婦癌手術新境界 曾志仁醫師中山醫學大學附設醫院婦產科台灣女性癌症協會 Gynecologic oncologist Vice President of the Chung-Shan Medical University Hospital President of the Taiwan Women Cancer Association tsengcj@gmail.com
曾志仁醫師 Chun Shan University Hospital, 中山醫學大學附設醫院 Specialty: 中山醫學大學附設醫院副院長 婦產科癌症腫瘤 中山醫學大學附設醫院婦科主任 電子病歷 台灣女性癌症協會理事長 實證醫學與醫療品質 1 1997 年 1998 年台灣婦產科醫學會最佳論文獎全國第一名 2 2000 年台灣徐千田醫學論文獎全國第一名 3 1998 1999 2000 2001 年國科會學術研究獎 4 2005 年行政院醫療品質獎全國第一名 7 2006 年醫策會醫療品質獎全國第一名 8 2007 年國健局子宮頸癌預防篩檢品質獎全國第一名 9 2008 年醫策會實證醫學獎全國第一名
Chung-Shan Medical University Hospital 婦癌治療新趨勢 根除治療保守治療預防醫學 Advanced Operation Preserved uterus Pap smear Chemotherapy Fertility HPV test Radiation Preserved function HPV vaccine
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L 中山醫學大學附設醫院 Chung-Shan Medical University Hospital 婦癌的治療演進 Disease treatment Functional preserved Organic preserved Fertility preserved Disease prevention
子宮頸癌 (Cervical cancer) 的治療 1 Consensus: Radical hysterectomy 1. 全子宮根除手術 2. 雙側卵巢切除手術 3. 骨盆腔淋巴腺切除手術 4. 雙側輸卵管切除手術 5. 陰道部分切除手術
手術 的醫療品質 Chun Shan University Hospital, 中山醫學大學附設醫院 Find a problem 婦癌手術常見的併發症
Chun Shan University Hospital, 中山醫學大學附設醫院 手術 的醫療品質 併發症發生的原因 1. 神經破壞 2. 組織纖維化 3. 器官切除 4. 骨盆腔底結構破壞 漏尿 尿失禁 下肢水腫 便秘 性功能障礙
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L 子宮頸癌是女性健康重大的威脅 威脅生命 生育 性生活 排尿解便 性意象傷害
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L 中山醫學大學附設醫院 Chung-Shan Medical University Hospital 婦癌的治療演進 Disease treatment Functional preserved Organic preserved Fertility preserved Disease prevention
Chun Shan University Hospital, 中山醫學大學附設醫院 婦科癌症手術新發展 New technique of GYN surgery Evidence based surgical improving program 手術品質檢討 手術方法的改進 Nerve-Sparing Radical Hysterectomy in Uterine Cervical Cancer Chun Shan University Hospital, 中山醫學大學附設醫院
Chun Shan University Hospital, 中山醫學大學附設醫院 婦科癌症手術新發展 New technique of GYN surgery Evidence based surgical improving program 傳統手術品質檢討 Chun Shan University Hospital, 中山醫學大學附設醫院
Chun Shan University Hospital, 中山醫學大學附設醫院 婦科癌症手術新發展 New technique of GYN surgery Evidence based surgical improving program 傳統手術品質檢討 Chun Shan University Hospital, 中山醫學大學附設醫院
Chun Shan University Hospital, 中山醫學大學附設醫院 婦科癌症手術新發展 New technique of GYN surgery Evidence based surgical improving program 傳統手術品質檢討 Chun Shan University Hospital, 中山醫學大學附設醫院
Evidence Chun Base Medicine Shan University Center, Hospital, Chang Gung 中山醫學大學附設醫院 Memorial Hospital, Chia-Yi 證據搜尋與證據解讀 Search and Clinical Appraise Evidence based surgical improving program Systemic Review Systemic Review 傳統手術品質檢討手術品質改善計畫 Kyoto University Stanford University 神經保護手術品質改善方案 Nerve sparing surgery Nerve sparing surgery
Evidence Chun Base Medicine Shan University Center, Hospital, Chang Gung 中山醫學大學附設醫院 Memorial Hospital, Chia-Yi 文獻蒐集 證據搜尋與證據解讀 Search Evidence and Clinical Appraise 等級分類 文獻評讀 Patient Intervention Comparison Outcome 文獻等級 Review Randomized Case control Cervical Cancer Traditional operation New surgical technique Complications Disease free survival Cost-effective 篇數 2 2 3 References [19-20] [21-22] [23-25]
Nerve sparing Radical Hysterectomy 神經保護式子宮根除手術
Nerve sparing Radical Hysterectomy Technique Key Points - Preserving the inferior hypogastric plexus Clamping and transection of cardinal ligament O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L 手術品質 的實證醫學臨床運用 Evidence based surgical improving program : Nerve-Sparing Radical Hysterectomy in Cervical Cancer Chih-Jen Tseng, et al; Am J OB GYN; 2008 The Departments of Obstetrics and Gynecology, and Urology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan. A prospective case-control study in patients with cervical carcinoma Nerve-sparing radical hysterectomy vs conventional radical hysterectomy March 2005 to Nov 2009 Total of 297 patients:
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L 手術品質 的實證醫學臨床運用 Evidence based surgical improving program : Nerve-Sparing Radical Hysterectomy in Cervical Cancer Chih-Jen Tseng, et al; Am J OB GYN; 2008 The Departments of Obstetrics and Gynecology, and Urology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan. A prospective case-control study in patients with cervical carcinoma Nerve-sparing radical hysterectomy vs conventional radical hysterectomy March 2010 to June 2011 Total of 45 patients:
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Step 1: Preserving the distal part of the inferior hypogastric plexus. Identifying the nerve plexus.
Step 1: O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Preserving the distal part of the inferior hypogastric plexus.
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Step 2: Preserving the distal part of the inferior hypogastric plexus. Identifying the nerve plexus.
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Nerve Sparing Radical Hysterectomy Preserving the inferior hypogastric plexus Clamping and transection of cardinal ligament
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Preserving the distal part of the inferior hypogastric plexus Transecting the uterosacral ligament
Step 3: Transecting cardinal ligament O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Preserving the splanchnic nerve and the proximal part of the inferior hypogastric plexus.
impairing bladder function constipation sexual dysfunction
Step 4: O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Preserving the middle part of the inferior hypogastric plexus (after transected uterosacral ligament) Dissecting vesicouteral pillar
Step 5: O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Ureter dissected through tunnel Preserving the proximal part of the inferior hypogastric plexus
Step 6: Clumping and transection of vaginal cuff O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Post Op care: Bladder function
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L RESULTS Mean duration of spontaneous voiding Days NRAH (N=65) Bilateral Success 7.1 ± 1 Unilateral success* 10.0 ± 2 Failure cases 18.5 ±4 RAH (N=46) 24.9 ± 7 P=.02
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Spontaneous voiding (%)
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L RESULTS Adjuvant radiation and chemotherapy after operation NRH (N=65) RH (N=46) P value Radiation 0 0 NS Concurrent chemoradiation 8 7 NS Chemotherapy 1 1 NS
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L RESULTS After a mean length of follow-up of 46.8 months (range, 12-69 months). NRH (N=65) RH (N=46) P value Recurrence rate 9.2% (6) 10.8% (5) NS Survival 95.4% (62) 95.7% (44) NS
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Results: 5 years experience Blood loss (average: 128 ml) Blood transfusion : 5.2%. Average Op time: 2 hr 48 min (range, 132-255) Removed Foley on Day-6 No need of bladder training Successful rate: 92 %. Mean self-voiding date: the day-7
Applying 運用於臨床 Chun Shan University Hospital, 中山醫學大學附設醫院 建議合適治療條件 (1) - Stage Ia2, Ib1, IIa (2) - Tumor volume <4CM (3) - Parametrium negative 五年存活率為 92%
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L Evidence Base Medicine Center, Chang Gung Memorial Hospital, Chia-Yi 手術品質 的實證醫學臨床運用 手術併發症 手術治癒率 Assessing Study P<0.02
婦癌手術新境界 - 手術品質改善 Chun Shan University Hospital, 中山醫學大學附設醫院 Quality of Life 減低併發症保護功能保護器官生育能力性生活
O B G Y N, C H U N G S H A N M E D I C A L U N I V E R S I T Y H O S P I T A L