Costi Renato, Leonardi Francesco, Zanoni Daniele, Violi Vincenzo, Roncoroni Luigi
Renato Costi, Vincenzo Violi, Luigi Roncoroni, Istituto di Clinica Chirurgica Generale e Terapia Chirurgica, Dipartimento di Scienze Chirurgiche, Università di Parma, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy.
World J Gastroenterol. 2014 Jun 28;20(24):7602-21. doi: 10.3748/wjg.v20.i24.7602.
Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.
结直肠癌（CRC）在西方国家是一种常见的肿瘤，具有相当高的发病率和死亡率。每五名CRC患者中就有一名患有转移性疾病，在大约80%的病例中，这种疾病无法通过根治性手术治愈。传统上，IV期不可治愈的CRC患者通过手术切除原发肿瘤或造口进行治疗，在过去三十年中，其治疗方式发生了显著变化，如今采用多学科治疗，化疗（CHT）起着关键作用。后者使生存率大幅提高，而结肠和肝脏手术的作用如今仍存在争议。尽管很难一概而论，但主要考虑两种情况，即无症状（或症状轻微）患者和需要积极治疗的严重症状患者，包括急诊病例。在无症状患者中，新的CHT方案如今能使部分患者长期存活，甚至超过两年。近年来，结肠切除术在这组患者中的作用受到了挑战，因为尚不清楚切除原发性CRC是否意味着生存率进一步提高，从而证明在这类生存期短的患者中进行与手术相关的发病率/死亡率是合理的。肝转移的二次手术越来越被接受，因为在新一代CHT方案下，越来越多最初被认为不可切除的远处转移患者变得可切除，长期生存率显著提高。CRC急诊患者的治疗在西方国家仍然是一个主要问题，且与高发病率/死亡率相关。传统上，梗阻通过结肠切除术、造口术或内部旁路手术进行治疗，尽管如今CRC支架置入术是一种可行的选择。然而，CRC支架有特殊的禁忌症和并发症，其长期成本效益值得怀疑，尤其是考虑到最近生存率的提高。穿孔与最高的死亡率相关，主要仍是外科医生处理的问题，通过腹腔灌洗/引流、结肠切除术和/或造口术。出血和其他与CRC相关的症状（疼痛、里急后重等）可以通过几种微创方法进行处理，包括放疗、激光治疗和其他经肛门手术。
