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目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)根治右半结肠癌的技术可行性。方法回顾性分析2010年3月至2011年9月上海交通大学医学院附属瑞金医院行腹腔镜CME术35例的临床病理数据及视频资料,分析其安全性与技术可行性;采用West分级系统评价手术质量;通过解剖学绘图描述腹腔镜CME的手术入路,解剖层次及技术要点。结果 (1)脏层筋膜呈"信封样"包绕整个结肠系膜,需超声刀锐性分离脏壁层筋膜,达到血管根部结扎与完整系膜切除。(2)中间入路以回结肠血管解剖投影为起步点,沿肠系膜上静脉为主线解剖血管,进入Told与肾前筋膜间的天然外科平面。(3)盲肠及升结肠癌,需清扫回结肠、右结肠及结肠中血管根部淋巴结;结肠肝曲癌,还需清扫No.6淋巴结及切除距肿瘤以远10～15cm胃大弯侧胃网膜。(4)35例均成功完成腹腔镜下CME;手术质量等级判定C级33例;中位清扫淋巴结数19(15～25)枚,Ⅲ期病人系膜根部淋巴结阳性25%;中位手术时间2.6(2～4)h,术中出血80(50～300)mL,术后排气时间2(1～4)d,住院时间12(6～20)d;术后发生肺部感染1例,出血1例,乳糜漏1例。结论 CME为基于胚胎解剖学与肿瘤外科学的新理念,有望成为规范化手术方式;中间入路腹腔镜下CME技术上可行,是否改善远期疗效有待对照研究证实。     

Laparoscopic complete mesocolic excision for right colon cancer

Laparoscopic colectomy for colon cancer has become a standard of care, with a number of publications highlighting its safety, improved postoperative recovery, and excellent oncologic outcomes. Complete mesocolic excision, recently reemphasized, is associated with superior oncologic outcomes, although this has not been discussed for laparoscopic surgery. A laparoscopic approach was performed for right colon cancer using a four-trocar technique. The key steps demonstrated are identification and high division of the ileocolic pedicle, medial-to-lateral mobilization of the ascending colon preserving the posterior mesocolic fascia, identification and high division of the right branch of the middle colic artery, mobilization of the greater omentum and hepatic flexure, completion of lateral mobilization of the ascending colon from the retroperitoneum, and mobilization of the small bowel mesentery up to the duodenum. A prospective series of 52 consecutive patients with right colon cancer underwent laparoscopic complete mesocolic excision with high-vessel ligation. Four of the patients required laparoscopic en bloc extended resections for local invasion. The median operative time was 136 min (interquartile range [IQR], 105–167 min), and the median blood loss was 20 ml (IQR, 10–45 ml). The median hospital stay was 3 days (IQR, 3–5 days). All the patients had an R0 oncologic resection with median margins of 12 cm, and a median of 22 lymph nodes (IQR, 18–29 lymph nodes) was retrieved. The median follow-up period was 38 months (IQR, 23–54 months). Of 14 patients with tumor-positive lymph nodes, 2 experienced distant recurrence. There were no local recurrences, but four patients experienced metastatic disease at a median of 37 months (IQR, 22–46 months). The median overall survival time was 38 months (IQR, 23–54 months). The embedded didactic video demonstrates a straight laparoscopic complete mesocolic excision with high-vessel ligation for a patient who had a right colon cancer. Laparoscopic right complete mesocolic excision is a safe and effective procedure associated with excellent 3-year oncologic outcomes and accelerated postoperative recovery.     

腹腔镜下完整结肠系膜切除在左半结肠癌根治术中的应用

目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)在左半结肠癌手术中的应用。方法回顾性分析2010年8月至2014年9月间42例行腹腔镜下 CME 治疗左半结肠癌病人的临床资料。结果本组所有病人手术均获成功,手术时间平均为(112.2±25.3) min,术中出血量平均为(54.4±21.6)ml;手术切除肠管的长度平均为(24.1±5.7)cm,清扫淋巴结数量平均为(18.5±6.2)枚;术后肛门首次排气平均时间为(3.3 ± 1.4)d,平均住院时间为(12.7±3.5)d,术后并发症发生4例,发生率为9.52%,其中切口感染 2例,肺部感染1例,吻合口出血1例,均经保守治疗后恢复。结论腹腔镜下左半结肠癌 CME 手术是安全可行的。     

Laparoscopic complete mesocolic excision via combined medial and cranial approaches for transverse colon cancer

Purpose

To evaluate the safety and feasibility of laparoscopic complete mesocolic excision via combined medial and cranial approaches with three-dimensional visualization around the gastrocolic trunk and middle colic vessels for transverse colon cancer.

Methods

We evaluated prospectively collected data of 30 consecutive patients who underwent laparoscopic complete mesocolic excision between January 2010 and December 2015, 6 of whom we excluded, leaving 24 for the analysis. We assessed the completeness of excision, operative data, pathological findings, length of large bowel resected, complications, length of hospital stay, and oncological outcomes.

Results

Complete mesocolic excision completeness was graded as the mesocolic and intramesocolic planes in 21 and 3 patients, respectively. Eleven, two, eight, and three patients had T1, T2, T3, and T4a tumors, respectively; none had lymph node metastases. A mean of 18.3 lymph nodes was retrieved, and a mean of 5.4 lymph nodes was retrieved around the origin of the MCV. The mean large bowel length was 21.9 cm, operative time 274 min, intraoperative blood loss 41 mL, and length of hospital stay 15 days. There were no intraoperative and two postoperative complications.

Conclusion

Our procedure for laparoscopic complete mesocolic excision via combined medial and cranial approaches is safe and feasible for transverse colon cancer.

     

结肠癌完整结肠系膜切除术的可行性与安全性的Meta分析

目的评价结肠癌完整结肠系膜切除术（CME）的可行性与安全性。方法计算机检索万方、CNKI、CBM、维普、PubMed、Medline、OVID、Elsevier、IsIWebofKnowledge平台（SCI、ISIP、CCR、IC）和Cochrane等近5年来公开发表的有关CME与传统结肠癌手术的随机对照试验（RCT）或非随机对照试验（RNT）文献,严格按标准筛选后,评估文献质量并提取数据资料,最后用ReviewManager5．1软件进行系统评价。结果共纳入8篇非随机对照试验文献。计有病例1209例,其中CME组615例,对照组594例。Meta分析结果显示：（1）CME在术中出血量少于传统手术（WMD=-13．05,95％CI：-25．03—1．07,P=0．03）,在手术时间上两组差异无统计学意义（WMD=O．46,95％CI：-26．50～27．41,P=0．97）;（2）CME在术后病理标本淋巴结检出数、平均切除结肠长度和系膜面积以及营养血管长度等方面均优于传统结肠癌手术（分别为P〈0．01、P〈0．01、P〈0．01和P〈0．05）;（3）两组术后首次排气时间和住院时间差异无统计学意义（P=0．87,P=0．05）;（4）CME并没有增加手术并发症发生率（P=0．74）。结论CME符合胚胎解剖学、肿瘤外科学和精细外科学理念,安全、可行．有望成为结肠痛规范化的手术方式．     

腹腔镜右半结肠癌CME根治术与策略

相对传统右半结肠癌手术,完整全结肠系膜切除(CME)手术可以提供高质量的手术标本和更多的淋巴结清扫数目。因此,腹腔镜右半结肠癌CME根治术既结合了腔镜手术的微创性又兼具CME手术的肿瘤根治性。右半结肠因解剖结构复杂、比邻器官众多、血管变异等因素,手术难度较大。高质量腹腔镜右半结肠癌CME手术的完成需要术者丰富的腹腔镜操作经验与技巧、扎实的解剖学知识和助手的良好配合。腹腔镜右半结肠癌CME手术目前没有标准的手术方式,因此本文拟从右半结肠CME概念、手术适应证、手术步骤、外科操作平面及中央组淋巴结清扫边界等方面介绍腹腔镜右半结肠CME手术的相关内容及注意事项。     

尾侧入路腹腔镜右半结肠癌CME术

主要步骤包括:(1)腹腔探查;(2)右结肠后间隙(RRCS)拓展:进入Told筋膜与结肠系膜间的天然外科平面。至结肠肝曲水平,同时向内侧暴露十二指肠,此为进入横结肠后间隙(TRCS)的标志。(3)中间入路结扎肠系膜血管:以回结肠血管(ICV,ICA)在肠系膜表面投影为解剖标志打开结肠系膜,可轻易与其后方已打开的RRCS间隙相汇合。以肠系膜上静脉(SMV)为主线,清扫外科干,进一步解剖Henle’s干及其分支。(4)幽门下淋巴结清扫;(5)消化道重建。本文对由外周入路和中间入路发展而来的尾侧联合中间入路进行了简要介绍,该术式技术上可行,术者操作相对简便,手术安全性高,可供结直肠外科医生参考。     

结肠癌切除标准化手术——全结肠系膜切除术

为了将结肠癌切除术标准化,学者们提出了全结肠系膜切除(CME)的概念,即在直视下连续锐性分离,将脏层筋膜层从壁层分离,获得被脏层筋膜层完全包被的整个结肠系膜,保证安全地暴露并结扎供血动脉起始部.CME的核心目的是通过标准化的手术步骤,最大化地清扫肿瘤负载区域的淋巴结,从而进一步提高结肠癌的手术疗效.CME的肿瘤学优势为保证获得由完整结肠系膜包被的肿瘤标本,防止因结肠系膜内血管及淋巴引流暴露而增加肿瘤播散的概率;从根部结扎血管可以保证获得最多的淋巴结检出数量.初步研究显示,CME并血管高位结扎可以明显提高Ⅲ期患者的疗效,对于其他分期患者的疗效有待进一步研究.目前尚未得出腹腔镜是否适合行CME手术的结论.     

结肠癌切除标准化手术——全结肠系膜切除术

为了将结肠癌切除术标准化。学者们提出了全结肠系膜切除（CME）的概念,即在直视下连续锐性分离,将脏层筋膜层从壁层分离,获得被脏层筋膜层完全包被的整个结肠系膜,保证安全地暴露并结扎供血动脉起始部。CME的核心目的是通过标准化的手术步骤,最大化地清扫肿瘤负载区域的淋巴结,从而进一步提高结肠癌的手术疗效。CME的肿瘤学优势为保证获得由完整结肠系膜包被的肿瘤标本,防止因结肠系膜内血管及淋巴引流暴露而增加肿瘤播散的概率：从根部结扎血管可以保证获得最多的淋巴结检出数量。初步研究显示,CME并血管高位结扎可以明显提高Ⅲ期患者的疗效,对于其他分期患者的疗效有待进一步研究。目前尚未得出腹腔镜是否适合行CME手术的结论,     

完整结肠系膜切除治疗结肠癌初步分析

目的:探讨完整结肠系膜切除(CME)在结肠癌手术治疗中的应用.方法:回顾性分析2009年12月-2012年6月行CME和中央血管高位结扎(CVL)的34例结肠癌患者临床资料.结果:患者术后UICC病理分期:Ⅰ期4例,Ⅱ期14例,Ⅲ期16例.中位淋巴结清扫数18枚,Ⅲ期患者中18.8％ (3/16)的系膜根部淋巴结转移阳性.全组无围术期死亡,无术中副损伤.手术时间2.5～3.5(中位数2.75)h,术中出血量80～200(中位数110)mL,术后排气时间3～5(中位数4)d,排便时间4～6(中位数5)d,术后住院时间11～20(中位数14)d.术后并发症包括切口感染3例,肺部感染1例,乳糜漏1例,无吻合口瘘发生,近期无肠梗阻发生.34例患者获6个月至2年的随访,未发现局部复发;1例术后16个月发现肝转移,3个月后死亡.结论:结肠癌患者行CME联合CVL安全、可行,短期效果良好,CME联合CVL有可能成为一种标准化的结肠癌手术术式.     

结肠癌完整结肠系膜切除术的学习曲线

目的探讨结肠癌完整结肠系膜切除术（CME）的学习曲线。方法回顾性分析2009年11月至2011年6月间,在北京大学人民医院胃肠外科接受CME手术的75例结肠癌患者的临床资料,按手术先后依次分A、B、C3组,每组25例。结果3组病例一般资料的比较差异均无统计学意义（均P〉0．05）。A、B、C3组患者手术时间依次递减,A组显著长于B组和C组[（205．4±53．2）rain比（180．4±29．7）min和（169．8±4113）rain,P〈0．05];3组住院时间也依次递减,A组也显著长于B组和C组[（17．8±10．9）d比（12．9±4．1）d和（11．0±3．5）d,P〈0．05]。C组患者术后并发症发生率（8％,2／25）明显低于A组（32％．8／25）和B组（36％,9／25）（P〈0．05）。C组患者手术标本的质量明显优于A组（大体标本WESTC级以上例数分别为20例和11例,P〈0．05）。3组术中出血量、肛门排气时间、术后进食时间、淋巴结检获数方面的差异均无统计学意义（均P〉0．05）。结论结肠癌CME手术的学习曲线大约为25例,即可达到较熟练程度。     

Laparoscopic right hemicolectomy with complete mesocolic excision

Background

Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided.

Methods

A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study.

Results

There was no conversion to open surgery. The median operation time was 192 min (interquartile range [IQR] 118–363 min). The median proximal and distal resection margins were 11 and 10 cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3–88). There were six postoperative complications (4.6 %). The median hospital stay was 5 days (IQR 4–37 days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer.

Conclusion

In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.     

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer:A comprehensive review

Aim of the study is to comprehensively review the latest trends in laparoscopic complete mesocolic excision(CME) with central vascular ligation(CVL) for the multimodal management of right colon cancer. Historical and up-to-date anatomo-embryological concepts are analyzed in detail,focusing on the latest studies of the mesenteric organ,its dissection by mesofascial and retrofascial cleavage planes,and questioning the need for a new terminology in colonic resections. The rationale behind Laparoscopic CME with CVL is thoroughly investigated and explained. Attention is paid to the current surgical techniques and the quality of the surgical specimen,yielded through mesocolic,intramesocolic and muscularis propria plane of surgery. We evaluate the impact on long term oncologic outcome in terms of local recurrence,overall and disease-free survival,according to the plane of resection achieved. Conclusions are drawn on the basis of the available evidence,which suggests a pivotal role of laparoscopic CME with CVL in the multimodal management of right sided colonic cancer: performed in the right mesocolic plane of resection,laparoscopic CME with CVL demonstrates better oncologic results when compared to standard non-mesocolic planes of surgery,with all the advantages of laparoscopic techniques,both in faster recovery and better immunological response. The importance of minimally invasive mesoresectional surgery is thus stressed and highlighted as the new frontier for a modern laparoscopic total right mesocolectomy.     

腹腔镜右半结肠癌全结肠系膜切除术的安全性与可行性分析

目的:探讨腹腔镜右半结肠癌全结肠系膜切除术的安全性与可行性。方法:将90例右半结肠癌患者按手术方法分为腹腔镜组与开腹组,观察两组患者术中、术后相关指标,探讨两种术式的近期疗效及肿瘤根治性。结果:两组手术时间、术中出血量、淋巴结清扫数量差异无统计学意义(P>0.05);腹腔镜组术后下床活动时间、排气时间、住院时间及术后并发症发生率明显优于开腹组,差异有统计学意义(P<0.05);两组术后1年、3年生存率及局部复发率、远处转移率差异均无统计学意义(P>0.05)。结论:腹腔镜全结肠系膜切除术具有疗效满意、术后康复快等优点,在掌握手术适应证、手术原则、手术技巧的前提下,腹腔镜辅助全右半结肠系膜切除术是安全、有效、可行的,对促进患者术后康复、提高近期生存率具有积极意义。     

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目的探讨完整结肠系膜切除(complete mesocolic excision,CME)在老年结肠癌病人手术治疗中的应用价值。方法回顾性分析2011-01-31至2011-12-31,就诊于吉林大学第二医院基本外科同一手术治疗组老年结肠癌病人的临床资料。36例行CME手术治疗(为CME组),28例行传统根治术治疗(为对照组),比较两组手术效果。结果 CME组与对照组淋巴结清扫数量分别为(22.4±3.3)枚、(19.5±3.1)枚,两组比较差异有统计学意义(P=0.001);Ⅲ期淋巴结清扫数量CME组为(23.8±3.8)枚,对照组为(20.7±2.7)枚,差异有统计学意义(P=0.010),Ⅲ期淋巴结阳性数CME组为(3.4±2.3)枚,对照组为(2.1±1.4)枚,差异有统计学意义(P=0.047)。CME组术中出血量少于对照组,差异有统计学意义(P=0.020)。手术并发症发生率比较差异无统计学意义(P=0.628)。结论老年结肠癌病人应用CME优于传统手术方式,不增加手术风险及术后并发症发生率。     

完整结肠系膜切除术后四例乳糜漏临床分析

目的 总结完整结肠系膜切除术所致4例乳糜漏诊治经验.方法 回顾性分析2009年11月至2011年12月收治的61例因结肠癌行完整结肠系膜切除术中4例术后并发乳糜漏患者的临床资料.结果 61例患者中有4 例术后发生乳糜漏,发生率为6.6%,右半结肠发生率100%,肿瘤分期Ⅱ期3例,Ⅲ期1例.发生乳糜漏的时间平均为术后第5(4～6)天,每日最大引流量285～490 ml,平均380 ml.全部患者经保守治疗痊愈.结论 完整结肠系膜切除术后乳糜漏多发生在右半结肠,以Ⅱ期、Ⅲ期结肠癌为主.避免发生术后乳糜漏应以术中预防为主;治疗首选支持及保守治疗.     

高龄结肠癌患者接受完整结肠系膜切除术的可行性研究

目的探讨高龄结肠癌患者接受完整结肠系膜切除术（CME）的短期疗效和安全性。方法回顾性分析北京大学人民医院胃肠外科2009年11月至2012年2月间接受CME治疗的71例结肠癌患者的临床资料,以70岁为界点分为高龄组（大于或等于70岁．37例）和非高龄组（小于70岁,34例）,比较两组患者的短期疗效和安全性。结果高龄组与非高龄组结肠癌患者CME手术切除系膜面积分别为（13049±4332）mmz和（13163±4725）mm2,高位结扎血管距肠壁距离为（95±22）mm和（98±20）mm,高位结扎血管距肿瘤距离为（130±25）mm和（128±25）mm,结肠切除长度（262±60）mm和（245±49）mm,淋巴结清扫数目为（22．0±6．4）枚和（24．8±9．9）枚,差异均无统计学意义（均P〉0．05）。两组患者手术时间、术中出血量、术后主要并发症、排气时间、排粪时间、引流管拔除时间、恢复进食时间、术后3d引流量、住院死亡等安全性指标的差异亦无统计学意义（均P〉0．05）,但高龄患者住院时间和住院费用明显增加（均P〈0．01）。结论高龄结肠癌患者接受择期CME手术可以达到与非高龄组患者一致的肿瘤切除及淋巴结清扫效果．且手术安全性良好．     

两种全结肠系膜切除术治疗右半结肠癌的临床疗效与安全性评价

目的探讨腹腔镜全结肠系膜切除术(LCME)与开腹全结肠系膜切除术(OCME)在治疗右半结肠癌上的临床效果及安全性。 方法回顾性分析2015年6月至2017年12月同期右半结肠癌患者共75例,按照手术方式不同分为LCME组36例,OCME组39例,应用SPSS20.0统计学软件对数据进行统计分析,术中术后指标以均数±标准差形式表示,采用独立t检验;两组术后并发症发生率组间比较采用χ²检验;P<0.05代表差异有统计学意义。 结果两组患者在手术时间、淋巴结清扫数量和术后并发症方面差异无统计学意义;LCME组术后出血量、术后肛门排气时间、术后首次进食时间显著低于OCME组(P<0.05)。两组术后并发症发生率比较,差异无统计学意义(P>0.05)。 结论LCME在治疗右半结肠癌上有利于患者术后恢复,更加安全有效,是治疗右半结肠癌首选的术式方案。     

腹腔镜右半结肠癌CME手术技巧

当腹腔镜结直肠手术普及的同时,完整全结肠系膜切除(CME)理念也逐渐成为右半结肠癌根治手术的标准。腔镜下完成CME手术涉及较为复杂的解剖结构,中央淋巴结的清扫可能带来潜在的风险,规范手术步骤、熟悉血管解剖,可以缩短学习曲线,减少并发症的发生。从解剖位置恒定的回结肠血管开始,完成肠系膜上静脉的裸化,直至完整游离右半结肠系膜,是目前国内外广泛采用的手术步骤。精细解剖可以减少出血,防止手术野的模糊,清晰分辨解剖层次,可以顺利完成手术过程。