循证病历 实例 1

病例：

病史：患者男性，45岁，因“反复便血2月”入院。近两月前，患者无明显诱因下出现反复出现便血,呈暗红色,量不多,无发热、无恶心、呕吐，无腹痛腹胀，无肛周疼痛，大便次数增多，一天2-3次，大便成形，无大便变细。

体格检查：体温：37.2℃；脉搏：85次/分；呼吸：20次/分；血压：128/72mmHg。一般情况尚好，自动体位。皮肤巩膜无明显黄染，心肺（—）。腹部平坦，腹无压痛、反跳痛（-），肝脾肋下未触及，未及腹部肿块。双侧下肢无水肿，神经系统体征（—）。肛门指检：未及直肠肿块，指套染血。

入院后检查：B超：肝、胆、脾、胰、肾未见明显异常。电子肠镜提示：距肛约10厘米一直肠肿块，占肠腔1/3圈，取活检二处，余结肠未见明显异常。活检病理：直肠中分化腺癌。

诊断：直肠癌。

构建背景问题

P：直肠中分化腺癌男性患者

I：直肠癌根治术

C: 腹腔镜手术

O:术后并发症及癌症复发

一．提出临床问题

患者直肠癌诊断明确，治疗方式传统术式为：直肠癌根治术（Dixon）。但随着腹腔镜技术的发展，以及其给病人带来创伤少，恢复快的特点越来越引起重视。提出：像患者的病情是否适合腹腔镜手术，与开腹手术相比其根治性如何，是否安全？

二．证据检索

1.证据来源：

PUBMED和C ochrane图书馆

2.检索词和检索策略：

1.检索词：

直肠癌[rectal cancer OR rectal carcinoma]、开放手术

[open abdominoperineal resection OR open approach]腹腔镜[laparoscopic]

(2) 检索词组合：

[rectal cancer OR rectal carcinoma] AND [open abdominoperine al resection OR open approach]AND [laparoscopic]

(3) 检索结果：

A. PUBMED--Clinical Queries--Find Systematic Reviews:

共6篇,其中4篇Review,1篇META分析。

1: Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection .

Cochrane Database Syst Rev. 2008 Apr 16;(2):CD003432. Review. PMID: 18425886 [PubMed - indexed for MEDLINE]

2: Kuhry E, Saetnan E, Graeslie H, Gaupset R.

[Laparoscopic surgery for colorectal cancer]

Tidsskr Nor Laegeforen. 2007 Nov 15;127(22):2946-9. Review. No rwegian.

PMID: 18026242 [PubMed - indexed for MEDLINE]

3: Breukink S, Pierie J, Wiggers T.

Laparoscopic versus open total mesorectal excision for recta l cancer.

Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005200. Review. PMID: 17054246 [PubMed - indexed for MEDLINE]

4: Meyer C, Kanor MA, Rohr S, Reche F.

[Critical analysis of the laparoscopic approach in colorecta l surgery based on

the personal experience of 613 interventions]

Bull Acad Natl Med. 2003;187(3):507-19. Review. French.

PMID: 14556466 [PubMed - indexed for MEDLINE]

5: Bachoo P, Brazzelli M, Grant A.

Surgery for complete rectal prolapse in adults.

Cochrane Database Syst Rev. 2000;(2):CD001758. Review. Update in: Cochrane

Database Syst Rev. 2008;(4):CD001758.

PMID: 10796817 [PubMed - indexed for MEDLINE]

B.Cochrane Library：共13篇,其中Reviews 2篇,Clinical Trials 8篇Reviews:

1、Long-term results of laparoscopic colorectal cancer resection

Esther Kuhry, Wolfgang Schwenk, Robin Gaupset, Ulla Romild, H. Jaap Bonj er, Year: 2008

2、Laparoscopic versus open total mesorectal excision for rectal cancer Stephanie Breukink, Jean-Pierre Pierie, Theo Wiggers

Year: 2006

Clinical Trials 10篇:

1、

Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial.

Ng SS, Leung KL, Lee JF, Yiu RY, Li JC, Teoh AY, Leung WW

Year: 2008

2、

Patient factors influencing conversion from laparoscopically assisted to open s urgery for colorectal cancer.

Thorpe H, Jayne DG, Guillou PJ, Quirke P, Copeland J, Brown JM, Medical R esearch Council Conventional versus Laparoscopic-Assisted Surgery In Color ectal Cancer Trial Group

Year: 2008

3、

Clinical comparison of systemic stress responses between laparoscopic or op en anterior resection in rectal cancer patients with anal sphincter preservation] Zhou B-J, Zhang G-J, Duan G-Q, Zhang Z-X, Yan Q-H, Song W-Q, Cai J-H Year: 2007

4、

Lymph node clearance after total mesorectal excision for rectal cancer: laparo scopic versus open approach.

Pechlivanides G, Gouvas N, Tsiaoussis J, Tzortzinis A, Tzardi M, Moutafidis M, Dervenis C, Xynos E

Year: 2007

5、

Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3 -year results of the UK MRC CLASICC Trial Group.