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摘要:目的
探讨模式化腹腔镜左半结肠癌根治术的临床价值。
方法采用回顾性描述性研究方法。收集2016年1月至2020年12月南京医科大学第一附属医院收治的174例行腹腔镜左半结肠癌根治术患者的临床病理资料;男106例,女68例;年龄为59(17~86)岁。所有患者行模式化腹腔镜左半结肠癌根治术。观察指标:(1)手术情况。(2)术后并发症情况。(3)术后组织病理学检查情况。(4)随访情况。采用门诊或电话方式进行随访。术后2年内每3个月随访1次,2~5年每6个月随访1次,5年后每12个月随访1次,了解患者术后肿瘤复发、转移和生存情况。随访终点为肿瘤复发、转移或患者死亡。随访时间截至2021年10月。正态分布的计量资料以x±s表示。偏态分布的计量资料以M(范围)或M(Q1,Q3)表示。计数资料以绝对数或百分比表示。采用Kaplan⁃Meier法绘制生存曲线并计算生存率。
结果(1)手术情况:174例患者均顺利完成模式化腹腔镜左半结肠癌根治术,其中6例术前行肠道支架置入(因肿瘤导致肠梗阻),3例行预防性末端回肠造口,1例行Hartmann手术。174例患者手术时间为97(80,106)min,术中出血量为45(25,60)mL,术后首次肛门排便时间为5(3,6)d,术后住院时间为7(6,8)d。(2)术后并发症情况:174例患者中,12例发生并发症,其中切口感染和(或)脂肪液化4例,吻合口漏3例,不全性肠梗阻2例,腹腔出血、乳糜漏、肺部感染各1例。2例吻合口漏患者行末端回肠造口术。1例腹腔出血患者行剖腹探查腹腔成功止血。1例高龄患者术后发生肺部感染死亡。其余患者均经保守治疗后好转。(3)术后组织病理学检查情况:174例患者中,肿瘤TNM分期Ⅰ期27例,Ⅱ期68例,Ⅲ期77例,Ⅳ期2例;肿瘤高分化9例,中分化107例,低分化58例。174例患者淋巴结检出数目为19(15,23)枚,阳性淋巴结检出数目为0(0,2)枚,肿瘤长径为4(3,5)cm。174例患者中,淋巴结转移79例,癌结节21例,脉管侵犯35例,神经侵犯29例。(4)随访情况:174例患者中,157例获得随访,随访时间为27(1~70)个月。157例获得随访的患者中,20例出现肿瘤转移,其中9例多发转移、5例肝转移、4例肺转移、骨转移和脾脏转移各1例。157例患者5年总生存率、无瘤生存率分别为90.9%、80.8%。
结论模式化腹腔镜左半结肠癌根治术安全、可行。
Abstract:ObjectiveTo investigate the clinical value of stylized laparoscopic hemicolec-tomy for left colon cancer.
MethodsThe retrospective and descriptive study was conducted. The clinicopathological data of 174 patients who underwent laparoscopic hemicolectomy for left colon cancer in the First Affiliated Hospital of Nanjing Medical University from January 2016 to December 2020 were collected. There were 106 males and 68 females, aged 59(range, 17‒86)years. All patients underwent stylized laparoscopic hemicolectomy for left colon cancer. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative histopathological examinations; (4) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect tumor recurrence and metastasis and survival of patients up to October 2021. Follow-up was performed once every 3 months within postoperative 2 years, once every 6 months within postoperative 2 to 5 years and once a year after postoperative 5 years, with the end point as tumor recurrence and metastasis or death of patients. Measurement data with normal distribution were represented as Mean±SD and measurement data with skewed distribution were represented as M(range) or M(Q1,Q3). Count data were described as absolute numbers or percentages. Kaplan-Meier method was used to draw survival curve and calculate survival rate.
Results(1) Surgical situations. All the 174 patients underwent stylized laparoscopic hemicolectomy for left colon cancer successfully, including 6 cases receiving preoperative enteral stent placement due to bowel obstruc-tion, 3 cases receiving defunctioning ileostomy and 1 case receiving Hartmann procedure. The operation time, volume of intraoperative blood loss, time to postoperative initial defecation and duration of postoperative hospital stay of the 174 patients were 97(80,106)minutes, 45(25,60)mL, 5(3,6)days and 7(6,8)days, respectively. (2) Postoperative complications. Twelve of the 174 patients had complications, including 4 cases with incision infection or fat liquefaction, 3 cases with anastomotic leakage, 2 cases with incomplete bowel obstruction, 1 case with abdominal hemo-rrhage, 1 case with chylous leakage and 1 case with pulmonary infection. The 2 cases with anastomotic leakage underwent ileostomy. The patient with abdominal hemorrhage underwent laparotomy to stop bleeding. One elder patient died of postoperative pulmonary infection. The other patients with complications recovered with conservative treatment. (3) Postoperative histopatho-logical examinations. Of the 174 patients, there were 27 cases in stage Ⅰ of TNM staging, 68 cases in stage Ⅱ, 77 cases in stage Ⅲ and 2 cases in stage Ⅳ. There were 9 cases with well differentiated tumor, 107 cases with moderately differentiated tumor and 58 cases with poorly differentiated tumor. The number of lymph node detected, the number of positive lymph node and tumor diameter of the 174 patients were 19(15,23), 0(0,2) and 4(3,5)cm, respectively. Of the 174 patients, there were 79 cases with lymph node metastases, 21 cases with cancerous nodules, 35 cases with vascular invasion and 29 cases with nerve invasion. (4) Follow-up. Of the 174 patients, 157 cases were followed up for 27(range, 1‒70)months. Of the 157 patients who conducted follow-up, 20 cases had tumor metastasis, including 9 cases with multiple metastasis, 5 cases with liver metastasis, 4 cases with lung metastasis, 1 case with bone metastasis and 1 case with spleen metastasis. The 5-year overall survival rate and tumor free survival rate of the 157 patients were 90.9% and 80.8%, respectively.
ConclusionThe stylized laparoscopic hemicolectomy for left colon cancer is safe and feasible.
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Keywords:
- Colorectal neoplasms /
- Left colon /
- Surgical procedures, operative /
- Compli-cations /
- Laparoscopy
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左半结肠癌根治术手术范围广,操作跨度大,技术水平要求较高[1‑4]。左半结肠毗邻脾脏下极和胰体尾部,解剖结构相对复杂,结肠脾曲、膈结肠韧带位置较高,脾结肠韧带较短,手术视野暴露及术中操作困难,容易出现术中出血以及脾脏、胰腺、输尿管等脏器的副损伤,甚至结肠自身损伤[5‑7]。腹腔镜左半结肠癌根治术学习曲线较长,一直是结直肠外科医师学习和成长的重点和难点[8‑10]。笔者团队总结临床经验,提出模式化腹腔镜左半结肠癌根治术,旨在提高手术效率、降低手术风险、缩短学习曲线,促进年轻医师成长。本研究回顾性分析2016年1月至2020年12月南京医科大学第一附属医院结直肠外科收治的174例行腹腔镜左半结肠癌根治术患者的临床病理资料,探讨模式化腹腔镜左半结肠癌根治术的临床价值。
资料与方法
一、一般资料
采用回顾性描述性研究方法。收集174例行腹腔镜左半结肠癌根治术患者的临床病理资料;男106例,女68例;年龄为59(17~86)岁。174例患者BMI为(24±3)kg/m2;肿瘤位于横结肠左侧30例,结肠脾曲39例,降结肠85例,降结肠乙状结肠交界部20例。本研究通过南京医科大学第一附属医院医学伦理委员会审批,批号为2017⁃SR‑352。患者及家属均签署知情同意书。
二、纳入标准和排除标准
纳入标准:(1)组织病理学检查确诊为左半结肠原发性腺癌,肿瘤位置为横结肠左侧至降结肠乙状结肠交界部。(2)行模式化腹腔镜左半结肠癌根治术。(3)限期手术。
排除标准:(1)有胃肠手术病史。(2)多原发结直肠癌。(3)肿瘤侵犯其他组织器官。(4)中转开放手术。
三、手术方法
所有手术由同1个手术团队完成,行模式化腹腔镜左半结肠癌根治术,遵循完整结肠系膜切除(complete mesocolic excision,CME)及无瘤原则。手术步骤:患者气管插管行全身麻醉,取平卧分腿位。建立CO2气腹,气腹压力为15 mmHg(1 mmHg=0.133 kPa),脐上8 cm处置入10 mm Trocar作为观察孔,脐水平线与右侧腹直肌外缘交点处置入12 mm Trocar作为主操作孔,腹上区、腹下区、左外侧区分别置入5 mm Trocar作为辅助操作孔。根据患者体型、肿瘤位置等因素可适当调整Trocar位置。主刀及扶镜手站于患者右侧,一助站于患者两腿之间。进镜后先进行腹腔探查,明确腹腔转移、肿瘤位置及对应结肠系膜淋巴结情况(图1A、1B)。手术台头低足高约30°,左侧抬高20~30°,将小肠翻置于腹主动脉右侧,暴露Treitz韧带及左侧结肠系膜根部,提起肠系膜下静脉(inferior mesenteric vein,IMV)处腹膜,于其下方打开筋膜,钝、锐性结合仔细分离,寻找Toldt′s间隙,沿此间隙由内向外拓展(图1C),至左侧结肠旁沟融合筋膜。沿腹主动脉解剖肠系膜下动脉(inferior mesenteric artery,IMA)。见图1D。清扫其根部淋巴结(第253组淋巴结),沿IMA向远端分离解剖出左结肠动脉及其相邻IMV,依次离断。依据肿瘤位置不同,可以继续分离解剖并离断乙状结肠动脉。向头侧分离拓展Toldt′s间隙,显露胰腺下缘,在此二次离断IMV。向右牵拉乙状结肠,松解乙状结肠与左侧腹壁粘连,沿Toldt′s白线自下向上打开左侧结肠旁沟融合筋膜(图1E),直至结肠脾曲。结肠上区由右向左分离胃结肠韧带及横结肠系膜。一助提起胃大弯,主刀向下牵拉横结肠,展开胃结肠韧带,于胃网膜血管弓外打开,进入小网膜囊,由右向左分离胃结肠韧带至脾脏下极(图1F)。横结肠左侧及脾曲肿瘤需解剖中结肠动脉并离断其左支,清扫其根部淋巴结(第223组淋巴结)。见图1G。胰腺下缘由右向左分离横结肠系膜根部(图1H),与下方分离间隙会师,向左分离至脾脏下极。至此,横结肠左侧、结肠脾曲、降结肠、乙状结肠游离完毕。取腹部正中辅助切口长约8 cm,置入切口保护套,将左侧结肠及其系膜、网膜移至腹腔外,分离网膜,于肿瘤两侧10~15 cm处裁剪结肠系膜、裸化肠管,切除肠管及肿瘤,行乙状结肠横结肠端‑侧或侧‑侧吻合。关闭辅助切口,重建气腹(气腹压力为15 mmHg),将小肠拖出结肠系膜裂孔,重建后的左侧结肠及其吻合口置于小肠后方(图1I)。冲洗腹腔,于左外侧区穿刺孔置入腹腔引流管于吻合口旁,退镜,关闭Trocar孔,扩肛至4指,结束手术。
图 1 模式化腹腔镜左半结肠癌根治术 1A:腹腔探查见降结肠肿瘤;1B:腹腔探查见中结肠动脉根部淋巴结肿大;1C:肠系膜下静脉下方打开筋膜,钝、锐性结合仔细分离,寻找Toldt′s间隙,沿此间隙由内向外拓展;1D:沿腹主动脉解剖肠系膜下动脉;1E:沿Toldt′s白线自下向上打开左侧结肠旁沟融合筋膜;1F:由右向左分离胃结肠韧带至脾脏下极;1G:解剖中结肠动脉并离断其左支,清扫其根部淋巴结(第223组淋巴结);1H:胰腺下缘由右向左分离横结肠系膜根部;1I:重建后的左侧结肠及其吻合口置于小肠后方Figure 1. Surgical procedures of stylized laparoscopic hemicolectomy for left colon cancer 1A: Abdominal exploration revealed tumor at descending colon; 1B: Abdominal exploration revealed swollen lymph nodes at the root of middle colic artery; 1C: Dissection of the fascia under the inferior mesenteric vein, bluntly and sharply dissection was performed to identify the Toldt's space and extend this avascular plane from inside to outside; 1D: Dissection of inferior mesenteric artery along the abdominal aorta; 1E: Dissection of peritoneum reflex of left colonic sulcus from caudal to cranial following the white line of Toldt's; 1F: Dissection of gastrocolic ligament from right to left to the inferior pole of spleen; 1G: Dissection of middle colic artery and lymph nodes surrounding its root (No.223 lymph nodes), and ligation of left branch of the middle colic artery; 1H: Dissection of the root of transverse mesocolon from right to left along inferior edge of pancreas; 1I: After reconstruction, the colon and its anastomosis was placed behind the small intestine四、观察指标和评价标准
观察指标:(1)手术情况包括手术时间、术中出血量、术后住院时间、术后首次肛门排便时间。(2)术后并发症情况:切口感染和(或)脂肪液化、吻合口漏、不全性肠梗阻、腹腔出血、乳糜漏、肺部感染等。(3)术后组织病理学检查情况:肿瘤病理学TNM分期、肿瘤分化程度、淋巴结检出数目、阳性淋巴结检出数目、肿瘤长径、淋巴结转移、癌结节、脉管侵犯、神经侵犯情况。(4)随访情况:获得随访的患者例数,随访时间,患者术后肿瘤复发、转移和生存情况。
评价标准:参照国际抗癌联盟(UICC)和美国癌症联合委员会(AJCC)第8版TNM分期系统进行肿瘤病理学TNM分期。
五、随访
采用门诊或电话方式进行随访。术后2年内每3个月随访1次,2~5年每6个月随访1次,5年后每12个月随访1次,了解患者术后肿瘤复发、转移和生存情况。随访终点为肿瘤复发、转移或患者死亡。随访时间截至2021年10月。
六、统计学分析
应用SPSS 24.0统计软件进行分析。正态分布的计量资料以x±s表示。偏态分布的计量资料以M(范围)或M(Q1,Q3)表示。计数资料以绝对数或百分比表示。采用Kaplan‑Meier法绘制生存曲线并计算生存率。
结果
一、手术情况
174例患者均顺利完成模式化腹腔镜左半结肠癌根治术,其中6例术前行肠道支架置入(因肿瘤导致肠梗阻),3例行预防性末端回肠造口,1例行Hartmann手术。174例患者手术时间为97(80,106)min,术中出血量为45(25,60)mL,术后首次肛门排便时间为5(3,6)d,术后住院时间为7(6,8)d。
二、术后并发症情况
174例患者中,12例发生并发症,其中切口感染和(或)脂肪液化4例,吻合口漏3例,不全性肠梗阻2例,腹腔出血、乳糜漏、肺部感染各1例。2例吻合口漏患者行末端回肠造口术。1例腹腔出血患者行剖腹探查腹腔成功止血。1例高龄患者术后发生肺部感染死亡。其余患者均经保守治疗后好转。
三、术后组织病理学检查情况
174例患者中,肿瘤TNM分期Ⅰ期27例,Ⅱ期68例,Ⅲ期77例,Ⅳ期2例;肿瘤高分化9例,中分化107例,低分化58例。174例患者淋巴结检出数目为19(15,23)枚,阳性淋巴结检出数目为0(0,2)枚,肿瘤长径为4(3,5)cm。174例患者中,淋巴结转移79例,癌结节21例,脉管侵犯35例,神经侵犯29例。
四、随访情况
174例患者中,157例获得随访,随访时间为27(1~70)个月。157例获得随访的患者中,20例出现肿瘤转移,其中9例多发转移、5例肝转移、4例肺转移、骨转移和脾脏转移各1例。157例患者5年总生存率、无瘤生存率分别为90.9%、80.8%。见图2,3。
讨论
2009年,德国学者提出CME概念,使结肠癌手术技术迈向规范化、标准化[11‑12]。腹腔镜结肠癌根治术技术日趋成熟,其临床应用安全、可行[13‑15]。2006年美国国立综合癌症网络发布的临床实践指南确立了腹腔镜技术在结肠癌根治术中的应用价值[16]。中间入路成为腹腔镜结肠癌根治术的推荐入路[17‑19]。
左半结肠癌根治术中通常需要切除部分大网膜、左侧横结肠、结肠脾曲、降结肠、部分乙状结肠及其系膜淋巴结[20‑21]。结肠脾曲解剖结构复杂,脾曲位置较高,与脾门、胰尾关系密切,尤其是网膜肥厚、周围广泛粘连时,容易进入错误解剖层面[22‑23]。左半结肠癌根治术的要点在于层面寻找、脾曲游离、淋巴结清扫[24‑27]。通过临床实践,笔者提出模式化腹腔镜左半结肠癌根治术,其手术步骤及要点包括(1)1个层面:Toldt′s间隙。(2)2根动脉:IMA及其根部淋巴结清扫,中结肠动脉及其根部淋巴结清扫。(3)3个方向:①左半结肠后方由内向外分离Toldt′s间隙;②左半结肠外侧由下向上推进;③胃结肠韧带及横结肠系膜由右向左拓展延伸。(4)4个分离:①左半结肠后方分离Toldt′s间隙;②左半结肠外侧分离左侧结肠旁沟融合筋膜;③结肠上区分离打开胃结肠韧带;④胰腺下缘分离横结肠系膜根部。4个分离最终汇集至结肠脾曲,将左半结肠完全游离。上述16字模式化腹腔镜左半结肠癌根治术操作技巧的4个要点相互贯通。笔者认为:模式化腹腔镜左半结肠癌根治术中能够获得良好暴露,便于血管解剖和淋巴结清扫,有助于缩短手术时间,减少术中出血量,降低术中损伤发生率,缩短医师的学习曲线,提高手术效率。模式化腹腔镜左半结肠癌根治术是基于现有手术经验报道的概括和总结[28‑29]。其不仅是对手术步骤的高度概括,便于理解和记忆,同时是对CME和D3淋巴结清扫概念的诠释,要求手术过程中保持系膜分离的完整性及淋巴结清扫的彻底性。
已有多位研究者从手术入路、手术技巧、解剖结构等方面分享左半结肠手术技术的团队经验[5,30‑33]。笔者总结的手术模式属于中间入路,保持层次的关键在于寻找Toldt′s间隙。淋巴结的清扫根据肿瘤位置而定[34‑37]。笔者认为:如果肿瘤位于降结肠及降结肠乙状结肠交界,需要清扫第253组淋巴结;如果肿瘤位于横结肠左侧及结肠脾曲,建议同时清扫第253组及第223组淋巴结。本研究结果显示:结肠脾曲及左半结肠充分游离的关键在于3个方向的协同进行和4个分离的逐步深入。这与笔者中心早期腹腔镜左半结肠手术的研究及部分文献报道比较,该手术模式在手术时间、术中损伤、术后并发症、术后淋巴结检出数目等方面有优势[38‑41]。
综上,模式化腹腔镜左半结肠癌根治术安全、可行。由于本研究为单中心研究、样本量较小,所得结论尚需更大样本量的RCT进一步验证。
孙跃明:酝酿和设计实验,对文章的知识性内容批评性审阅,行政、技术支持;封益飞:酝酿和设计实验,起草文章,统计分析;张冬生:酝酿和设计实验,采集数据,起草文章,统计分析;张翼:采集数据,对文章的知识性内容批评性审阅,统计分析;唐俊伟:采集数据,对文章的知识性内容批评性审阅,统计分析;黄远健:分析并解释数据,对文章的知识性内容批评性审阅,统计分析;张川:采集数据,对文章的知识性内容批评性审阅,统计分析;李杨:酝酿和设计实验,对文章的知识性内容批评性审阅,病理分析支持; 王晓伟:分析并解释数据,对文章的知识性内容批评性审阅,统计分析所有作者均声明不存在利益冲突孙跃明, 封益飞, 张冬生, 等. 模式化腹腔镜左半结肠癌根治术的临床价值[J]. 中华消化外科杂志, 2022, 21(5): 635-641. DOI: 10.3760/cma.j.cn115610-20220318-00139.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20220318-22139
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图 1 模式化腹腔镜左半结肠癌根治术 1A:腹腔探查见降结肠肿瘤;1B:腹腔探查见中结肠动脉根部淋巴结肿大;1C:肠系膜下静脉下方打开筋膜,钝、锐性结合仔细分离,寻找Toldt′s间隙,沿此间隙由内向外拓展;1D:沿腹主动脉解剖肠系膜下动脉;1E:沿Toldt′s白线自下向上打开左侧结肠旁沟融合筋膜;1F:由右向左分离胃结肠韧带至脾脏下极;1G:解剖中结肠动脉并离断其左支,清扫其根部淋巴结(第223组淋巴结);1H:胰腺下缘由右向左分离横结肠系膜根部;1I:重建后的左侧结肠及其吻合口置于小肠后方
Figure 1. Surgical procedures of stylized laparoscopic hemicolectomy for left colon cancer 1A: Abdominal exploration revealed tumor at descending colon; 1B: Abdominal exploration revealed swollen lymph nodes at the root of middle colic artery; 1C: Dissection of the fascia under the inferior mesenteric vein, bluntly and sharply dissection was performed to identify the Toldt's space and extend this avascular plane from inside to outside; 1D: Dissection of inferior mesenteric artery along the abdominal aorta; 1E: Dissection of peritoneum reflex of left colonic sulcus from caudal to cranial following the white line of Toldt's; 1F: Dissection of gastrocolic ligament from right to left to the inferior pole of spleen; 1G: Dissection of middle colic artery and lymph nodes surrounding its root (No.223 lymph nodes), and ligation of left branch of the middle colic artery; 1H: Dissection of the root of transverse mesocolon from right to left along inferior edge of pancreas; 1I: After reconstruction, the colon and its anastomosis was placed behind the small intestine
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