卵巢癌手術(shù)治療—腹腔鏡與開腹誰(shuí)更合適課件

1、卵巢癌手術(shù)治療腹腔鏡與開腹誰(shuí)更合適1990s2000s2010s Second-look operation for evaluations with laparoscopyHand-assisted laparoscopy Staging LaparoscopyLaparoscopic Cytoreduction CONTENTS010302腹腔鏡在早期卵巢癌分期手術(shù)中的價(jià)值腹腔鏡在晚期卵巢癌細(xì)胞減滅手術(shù)中的應(yīng)用腹腔鏡下復(fù)發(fā)性卵巢癌減瘤術(shù)的應(yīng)用及價(jià)值01全面手術(shù)分期+減瘤術(shù)02低級(jí)別漿液性癌/G1子宮內(nèi)膜樣癌觀察隨訪以鉑為基礎(chǔ)的靜脈化療36療程內(nèi)分泌治療03A或B期/G2子宮內(nèi)膜樣癌觀察以鉑

2、為基礎(chǔ)的靜脈化療36療程04A或B期高級(jí)別漿液性癌或G3子宮內(nèi)膜樣癌和C期以鉑為基礎(chǔ)的靜脈化療36療程05證據(jù)支持期患者的初次化療需要6療程以上的化療初治浸潤(rùn)性上皮性卵巢癌治療原則2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南早期少見病理組織學(xué)類型的卵巢腫瘤的治療原則冰凍切片提示為惡性生殖細(xì)胞腫瘤、惡性線索-間質(zhì)腫瘤，可行保留生育功能的手術(shù)無(wú)生育要求者或間質(zhì)腫瘤患者或癌肉瘤患者，進(jìn)行全面手術(shù)分期。根據(jù)病理術(shù)后可選擇觀察或相應(yīng)化療2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南腹腔鏡可被用于評(píng)估是否能達(dá)到滿意的減瘤術(shù)腹腔鏡可被用于有經(jīng)驗(yàn)的婦瘤醫(yī)生完成手術(shù)分期及滿意的

3、減瘤術(shù)若腹腔鏡減瘤術(shù)不理想，必須中轉(zhuǎn)開腹手術(shù)基本原則2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南手術(shù)步驟Step Four全子宮+雙側(cè)附件切除；需要保留生育功能的患者，在符合適應(yīng)證的前提下可考慮行單側(cè)附件切除術(shù)或雙側(cè)附件切除術(shù)手術(shù)過程必須盡力完整切除腫瘤并避免腫瘤破裂可根據(jù)需要切除腸管、闌尾、脾臟、膽囊、部分肝臟、部分胃、部分膀胱、胰尾、輸尿管及剝除膈肌和其他腹膜；力求使殘余腫瘤病灶直徑1cm，最好切除所有肉眼可見病灶腹腔沖洗液行細(xì)胞學(xué)檢查；對(duì)腹膜表面進(jìn)行全面診視，腹膜活檢切除能夠切除的腫大或者可疑淋巴結(jié)；盆腔外腫瘤病灶2cm者（即B期）必須行雙側(cè)盆腔和主動(dòng)脈旁淋巴結(jié)切除術(shù)S

4、tep ThreeStep TwoStep One2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南腹腔鏡手術(shù)爭(zhēng)議術(shù)中腫瘤破裂氣腹致腫瘤擴(kuò)散手術(shù)分期不全面穿刺孔腫瘤種植ABC腹腔鏡術(shù)中出血更少(466.8 95% CI, 340.1-593.4 vs 233.8; 95% CI,195.7-272.0 mL; P .001)組間術(shù)后分期提高無(wú)明顯差異 (I2 = 43.8%)腹腔鏡術(shù)中腫瘤破裂率為可接受范圍內(nèi)(I2 =35.6%, 總體 25.4%)Staging laparoscopy for the management of early-stage ovarian cance

5、r: a meta-analysisHyun Jong Park et al. / American Journal of Obstetrics & Gynecology / JULY 2013開腹手術(shù)出血更多PFS無(wú)顯著差異OS無(wú)顯著差異PPT模板下載：/moban/ 行業(yè)PPT模板：/hangye/ 節(jié)日PPT模板：/jieri/ PPT素材下載：/sucai/PPT背景圖片：/beijing/ PPT圖表下載：/tubiao/ 優(yōu)秀PPT下載：/xiazai/ PPT教程： /powerpoint/ Word教程： /word/ Excel教程：/excel/ 資料下載：/ziliao/

6、 PPT課件下載：/kejian/ 范文下載：/fanwen/ 試卷下載：/shiti/ 教案下載：/jiaoan/ 字體下載：/ziti/ L. Minig et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 201 (2016）腹腔鏡與開腹手術(shù)分期范圍相似Laparoscopic surgical staging in women with early stage epithelial ovarian cancer81 of 665 (12.2%) laparoscopy groupVS

7、 126 of 656 (19.2%) laparotomy groupUpstaged on the final pathological evaluation (P 0.001)腹腔鏡手術(shù)的腫瘤負(fù)荷較開腹手術(shù)小組間PFS及OS無(wú)顯著性差異Laparoscopic staging for apparent stage I epithelial ovarian cancerAlexander Melamed et al. /American Journal of Obstetrics & Gynecology / JANUARY 2017LAC 手術(shù)在早期EOCLonger operative

8、 time-not statistically significantLower estimated blood loss (WMD = 156.5 mL; 95% CI, 216.4 to 96.5),Shorter length of hospital stay (WMD = 3.7 days; 95% CI, 5.2 to 2.1)Lower postoperative complication rate (odds ratio OR = 0.48; 95% CI, 0.290.81)Upstaging (OR = 0.81; 95% CI, 0.551.20) Cyst rupture

9、 (OR = 1.32; 95% CI, 0.523.38)Rates were similar between groups. A shorter time to chemotherapy (WMD = 5.16 days; 95% CI, 8.68 to 1.64).Survival outcomes were not influenced by the route of surgery. Minimally Invasive Surgical Staging in Early-stage OvarianCarcinoma: A Systematic Review and Meta-ana

10、lysisGiorgioBogani, et al./Journal of Minimally Invasive Gynecology, Vol 24, No 4, May/June 2017小結(jié)術(shù)中出血少術(shù)后住院日短有經(jīng)驗(yàn)的手術(shù)醫(yī)生可將腹腔鏡更廣泛地應(yīng)用于早期卵巢癌的全面分期手術(shù)未提高手術(shù)分期無(wú)更高的腫瘤破裂率，且術(shù)中破裂并不明確影響預(yù)后PFS及OS相比開腹手術(shù)無(wú)顯著性差異CONTENTS010302腹腔鏡在早期卵巢癌分期手術(shù)中的價(jià)值腹腔鏡在晚期卵巢癌細(xì)胞減滅手術(shù)中的應(yīng)用腹腔鏡下復(fù)發(fā)性卵巢癌減瘤術(shù)的應(yīng)用及價(jià)值PDSNACT+IDS晚期卵巢癌的初始手術(shù)策略Phase III randomise

11、d clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load (SCORPION trial): Final analysis of peri-operative outcome A. Fagotti et al. / European Journal of Cancer 59 (2016) 22e33Fagotti laparoscopy-based scoreN.R. Gmez-Hid

12、algo et al. / Gynecologic Oncology 137 (2015) 553558“The Fagotti laparoscopy-based score is a useful predictor of optimal cytoreduction.” Predictive Index Value (PIV)2 Low Tumor LoadG. Vizzielli et al. / Gynecologic Oncology 142 (2016) 1924 “Early identification of high-risk patients could help the

13、surgeon to adopt tailored strategies on individual basis.”A laparoscopic risk-adjusted model to predict major complications afterprimary debulking surgery in ovarian cancer: Asingle-institution assessmentMore favorable estimated blood loss and median length of stay and TTC. No difference in PFS or O

14、S.Minimally invasive approach could representation advantage alternative surgical way.Minimally invasive versus standard laparotomic interval debulking surgery in ovarian neoplasmS. Gueli Alletti et al. / Gynecologic Oncology 143 (2016) 516520The high rate of complete cytoreductionis perhaps because

15、 of the accurate selection of patientsLaparoscopy potentially improves the detection of microscopic peritonealimplantsLaparoscopy significantly reduces procedure-related morbidity and expedites recovery.Fanning et al Feuer et al suggested laparoscopy in advanced ovarian cancerFanning J, Yacoub E, Ho

16、jat R. Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: success, morbidity and survival. Gynecol Oncol. 2011;123:472011.Laparoscopic Management of Ovarian Cancer Patients Journal of Minimally Invasive Gynecology, Vol 23, No 4, May/June 2016CONTENTS010302腹腔鏡在早期卵巢癌分期手術(shù)中的價(jià)值腹腔鏡在晚

17、期卵巢癌細(xì)胞減滅手術(shù)中的應(yīng)用腹腔鏡下復(fù)發(fā)性卵巢癌減瘤術(shù)的應(yīng)用及價(jià)值影像學(xué)或臨床復(fù)發(fā)考慮再次減瘤術(shù)后參加臨床試驗(yàn)或以鉑為基礎(chǔ)的聯(lián)合化療或按復(fù)發(fā)治療或支持治療化療后繼續(xù)參加臨床試驗(yàn)或部分或完全緩解者既往用過貝伐珠單抗者繼續(xù)貝伐珠單抗維持治療，或考慮尼拉帕尼、或奧拉帕尼或雷卡帕尼維持治療鉑耐藥復(fù)發(fā)參加臨床試驗(yàn)或支持治療或按復(fù)發(fā)治療首選非鉑類單藥化療生化復(fù)發(fā)可以參加臨床試驗(yàn)、或推遲至出現(xiàn)臨床復(fù)發(fā)再治療、或立即開始以鉑為基礎(chǔ)的聯(lián)合化療或支持治療。復(fù)發(fā)性上皮性卵巢癌治療原則鉑敏感復(fù)發(fā)2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南減瘤術(shù)化療或臨床試驗(yàn)或支持治療復(fù)發(fā)性少見病理組織學(xué)類型的卵巢腫

18、瘤2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南初次化療結(jié)束后612個(gè)月后復(fù)發(fā)病灶孤立可以完整切除或病灶局限無(wú)腹水手術(shù)指征2018 NCCN卵巢癌包括輸卵管癌及原發(fā)性腹膜癌臨床實(shí)踐指南Minimal access surgery can be a possible treatment option for recurrent ovarian cancer. Laparoscopy is a feasible and safe approach to optimal cytoreductionValerio Gallotta et al / Surgical EndoscopyJ

19、une 2014, Volume 28, Issue 6, pp 18081815Robotic-assisted surgery is safe and feasible approachA. Lucidi et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 45 (2017) 74e82Laparoscopic approach for spleen removal is feasible.Journal of Minimally Invasive Gynecology, Vol 23, No 3, M

20、arch/April 2016Complete removal of the recurrent disease was achieved in all patients.All postoperative complications were managed without long-term sequeale.Secondary Laparoscopic Cytoreduction in Recurrent Ovarian Cancer: A Large, Single-Institution ExperienceValerio Gallotta, et al./Journal of Mi

21、nimally Invasive Gynecology, Vol 25, No 4, May/June 2018難以達(dá)到滿意的減瘤理想的手術(shù)目標(biāo)仍是達(dá)到無(wú)肉眼殘留。即使是上腹部轉(zhuǎn)移病灶也需徹底切除。前次手術(shù)可能致盆腹腔粘連影響手術(shù)操作腹腔鏡SCS手術(shù)難點(diǎn)您的內(nèi)容打在這里，或者通過復(fù)制您的文本，在此框中選擇粘貼，并選擇只保留文字。您的內(nèi)容打在這里，或者通過復(fù)制您的文本后，在此框中選擇粘貼，并選擇只保留文字。您的內(nèi)容打在這里，或者通過復(fù)制您的文本后，在此框中選擇粘貼，并選擇只保留文字。Analysis of secondary cytoreduction for recurrent ovarian

22、 cancer by robotics, laparoscopy and laparotomyJ.F. Magrina et al. / Gynecologic Oncology 129 (2013) 336340For selected patients“Extensive recurrent disease and/or ascites were not considered candidates for minimally invasive cytoreduction”接受微創(chuàng)手術(shù)患者腫瘤負(fù)荷小、病灶少(P0.01）微創(chuàng)手術(shù)術(shù)中出血少、術(shù)后住院時(shí)間短(P0.01）組間完全減瘤率無(wú)差異組間PFS、OS無(wú)差異For selected patients“Selection was based on surgeon preference rather than tumor and/or patient characteristics,and selection was highly dependent on the individual surgeons experience with MAS.”Feasible and Safe！Minimal access surger