腹腔镜与开腹完整结肠系膜切除术164例的临床对比研究

目的探讨腹腔镜与开腹结肠癌完整结肠系膜切除术(complete mesorectal excision,CME)在术后恢复、手术质量及中期疗效方面的差异。 方法收集滨州医学院附属淄博市中心医院腹腔镜外科2010年12月至2014年9月间实施的164例结肠癌CME手术患者的临床资料。其中腹腔镜手术组92例,开腹手术组72例,比较两组患者的术后恢复、肿瘤根治性、术后感染发生率及中期复发率方面的差异。 结果腹腔镜组在术中出血量、术后排气时间、术后下床时间、切口感染率方面均优于开腹手术组,两组患者的近端切缘、远端切缘长度及淋巴结清扫数目的差异均无统计学意义(P>0.05),两组患者在手术时间方面无统计学差异(P>0.05)。164例患者中,有134例(81.7%)接受了术后随访,中位随访时间21个月。腹腔镜组与开腹组的局部复发率分别为4.3%(4/92)和4.2%(3/72),差异均无统计学意义(P>0.05)。 结论腹腔镜结肠癌CME手术较开腹手术能显著缩短患者术后恢复时间,且能达到与开腹手术相同的肿瘤根治范围,中期复发率于开腹手术相当,有良好发展前景。     

完整结肠系膜切除术与传统根治术治疗结肠癌的疗效

结肠癌是临床常见的恶性肿瘤之一,在美国其发病率和病死率分别占恶性肿瘤的第2位和第3位[1].聂绍发等[2]早有研究提示我国普通人群中结肠癌的发病率也有逐渐增高的趋势,达到年均4％,考虑与生活水平提高、饮食习惯和饮食结构的改变、人口老龄化等因素有关.传统上,直肠癌由于局部复发率较高,预后差于结肠癌,但近年来随着全直肠系膜切除术(TME)手术的普及,预后显著改善,甚至超过了结肠癌[3,4].德国外科医生Bokey,Hohenberger在2009年提出了一种新的结肠癌规范化手术理念,称之为完整结肠系膜切除术(CME),能显著的提高结肠癌的治疗效果[5],本文通过CME与传统根治术的比较,评价CME的疗效.     

老年人结肠癌手术治疗中完整结肠系膜切除术的安全性及可行性

目的探讨完整结肠系膜切除术在老年人结肠癌手术治疗中的应用效果。方法选择120例老年结肠癌患者,随机分为观察组和对照组各60例。给予对照组传统结肠癌根治术治疗,给予观察组完整结肠系膜切除术治疗,比较两组患者的临床疗效、术后出血量和淋巴结清除术、并发症和复发情况、1年和3年生存情况。结果观察组总有效率明显比对照组46.67%(28/60)高,术后出血量明显比对照组少,淋巴结清除数明显比对照组多,术后并发症发生率和复发率均明显比对照组低,1、3年生存率均明显比对照组高(均P0.05)。结论老年人结肠癌手术治疗中完整结肠系膜切除术安全可行。     

右半结肠癌全结肠系膜切除术47例分析

目的探讨右半结肠癌完整结肠系膜切除（complete mesocolic excision,CME）在临床手术治疗中的应用。 方法回顾性分析我科2012年7月至2014年9月间手术治疗的47例右半结肠癌行CME治疗患者的临床资料。 结果47例均行CME,手术顺利,无副损伤出现,中位淋巴结清扫数为18枚,Ⅲ期病人系膜根部淋巴结阳性率为25.53%（12/47）,手术时间、出血量及并发症与我院以往的传统手术相比并无明显增加。 结论CME能够使右半结肠癌根治更合理化,系膜和淋巴结切除的更彻底,尤其是系膜根部的淋巴结清扫的更彻底,使Ⅲ期病人获益更大,而手术风险及并发症并无增加。因此,CME值得在临床中推广。     

结肠癌完整结肠系膜切除术术后远期疗效的Meta分析

目的系统评价结肠癌完整结肠系膜切除术(CME)术后复发率和生存率情况。方法全面检索维普、CNKI、万方、Pub Med、Medline、OVID、Embase、Cochrane、ISI Web of Knowledge平台等近8年来公开发表的有关CME与传统结肠癌手术比较的文献,按标准严格筛选后,评估文献质量并提取完整数据资料,最后用Review Manager5.1软件进行系统评价。结果最终共纳入5篇非随机对照试验文献,共有病例1 804例,其中CME组558例,对照组1 246例。CME术后5年内复发率约为9.99%,Meta分析结果显示,CME组术后无瘤生存率、总体生存率高于传统手术组,差异有统计学意义(P0.05)。结论 CME符合肿瘤学治疗原则,安全、可行,术后远期疗效确切,有望成为结肠癌全新的手术操作标准。     

基于CT血管造影和血管三维重建技术的肠系膜下动脉及分支临床解剖学研究

目的 应用CT血管造影(CTA)和血管三维重建技术评估肠系膜下动脉(IMA)及其分支的解剖结构、变异及走行等情况,以期为腹腔镜结直肠手术提供术前参考和术中指导.方法 采用回顾性研究的方法,收集2019年1月～2020年6月于中国医学科学院肿瘤医院结直肠外科就诊,具有完整影像资料和病历资料,能够进行血管三维重建的结直肠癌...     

腹腔镜结肠癌切除联合完整结肠系膜切除在老年结肠癌手术中的应用

目的探讨腹腔镜结肠癌切除联合完整结肠系膜切除在老年结肠癌手术中的应用。方法老年结肠癌手术患者82例,按照患者意愿进行分组,对照组41例采用开腹完整结肠系膜切除,研究组41例采用腹腔镜结肠癌切除联合完整结肠系膜切除。记录手术过程中淋巴结数量清扫状况,术前及术后指标,同时进行随访,记录生存率、局部复发及远处转移状况。结果在淋巴结清除数量上,研究组在Ⅲ期、右半结肠高于对照组(P<0.05);两组术中出血量和手术时间上无差异(P>0.05);研究组术后进食时间低于对照组(P<0.05),两组住院时间及术后并发症上无差异(P>0.05);研究组局部复发率、远处转移率、2年累积生存率(4.88%、2.44%、94.38%)与对照组(7.32%、4.88%、92.34%)相比无统计学意义(P>0.05)。结论腹腔镜结肠癌切除联合完整结肠系膜切除治疗老年结肠癌安全有效,达到淋巴组织切除最大化,获得较好的肿瘤根治效果。     

浅谈中德右半结肠癌CME手术的统一和差异

德国Hohenberger先生提出的结肠癌完整系膜切除(complete mesocolic excision,CME)手术概念,已逐渐得到我国外科医生的认可和重视。但右半结肠癌完整系膜的上缘和内侧缘在哪里更符合CME要求呢？D3手术作为右半结肠CME手术的方法合理吗？是否有更符合CME理念的右半结肠癌根治手术方法呢？笔者将腹腔镜右半结肠CME手术方法与Hohenberger先生的CME进行对比阐述,以探讨右半结肠CME手术方法的合理性。     

完整系膜切除原则下的腹腔镜降结肠癌根治术

在全直肠系膜理论的基础上,基于解剖学和胚胎学原理,提出的完整系膜切除理念治疗结肠癌,改善了预后。腹腔镜技术在结直肠外科领域的发展亦很迅猛,但降结肠癌由于发病低,操作有难度,报道较少。本文根据笔者的经验结合手术视频介绍完整系膜切除原则下的腹腔镜降结肠癌根治术。     

肠系膜下动脉不同的分支和变异在直肠癌根治术中的临床意义

肠系膜下动脉系的解剖变异对直肠癌根治术具有重要的临床意义。左结肠动脉、结肠边缘动脉弓的解剖变异要求我们在处理肠系膜下动脉时,在彻底清扫肠系膜下动脉根部至左结肠动脉根部的中央组淋巴结的同时,保留左结肠动脉主干,这样既达到了根治的目的,又有利于控制手术风险,促进手术后恢复,减少吻合口瘘等术后并发症。对乙状结肠动脉、肠系膜下静脉的解剖变异的认识提示我们在术中时刻谨慎操作,防范意外出血等并发症。     

Laparoscopic complete mesocolic excision for right-sided colon cancer using a cranial approach: anatomical and embryological consideration

Background

Complete mesocolic excision (CME) with central vascular ligation (CVL) should be employed for the treatment of colon cancer patients because of its superior oncological outcomes. However, this technique is technically challenging in laparoscopic right hemicolectomy because of the anatomical complexity of the transverse mesocolon.

Methods

We focused on the embryology and anatomy of the transverse mesocolon to overcome the difficulty of this surgery. The validity and efficacy of a cranial approach in achieving CME with CVL in laparoscopic right hemicolectomy was elucidated from the embryological point of view.

Results

In total, 28 consecutive patients with right-sided colon cancer were treated by laparoscopic right hemicolectomy using a cranial approach. There were no conversion to open surgery or switching to another approach. Using this approach, torsion and fusion of the transverse mesocolon, which occurred during embryological development, could be reversed and the complex anatomy of the transverse mesocolon could be simplified before performing CVL of colonic vessels.

Conclusions

A cranial approach is considered valid and useful for CME with CVL in laparoscopic right hemicolectomy from the embryological point of view.

     

Laparoscopic complete mesocolic excision: West meets East

Complete mesocolic excision is a relatively new concept in western literature. It follows the same concept of total mesorectal excision and units’ routinely performing complete mesocolic excisions have good pathological results as well as good improvements in overall survival, disease free survival and local recurrence. And yet unlike total mesorectal excision, uptake in the West has been relatively slow with many units sceptical of the true benefits gained by taking up a more technically challenging and potentially more morbid procedure when there is a paucity of literature to support these claims. This article reviews complete mesocolic excision for colon cancer, attempting to identify the risks and benefits of the technique and particularly looking at the reasons why its uptake has not been universal. It also discusses the similarities of a complete mesocolic excision to a colon resection with a D3 lymphadenectomy as well as the role of a laparoscopic approach to this technique. Considering a D3 lymphadenectomy has been the standard of care for stage Ⅱ and Ⅲ colon cancers in many of our Asian neighbours for over 20 years, combining this data with data on complete mesocolic excision may provide enough evidence to support or refute the need for complete mesocolic excisions. Maybe there might be lessons to be learnt from our colleagues in the east.     

Surgery along the embryological planes for colon cancer: a systematic review of complete mesocolic excision

Background

Complete mesocolic excision (CME) for colonic cancer offers a surgical specimen of higher quality, with higher number of lymph nodes compared to conventional colectomy. However, evidence on oncological outcomes is limited. The aim of the present study is to review recent literature and provide more information regarding the effect of CME colectomy on short- and long-term outcomes.

Method

PubMed and MEDLINE databases were searched, and articles in English reporting data on CME were reviewed. Intraoperative events; postoperative morbidity and mortality; histopathological characteristics, including macroscopic assessment, number, and status of retrieved lymph nodes; and oncological outcomes were the end-points.

Results

Thirty-two studies were analyzed. As regards the macroscopic assessment, a larger specimen (p = 0.02) that contains a higher number of lymph nodes (p < 0.00001) is acquired after CME. Two studies report a higher disease-free survival, in stage I and II and particularly in stage III disease after CME. CME by laparoscopy offers comparable outcomes, as regards intraoperative blood loss and immediate postoperative morbidity and mortality rates. Specimen quality is similar after either approach, for cancers located at the right and left colon, but not at the transverse colon.

Conclusion

There is strong evidence that CME offers a longer central pedicle that contains more lymph nodes than conventional surgery for colon cancer. CME represents the surgical background for the maximum lymph node harvest, an important quality marker for the surgical outcome. However, and according to present data, there is limited evidence that colectomy in terms of CME leads to improved long-term oncological outcomes.

     

Pancreatic segmentation on an embryological and anatomical basis

Limited resection of the pancreas is recommended for low-grade malignancies such as mucin-producing tumors. We propose a system of segmentation of the pancreas for the purposes of limited resection. The proposed system has an anatomical and embryological basis, and divides the pancreas into four segments, namely the anterior head, posterior head, body and tail. These segments are based on the conventional anatomical division of the pancreas, identification of the originating primordium, and distribution of the ventral and dorsal pancreas.