches in the Tx stage (1/1 patient), followed by T2 (81.8 %
%), T3 (81.4%), T1 (60.0%) and T4 (50.0%)
Trang 143.2.2 Diagnosis of lymph node metastasis through multithreaded computer tomography
Table 3.14. Reconstructing lymph node metastases stage of rectal cancer via multithreaded computer tomography with pathology
Stage N on
pathological
surgery
Stage N on computeriz
ed tomography (Number of patients,%)
Rate(%)
Stage I T1N0M0;
Trang 15computed
tomograp
hy (Number
of patients,
%)
Total (n = 118)
Stage 0 Stage I Stage II Stage III
Trang 16Stage III 0 0 9.1%2 36
46.8% 32.2%38Total 100.0%1 100.0%18 100.0%22 100.0%77 100.0%118Comparison of diagnosis of stage rectal cancer through multithreaded computer tomography with GPB found the highest proportion of diagnosis matching in stage 0 (1/1 patient), followed by stage I (88.9% ), Phase II (86.4%) and the lowest is Stage III (46.8%)
Positive predictive value in rectal cancer stage diagnosis of multicomputed tomography ranged from 46.7% to 100.0%
Negative predictive value in rectal cancer stage diagnosis of multidisciplinary computed tomography ranged from 1.7% to 29.1%
The accuracy in diagnosing rectal cancer stage of multithreading computer tomography ranges from 63.5% to 98.3%
3.3. LAPAROSCOPIC SURGERY METHOD OF RADICAL
TREATMENT OF RECTAL CANCER
3.3.2. Surgical time
Trang 17Numbe
r of patients
Rate (%)
Number
of patients
Rate (%)
The average laparoscopic surgery time in the immediate rectal segmentation group (170.0 42.1 minutes) was not different from the Miles surgery group (174.6 30.0 minutes), p> 0.05
Total(n= 118)
Numbe
r of
patient
Rate (%) Number of
patients
Rate (%) Number of
patients
Rate (%)
Trang 183.5. DISTANT RESULTS AFTER RADICAL LAPAROSCOPIC TREATMENT OF RECTAL CANCER
107/118 patients (90.7%) were monitored after surgery with an average time of 29.3 8.3 months (2 47 months)
Rate(%) (± SD) [median]TimeDeath 10 9.3 23.3 ± 11.4 (1 36)[median: 25.0]Recurrence 16 15.0 26.0 ± 9.8 (7.0 47.0)[median: 25.5]
The recurrence rate is 15.0%. The average relapse time was 26.0 9.8 months (7 47 months) [median: 25.5 months]
The death rate is 9.3%. The average time of death was 23.3 ± 11.4 months (136 months) [median: 25.0 months]
3.5.2. Complete survival time and diseasefree survival
Table 3.29. Complete survival time of rectal cancer patients
Complete survival Number of died Rate (%)
Trang 19Figure 3.1. Complete survival time of rectal cancer patients Table 3.30. Diseasefree survival time of rectal cancer patients
Diseasefree
survival time
(month)
Number of relapsed patients (n = 16)
Rate (%) (±SE)
Trang 20The rate of survival without disease 12, 24 and 36 months was 98.1%; 93.8% and 76.9%. The median nondisease survival time was 42.5 1.0 (95% CI: 40.344.6)
Figure 3.2. Diseasefree survival time of rectal cancer patient
CHAPTER 4DISCUSSION
4.1. CHARACTERISTICS OF STUDIED SUBJECTS
4.1.1. Age
Rectal cancer is increasing, usually after 40 years of age and increases most in the age group of 5070 years. Through research, the average age of patients is 60.0 ± 12.5 years old. (2686 years old). The mean age of male patients (59.8±12.2 years) was not different from female patients (60.2 ±12.8 years), p> 0.05
4.1.2. Gender
The majority of studies show that the proportion of rectal cancer patients is male than female. Male patients have a harder time predicting surgery than female patients due to the narrower pelvic anatomy
The research results show that men account for 54.2%, women are 45.8%. The male to female ratio is 1.19. This is also consistent with some studies on the sex of rectal cancer patients
4.1.3. Distribution of patients by geography
Research shows that patients in rural areas still account for the majority