结直肠癌伴同时性肝转移外科治疗的策略与实践

Surgical management of synchronous colorectal liver metastases: strategies and clinical practice

  • 摘要: 临床实践中结直肠癌伴同时性肝转移(sCRLM)的外科治疗非常复杂。其中,对于可切除sCRLM的手术策略存在显著争议,包括同期切除与分期切除的抉择、分期切除中肠优先或肝优先的时序选择,以及肝转移瘤行腹腔镜手术的可行性。笔者结合国内外手术治疗现状及团队的临床实践经验,比较同期切除、肠优先及肝优先3种策略的疗效差异,深入探讨腹腔镜技术在肝转移瘤治疗中的应用。笔者发现根据肝转移瘤负荷选择手术策略可显著提高手术安全性和生存获益:单发和单叶多发患者,3种方案的生存预后相当,但同期切除可能增加感染率;双叶多发转移患者,肝优先策略的总并发症发生率、感染率、病死率更低,远期生存率更优,应作为优选。此外,手术策略还需综合考虑患者耐受性、手术团队技术水平、手术预估时间和风险。与开腹手术比较,肝转移瘤治疗中腹腔镜手术具有创伤小、恢复快、并发症少等优点,且远期预后无显著差异。同期或分期切除均建议优选腹腔镜手术。

     

    Abstract: The surgical treatment of synchronous colorectal liver metastases (sCRLM) is complex, especially regarding the optimal strategy for resectable cases is controversy. The contro-versies exist in choosing between simultaneous and staged resection, the sequence of bowel‑first or liver‑first in staged resection, and the feasibility of laparoscopic surgery for liver metastases. Based on current situations of surgical treatment at home and abroad and clinical practice experience of the team, the authors compare the efficacy of simultaneous, bowel‑first, and liver‑first resection, and discuss the application of laparoscopic techniques in the treatment of liver metastases. Analysis indicates that the selection of surgical strategy according to liver metastasis burden can significantly improve the surgical safety and survival benefits: for solitary and unilobar multifocal metastases, the three strategies yield similar survival prognoses, yet simultaneous resection may elevate infection risks; for bilobar multifocal metastases, the liver‑first approach shows lower total complications, infection, and mortality rates, and better long‑term survival, making it preferable. In addition, strategy selection should also account for patient tolerance, surgical team skills, estimated operation time and risks. Laparoscopic surgery has advantages as minimal invasiveness, faster recovery, fewer complications, and equivalent long‑term prognosis to open surgery. It should be the first‑choice approach for both simultaneous and staged resection in the treatment of liver metastases.

     

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