腹腔镜与开腹全直肠系膜切除术治疗中低位直肠癌的对比研究

目的:探讨腹腔镜全直肠系膜切除术治疗中低位直肠癌的临床疗效与安全性。方法:回顾分析121例中低位直肠癌患者的临床资料,将其分为腹腔镜全直肠系膜切除术组(观察组,n=67)与开腹全直肠系膜切除术组(对照组,n=54),比较两组手术及术后相关指标、预后指标、并发症发生情况。结果:观察组手术保肛率、术中出血量、肛门排气时间、切口愈合时间、术后住院时间及并发症总发生率均显著优于对照组,差异有统计学意义(P0.05);两组淋巴结清扫数量、肿瘤下缘与远切缘距离、局部复发率、远处转移率及3年生存率差异无统计学意义(P0.05)。结论:腹腔镜全直肠系膜切除术治疗中低位直肠癌较开腹手术具有明显的微创优势,术后并发症少,安全、可行,临床疗效及预后与开腹手术相当。     

Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer

OBJECTIVE: To evaluate comparative outcome between adjuvant postoperative chemoradiotherapy (postoperative CRT) and lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in rectal cancer patients. BACKGROUND: Although TME results in lower rate of locoregional recurrence compared with conventional surgery, these 2 treatment modalities following TME have not adequately been appraised until the present trend of preoperative chemoradiotherapy. PATIENTS AND METHODS: Between 1995 and 2000, patients with stage II and III rectal cancer underwent TME plus postoperative CRT (n = 309) or LPLD (n = 176). Patients in the postoperative CRT group received 8 cycles of 5-fluorouracil plus leucovorin and 45 Gy pelvic radiotherapy. Patients in the LPLD group underwent lateral lymph node dissection outside the pelvic plexus. RESULTS: The 5-year overall and disease-free survival rates were 78.3% and 67.3% in the postoperative CRT group, respectively, and 73.9% and 68.6% in the LPLD group, respectively, without significant differences between these groups. Patients in the LPLD group with stage III lower rectal cancer had a locoregional recurrence rate 2.2-fold greater than those in the postoperative CRT group (16.7% vs. 7.5%, P = 0.044). Multivariate analysis showed that APR and advanced T-category (T4) were significantly associated with locoregional recurrence, whereas lymph node metastases, high preoperative serum carcinoembryonic antigen, and APR were significantly associated with shortening of disease-free survival. CONCLUSIONS: Postoperative-CRT and LPLD following TME resulted in comparable survival rates, but the locoregional recurrence rate was higher in the LPLD group. These findings suggest that initial surgery is appropriate for rectal cancer patients who are candidates for low anterior resection without extensive local disease (T1-T3), regardless of lymph node status.     

Treatment of the early form of rectal carcinoma in the elderly

The early rectal cancer which needs conservative surgical treatment should present some pathological characters: intramucosal site without muscularis invasion (pT1), high or moderate differentiated grading (GI-G2), no lymph node metastasis or vascular invasion. Total mesorectal excision is the gold standard for these neoplasms and permits very low resection or colo-anal anastomosis with sphincter function preserving. However, this type of surgery has still a high percentage of postoperative morbidity and mortality (some authors report respectively 40% and 5%). Therefore the local excision in selected cases is able to preserve the sphincter function and to reduce the postoperative complications with high probability of recovery.     

Clinical significance of macroscopic completeness of mesorectal resection in rectal cancer

Aim Local recurrence after resection of rectal cancer is usually regarded as being due to a ‘failure’ of surgery. The completeness of resection of the mesorectum has been proposed as an indicator of the ‘quality’ of the resection. We determined the prognostic value of macroscopic evaluation of rectal cancer resection specimens and the circumferential resection margin (CRM) after curative surgery. Method From 1999 to 2006, the macroscopic quality of the mesorectum and the CRM were prospectively assessed in 127 patients who underwent rectal cancer resection with curative intent (R0+R1). Chemoradiotherapy was administered for 61 tumours staged as locally advanced tumours (T3, T4 and N+). Univariate analysis of time to local recurrence and cancer‐free survival were tested (Kaplan–Meier) and multivariate analysis calculated with a Cox regression model. Results The mesorectum was incomplete in 34 (26.8%) patients. At a median follow up of 34 months (range, 9–96 months), in the group with an adequate mesorectal excision, the cumulative risk of local recurrence at 5 years was 10%. This was 25% if the mesorectum was incomplete (P < 0.01). Five‐year cancer‐free survival was 65% if the mesorectal excision was adequate and 47% if it was not (P < 0.05). Multivariate analysis identified T status, the CRM and the mesorectal score as independent factors for local recurrence, and T and N status and the mesorectal score as independent factors for disease‐free survival. Conclusion The outcome of surgical treatment of rectal cancer is related to the completeness of mesorectal excision. It is a more discriminative prognostic factor than the classic tumour–node–metastasis (TNM) system.     

腹腔镜与开腹直肠癌根治术的对照研究

目的:评价腹腔镜直肠癌根治术的临床应用价值及疗效。方法:回顾分析77例直肠癌患者的临床资料,其中35例行腹腔镜直肠癌根治术,42例行开腹直肠癌根治术。对比分析两组患者术中失血量、手术时间、术后恢复情况、术后并发症、直肠全系膜切除情况、淋巴结清除数量、保肛率、术后排尿功能等。结果:77例直肠癌根治术均获成功,腹腔镜组无一例中转开腹。术中出血量、术后下床活动时间、胃肠功能恢复时间、直肠系膜切除质量腹腔镜组显著优于开腹组;手术时间腹腔镜组长于开腹组;保肛率、淋巴结清除数量、术后并发症发生率及术后排尿功能两组差异无统计学意义。结论:腹腔镜直肠癌根治术微创、安全、有效,患者术后下床活动时间、胃肠功能恢复、住院时间及术中失血量、直肠系膜切除质量均优于开腹手术。     

��Ѫ�������·��ǻ���е�λֱ�����෽�ܰͽ���ɨ72���ٴ�����

??Lateral lymph node dissection via lateral vascular approach with en-bloc dissection of laparoscopic total mesorectal excision for advanced middle and low rectal cancer LIANG Jian-wei, LIU Qian, ZHOU Si-cheng, et al. National Cancer Center & National Clinical Research Center for Cancer & Cancer Hospital??Chinese Academy of Medical Sciences and Peking Union Medical College??Beijing 100021??China
Corresponding authors: LIU Qian??E-mail: fcwpumch@163.com??WANG Xi-shan??E-mail: wxshan1208@126.com
Abstract Objective To investigate the feasibility and safety of the en-bloc resection via lateral vascular approach combined with lateral lymph node dissection (LLND). Methods The clinical and pathological data of 72 cases of laparoscopic total mesorectal excision resection of rectal cancer combined with LLND via lateral vascular approach were retrospectively analyzed. There were 38 cases of preoperative chemoradiotherapy??9 patients with neochemotherapy??25 cases without preoperative treatment. All patients were diagnosed with lateral lymph node metastasis by MRI or PET-CT before treatment. The first step of LLND was performed by the distal of external iliac artery??then high ligation the inferior mesenteric vascular and opened the left Toldt’ space??and the final step was the total mesorectal excision. All of the spacemen were en-bloc dissection of the later lymph node with the rectal cancer. Results There were 19 cases of bilateral LLND??28 cases with unilateral left LLND??25 cases on the right side. The harvested pelvic lymph node detection was 8.3??19.4% of lateral lymph node metastasis rate??14/72????12 cases of unilateral lateral lymph node metastasis??2 cases of bilateral metastasis??and 7 patients combined viscera resection??9.7%??. The operative time was 281.4??145~600??min and the intraoperative blood loss was 89.7??30~1200??mL. A total of 11 cases??15.3%??had surgical complications and no surgical death. The positive rate of lateral pelvic lymph node in preoperative chemoradiotherapy patients was 23.7% ??9/38????and 22.2%??2/9??in the neochemotherapy group. Conclusion Laparoscopic resection of rectal cancer combined with LLND via transvascular lateral approach is safe and feasible??and not increase in operative complications.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

经血管外侧入路腹腔镜中低位直肠癌侧方淋巴结清扫72例临床分析

目的 探讨血管外侧入路腹腔镜直肠癌侧方淋巴结清扫（LLND）的可行性和安全性。方法 回顾性分析2016年10月至2018年6月中国医学科学院肿瘤医院收治的行经血管外侧入路腹腔镜直肠癌LLND的72例病人的临床资料。术前同步放化疗38例,术前单纯化疗9例,25例术前未进行治疗,治疗前均经MRI或PET-CT检查诊断为侧方淋巴结转移。采用经髂外动脉远端入路行淋巴结清扫,高位结扎切断肠系膜下动脉并按全直肠系膜切除原则行直肠癌根治术,所有病人均完成清扫后再完成直肠切除,标本均达到整块切除。结果 19例病人行双侧LLND,28例行左侧LLND,25例行右侧LLND。平均侧方淋巴结检出数目为（8.3±6.2）枚;侧方淋巴结转移14例（19.4%）,其中单侧转移12例,双侧转移2例。联合器官切除7例。手术时间为281.4（145~600）min,术中出血89.7（30~1200）mL。11例（15.3%）病人出现手术并发症,无手术死亡。术前同步放化疗病人侧方淋巴结阳性率为23.7%（9/38）,术前单纯化疗病人侧方淋巴结阳性率为22.2%（2/9）。结论 血管外侧入路腹腔镜中低位直肠癌LLND不增加手术并发症,安全可行。     

经肛门全直肠系膜切除术研究进展

低位直肠癌的治疗方式不仅仅要考虑肿瘤的完整切除,保留肛门生理功能也是一个至关重要的问题。随着对直肠肛管以及盆底肌肉神经局部解剖生理研究的深入,伴随医疗技术的进步,针对低位直肠癌保肛的各种手术方式应运而生,目前较为成熟的手术方式主要有结肠肛管吻合术（Parks术）、经括约肌间切除术（ISR）、经肛门全直肠系膜切除术（TaTME）等。其中,TaTME是体现经自然腔道内镜外科手术（NOTES）的一种理念和手术方式。目前关于TaTME在直肠恶性肿瘤中应用的安全性及有效性在国际上尚存在一定争议,本综述旨在通过查阅国内外现有关于TaTME的相关文献,总结探讨TaTME在低位直肠癌治疗中的安全性、有效性以及未来的发展趋势。     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

Multi-modality approach in curative local treatment of early rectal carcinomas

Objective Despite recent advances, surgery remains the mainstay for the management of rectal carcinoma. The conventional surgical treatment for low rectal carcinoma is total mesorectal excision. This results in either abdomino‐perineal excision of the rectum (APER) with permanent colostomy or low anterior resection (LAR) usually with a covering stoma. Local resection is an alternative treatment option and this could be offered either using manual trans‐anal resection (TAR) or transanal endoscopic microsurgery (TEM) if the tumour is situated higher. Patients Patient selection is an important factor if local resection is used. No further treatment is necessary for T1 tumours with clear surgical resection margins. Conventional radical surgery should be offered for T1 tumours with close resection margins (<1 mm) or T2 tumours with higher risk of lymph node metastases. Patients were treated by postoperative chemo‐radiotherapy or radiotherapy, if further radical surgery was not considered appropriate or if the patient refused further surgery. Using this approach, we describe our experience of 100 patients treated from January 1992 to June 2002. Results Only 13 patients had surgery alone and 87 patients had radiotherapy either pre‐operative (33 patients), postoperative (25 patients) or radical radiotherapy alone (29 patients). Local recurrence occurred in 10% of patients and salvage surgery was offered in over half (6 patients) of these patients. At median follow up of 33 months (range 3–120 months), the overall survival was 77% reflecting the fact that the majority of these patients were elderly with coexisting medical problems. However, cancer specific survival was 96%. More importantly, only 9 patients had colostomies and colostomy‐free survival in our cohort of patients from Liverpool was 91%. Conclusion We concluded that in selected patients, who were not medically fit (ASA 111 or above) or those who were unable to accept a permanent colostomy, local treatment could be offered with curative intent using a multimodality approach. In our experience, relapses can be salvaged effectively and we recommend a long‐term close follow up policy.     

Indications for and limitations of low anterior resection

The indications for low anterior resection are based mainly on tumor location, penetration depth, histology, macroscopic appearance, etc. Patients with tumors located 2 cm above the puborectal muscle by digital examination can undergo low anterior resection. Distal surgical margins should be at least 1 cm from the tumor in cases of differentiated cancer and localized tumors of stage T2 or less and more than 2 cm in poorly differentiated cancer and tumors of stage T3 or greater with total mesorectal excision (TME). Longer distal surgical margins should be provided in patients with unlocalized tumors and extensive node metastasis. The final decision on whether low anterior resection is appropriate should be made after mesorectal preparation down to the levator muscles with adequate surgical margins. Low anterior resection is contraindicated in patients with poor anorectal function and high age. A rectal stump 1 to 2 cm from the dentate line should be maintained for better postoperative anorectal function if radical excision can still be performed.     

溶脂法研究直肠癌在直肠远端系膜内的播散

目的 研究直肠癌在直肠远端系膜内播散的规律.方法 收集直肠癌根治手术标本60例,整体平铺用溶脂法处理后,绘制淋巴结分布图,逐个定位、计数淋巴结及癌转移结节,显微镜下观察其转移规律.结果 直肠癌在直肠远端系膜的播散方式主要为淋巴结转移和癌转移结节形成,远端系膜总播散率为13%（8/60）,淋巴结播散率为10%（6/60）,癌结节播散率为7%（4/60）,播散最远距离为4.5 cm.肿瘤大体类型、组织学类型和浸润深度是影响直肠癌远端系膜淋巴结播散的因素.肿瘤部位及Dukes分期是影响直肠癌远端系膜癌转移结节播散的因素.结论 利用溶脂法能全面客观地观察直肠远端系膜内癌组织的播散规律.直肠癌手术远端系膜切除距肿瘤下缘不应少于4.5 cm或行全系膜切除.     

经肛门全直肠系膜切除和腹腔镜全直肠系膜切除对直肠癌的疗效对比

目的分析比较经肛门全直肠系膜切除（TaTME）与腹腔镜全直肠系膜切除（LaTME）在中低位直肠癌治疗中的疗效及预后。 方法选择东营市东营区人民医院2015年2月至2016年2月收治的64例择期行全直肠系膜切除术（TME）的中低位直肠癌患者，随机分为TaTME组与LaTME组，各32例。观察并比较两组患者的手术时间、术中出血量、标本完整率、环周切缘（CRM）阳性率、远端切缘（DRM）阴性率、淋巴结清扫数目、保肛率、中转开放手术率、术中及术后并发症、术后住院时间、局部复发率、远处转移率、2年总体生存率（OS）各指标间的差异。 结果TaTME组患者的术中出血量、中转开放手术率、手术时间、标本完整率、CRM阳性率、保肛率、术后住院时间、尿潴留发生率均显著优于LaTME组（均P<0.05）。患者均获随访2~24个月，TaTME组中位生存时间为23.9个月，局部复发率、转移率分别为6.2%（2/32）、3.1%（1/32）。LaTME组中位生存时间为19.7个月，局部复发率、转移率均为3.1%（1/32）。两组术后复发率、转移率比较，差异无统计学意义（χ²=0.350、0.516，P=0.554、0.472）。TaTME组与LaTME组1年OS分别为100.00%、93.75%，2年OS分别为96.87%、81.25%。两组1年OS比较，差异无统计学意义（χ²=0.516，P=0.472），TaTME组的2年OS显著高于LaTME组患者（χ²=4.402，P=0.036）。 结论与LaTME术相比，TaTME术治疗中低位直肠癌具有较高的安全性和有效性，且术后并发症较少，术后住院时间短，可以改善患者预后。     

Quality of mesorectum after laparoscopic resection for rectal cancer - Results of an audited teaching programme in Spain

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.
Method  In April 2006, the Spanish Association of Surgeons started an audited teaching programme. The project was similar to the Norwegian one and several training courses were arranged. Patients were classified into two groups: laparoscopic rectal resection (LR) and open rectal resection (OR). The quality of the mesorectum was scored: complete, nearly complete or incomplete. The circumferential margin (CRM) was considered positive, if tumour was located 1 mm or less from the surface of the specimen.
Results  Between 2006 and 2008, 604 patients underwent rectal resection with total mesorectal excision for rectal cancer: 209 patients were included in the LR group and 395 patients in the OR group. There were no differences in terms of number of lymph nodes affected, distance of the tumour from CRM. The mesorectum was complete in 464 (76.8%), nearly complete in 91 (15.1%) and incomplete in 49 patients (8.1%). CRM was negative in 534 patients (88.4%). No differences were observed between the two groups. The overall postoperative morbidity rate was 38.8% in LR group and 44.6% in OR group ( P  = 0.170). Overall postoperative mortality rate was 2.5%. One patient died (0.5%) in the LR group and 14 patients died (3.5%) in the OR group ( P  = 0.021).
Conclusion  Laparoscopic resection for rectal cancer is feasible with the quality of mesorectal excision and postoperative outcomes similar to those of open surgery.     

单吻合器法腹腔镜全直肠系膜切除术的临床应用研究

目的:探讨直肠癌患者行免切割闭合器单吻合器法腹腔镜全直肠系膜切除术(total mesorectal excision,TME)的可行性及临床疗效。方法:回顾分析2009年1月至2011年12月为9例直肠癌患者使用免切割闭合器单吻合器法行腹腔镜全直肠系膜切除术的临床资料。结果:9例均顺利完成腹腔镜手术,无一例中转开腹及脏器损伤。术中、术后病理检查提示残端无肿瘤细胞残留。手术时间180～305 min,平均(243.9±43.4)min;术中出血量30～100 ml,平均(51.1±20.0)ml;淋巴结清扫数量5～12枚,平均(7.9±2.7)枚;术后住院10～17 d,平均(13.4±1.9)d;胃肠功能恢复时间平均(44.0±12.3)h,无吻合口漏及吻合口出血。术后随访3～20个月,无局部复发及远处转移。结论:免切割闭合器单吻合器法行腹腔镜全直肠系膜切除术治疗早中期直肠癌是安全、可行的,可降低医疗费用。     

Total mesorectal excision with radiofrequency in rectal cancer

AIM: The aim of this study was to compare the safety, the efficacy and the oncologic results in rectal cancer with total mesorectal excision using Ligasure (LS), a modern bipolar vessel sealing system, with monopolar electrocoagulation or stiches (ME). METHODS: From July 2005 to December 2007 one hundred twenty-nine patients underwent colon resection for cancer at the San Martino Hospital of Genoa (Italy); 43 patients underwent rectal resection. All patients underwent laparotomy rectal resection with total mesorectal excision; 9 (21%, group LS) underwent total mesorectal excision with radiofrequency, 34 (79%, group ME) with monopolar elettrocoagulations, vessels ligation or stiches. Patients of group LS were similar to patients of group ME in age, gender, weight and body mass index. Cancer stage was for group A 3 stage B, 5 stage C and 1 stage D, for group B 4 stage A, 15 stage B, 8 stage C, 6 stage D and 1 non-staged tumor. RESULTS: There were no differences in intraoperative or postoperative complications. Operat-ing time was similar in both group. Oncological results was similar in both groups. The major cost in group LS were attributable to cost of service. CONCLUSION: The Ligasure device does not reduce operating time in laparotomy rectal cancer resection but permit correct oncological results in patients submitted to total mesorectal excision. The costs of device reserved its use to surgery of low-rectal cancer or laparoscopic approach.     

A case of isolated lateral lymph node recurrence occurring after TME for T1 lower rectal cancer treated with lateral lymph node dissection: report of a case

We experienced a rare case of isolated lateral lymph node (LLN) recurrence after laparoscopic intersphincteric resection with total mesorectal excision for T1 lower rectal cancer that was successfully treated using LLN dissection with en bloc resection of the left superior vesical artery, the left ovary and the left obturator nerve, artery and vein. There are no guidelines for treating patients with isolated LLN recurrence because isolated LLN recurrence is rare, especially in patients with T1 rectal cancer. However, in patients with pT1N0 lower rectal cancer, follow-up examinations of the pelvis should be performed periodically. Patients with isolated LLN recurrence treated with surgery might have good long-term prognoses. Therefore, for such patients, surgical resection should be considered as a curative treatment only.     

腹腔镜下全直肠系膜切除治疗低位直肠癌的体会

【摘要】〓目的〓总结腹腔镜下全直肠系膜切除治疗低位直肠癌的手术体会。方法〓选择我院2007年3月至2012年6月收治的低位直肠癌患者,根据手术方法不同,选择腹腔镜下全直肠系膜切除术50例(腹腔镜组)和开腹下实施直肠癌全直肠系膜切除术50例(开腹组),对两组病人术中出血量、手术时间、术后肛门排气时间、住院时间、切除淋巴结总数、住院总费用、随访结果等资料进行对比及临床分析。 结果〓腹腔镜组术中出血量、手术时间、术后肛门排气时间、住院时间均较开腹组少(P均<0.05);术中淋巴结清扫、直肠远切端距癌灶最下缘距离与开腹组没有明显差异(P>0.05);腔镜组的术后并发症及术后复发均较开腹组少(P<0.05)。结论〓腹腔镜下全直肠系膜切除治疗低位直肠癌与开腹组相比,腹腔镜组在减少损伤及术后恢复方面优于开腹组。而且腹腹镜组术后复发率低于开腹组。