右半结肠癌CME/D3根治术淋巴结清扫内侧界的争议

doi:10.16139/j.1007-9610.2023.03.005

摘要/Abstract

摘要：

根治性外科手术是结肠癌的最主要治疗措施。完整系膜切除术（complete mesentery excision, CME）/D3淋巴结清扫术的发展应用，推动结肠癌手术技术的规范化、标准化进程。右半结肠癌手术相对复杂，是当前研究的热点之一。涉及的问题包括淋巴结清扫范围、肠管切除范围、肠管重建方式等。右半结肠癌淋巴结清扫的内侧界是当前争议的焦点之一。肠系膜上静脉左侧通常被认为是右半结肠癌CME/D3清扫的内侧界。然而，随着相关研究的深入开展，部分学者认为应当以肠系膜上动脉左侧为清扫的内侧界。该观点更符合CME的原则，且能做到彻底的淋巴结清扫，但其临床意义仍需深入研究论证。本文针对右半结肠癌淋巴结清扫内侧界的选择展开讨论，希望为临床实践提供参考。

关键词: 右半结肠癌, 完整系膜切除术, 淋巴结清扫, 肠系膜上动脉

Abstract:

Radical surgery is the most important treatment for colon cancer. The development and application of complete mesentery excision (CME)/D3 lymph node dissection has promoted the standardization of surgical techniques for colon cancer. Right colon cancer surgery is relatively complicated, and is a research hotspot currently. The issues involved the range of lymph node dissection, the range of bowel resection, and the method of bowel reconstruction. The medial border of lymph node dissection for right colon cancer is one of the controversies. The left side of the superior mesenteric vein is generally considered to be the medial border of CME/D3 dissection in right colon cancer surgery. However, with the in-depth development of related research, some scholars believed that the left side of the superior mesenteric artery should be used as the medial border for lymph node dissection. This approach is more consistent with the principle of CME, and can achieve complete lymph node dissection. However, its clinical significance still needs to be evaluated with further research. This article discusses the selection of medial border of lymph node dissection for right colon cancer, hoping to provide reference for clinical practice.

Key words: Right colon cancer, Complete mesentery excision, Lymph node dissection, Superior mesenteric artery

中图分类号:

R735.35

孙跃明, 张冬生. 右半结肠癌CME/D3根治术淋巴结清扫内侧界的争议[J]. 外科理论与实践, 2023, 28(03): 202-207.

SUN Yueming, ZHANG Dongsheng. Controversy over the medial border of lymph node dissection during CME/D3 surgery of right colon cancer[J]. Journal of Surgery Concepts & Practice, 2023, 28(03): 202-207.

参考文献 45

[1]	ZHENG R, ZHANG S, ZENG H, et al. Cancer incidence and mortality in China, 2016[J]. J Int Oncol, 2022, 2(1):1-9.
[2]	SIEGEL R L, MILLER K D, FEDEWA S A, et al. Colorectal cancer statistics,2017[J]. CA Cancer J Clin, 2017, 67(3):177-193. doi: 10.3322/caac.21395 URL
[3]	REIF DE PAULA T, SIMON H L, PROFETA DA LUZ M M, et al. Right sided colorectal cancer increases with age and screening should be tailored to reflect this: a national cancer database study[J]. Tech Coloproctol, 2021, 25(1):81-89. doi: 10.1007/s10151-020-02329-z
[4]	张川, 孙跃明. 腹腔镜下肠系膜上动脉为导向的尾侧中间入路右侧全结肠系膜切除术[J]. 中国肿瘤外科杂志, 2016, 8(5):281-283.
	ZHANG C, SUN Y M. Laparoscopic superior mesenteric artery guided caudal median approach for right total mesocolic excision[J]. Chin J Surg Oncol, 2016, 8(5):281-283.
[5]	王勇, 张冬生, 封益飞, 等. 以肠系膜上动脉为导向的腹腔镜完整结肠系膜切除术治疗右半结肠癌[J]. 中华胃肠外科杂志, 2017, 20(8):896-899.
	WANG Y, ZHANG D S, FENG Y F, et al. Clinical efficacy of superior mesenteric artery-oriented laparoscopic complete mesocolic excision in the treatment of right colonic cancer[J]. Chin J Gastrointest Surg, 2017, 20(8):896-899.
[6]	孙跃明, 封益飞, 张冬生, 等. 以肠系膜上动脉为导向的右半结肠全结肠系膜切除术治疗右半结肠癌的应用价值[J]. 中华消化外科杂志, 2019, 18(8):753-760.
	SUN Y M, FENG Y F, ZHANG D S, et al. Application value of superior mesenteric artery-oriented complete mesocolic excision in the treatment of right colon cancer[J]. Chin J Dig Surg, 2019, 18(8):753-760.
[7]	LUO W, CAI Z, LI F, et al. Laparoscopic complete mesocolic excision with central vascular ligation (CME + CVL) for right-sided ccolon ancer: a new “superior mesenteric artery first” approach[J]. Ann Surg Oncol, 2022, 29(8):5066-5073. doi: 10.1245/s10434-022-11773-0
[8]	HOHENBERGER W, WEBER K, MATZEL K, et al. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation: technical notes and outcome[J]. Colorectal Dis, 2009, 11(4):354-364. doi: 10.1111/cdi.2009.11.issue-4 URL
[9]	ANON. General rules for clinical and pathological stu-dies on cancer of the colon,rectum and anus. Part Ⅰ. Clinical classification. Japanese Research Society for Cancer of the Colon and Rectum[J]. Jpn J Surg, 1983, 13(6):557-573. doi: 10.1007/BF02469505 URL
[10]	TOYOTA S, OHTA H, ANAZAWA S. Rationale for extent of lymph node dissection for right colon cancer[J]. Dis Colon Rectum, 1995, 38(7):705-711. doi: 10.1007/BF02048026 URL
[11]	郑民华, 马君俊. 不断提高腹腔镜右半结肠癌根治规范化水平[J]. 中华普外科手术学杂志(电子版), 2015(1):1-3.
	ZHENG M H, MA J J. Standardized laparoscopic right hemicolectomy for right colon cancer[J]. Chin J Oper Proc Gen Surg (Electronic Edition), 2015(1):1-3.
[12]	肖毅, 徐徕, 陆君阳, 等. 根治性右半结肠癌淋巴结清扫范围的探讨[J]. 中华外科杂志, 2016, 54(6):408-412.
	XIAO Y, XU L, LU J Y, et al. Investigate the radical extent of lymphadenectomy of right colon cancer[J]. Chin J Surg, 2016, 54(6):408-412.
[13]	刁德昌, 卢新泉, 何耀彬, 等. 动脉优先入路法腹腔镜右半结肠癌根治术的可行性及应用价值[J]. 中华胃肠外科杂志, 2017, 20(1):90-93.
	DIAO D C, LU X Q, HE Y B, et al. Feasibility and application value of laparoscopic radical resection of right colon cancer by arterial priority approach[J]. Chin J Gastrointest Surg, 2017, 20(1):90-93.
[14]	韩方海, 钟广宇. 对右半结肠癌根治手术外科膜间隙平面的认识[J]. 中华胃肠外科杂志, 2019, 22(5):436-440.
	HAN F H, ZHONG G Y. Recognition of the interstitial plane of the surgical membrane in radical resection of right semicolon cancer[J]. Chin J Gastrointest Surg, 2019, 22(5):436-440.
[15]	TEJEDOR P, FRANCIS N, JAYNE D, et al. Consensus statements on complete mesocolic excision for right-sided colon cancer-technical steps and training implications[J]. Surg Endosc, 2022, 36(8):5595-5601. doi: 10.1007/s00464-021-08395-0
[16]	BENZ S R, FEDER I S, VOLLMER S, et al. Complete mesocolic excision for right colonic cancer: prospective multicentre study[J]. Br J Surg, 2022, 110(1):98-105. doi: 10.1093/bjs/znac379 URL
[17]	MUNKEDAL D L E, ROSENKILDE M, NIELSEN D T, et al. Radiological and pathological evaluation of the level of arterial division after colon cancer surgery[J]. Colorectal Dis, 2017, 19(7):238-245.
[18]	LIVADARU C, MORARASU S, FRUNZA T C, et al. Post-operative computed tomography scan - reliable tool for quality assessment of complete mesocolic excision[J]. World J Gastrointest Oncol, 2019, 11(3):208-226. doi: 10.4251/wjgo.v11.i3.208 URL
[19]	IGNJATOVIC D, BERGAMASCHI R. Defining the extent of mesenterectomy in right colectomy: a controversy[J]. Colorectal Dis, 2016, 18(7):649. doi: 10.1111/codi.2016.18.issue-7 URL
[20]	SPASOJEVIC M, STIMEC B V, DYRBEKK A P, et al. Lymph node distribution in the D3 area of the right mesocolon: implications for an anatomically correct cancer resection. A postmortem study[J]. Dis Colon Rectum, 2013, 56(12):1381-1387. doi: 10.1097/01.dcr.0000436279.18577.d3 URL
[21]	NESGAARD J M, STIMEC B V, BAKKA A O, et al. Right colectomy with extended D3 mesenterectomy: anterior and posterior to the mesenteric vessels[J]. Surg Technol Int, 2019,35.
[22]	NESGAARD J M, STIMEC B V, SOULIE P, et al. Defi-ning minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study[J]. Surg Endosc, 2018, 32(9):3806-3812. doi: 10.1007/s00464-018-6106-3
[23]	NEGOI I, BEURAN M, HOSTIUC S, et al. Surgical anatomy of the superior mesenteric vessels related to colon and pancreatic surgery: a systematic review and meta-analysis[J]. Sci Rep, 2018, 8(1):4184. doi: 10.1038/s41598-018-22641-x
[24]	AGUSTSDOTTIR E E S, STIMEC B V, STROEMMEN T T, et al. Preventing chylous ascites after right hemicolectomy with D3 extended mesenterectomy[J]. Langenbecks Arch Surg, 2020, 405(7):1017-1024. doi: 10.1007/s00423-020-01938-4
[25]	NESGAARD J M, STIMEC B V, BAKKA A O, et al. Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy[J]. Colorectal Dis, 2015, 17(9):810-818. doi: 10.1111/codi.2015.17.issue-9 URL
[26]	STIMEC B V, IGNJATOVIC D. Visible lymph affluents in the D3 volume: an MDCTA pictorial essay[J]. Diagnostics(Basel), 2022, 12(10):2441.
[27]	廖伟林, 刁德昌, 汪佳豪, 等. 腹腔镜右半结肠癌根治术采用淋巴示踪技术引导肠系膜上动脉旁淋巴结清扫的临床意义[J]. 结直肠肛门外科, 2022, 28(5):449-455.
	LIAO W L, DIAO D C, WANG J H, et al. Tracer-guided lymphatic mapping in dissection of para-superior mesenteric artery lymph nodes in laparoscopic radical resection of right-sided colon cancer[J]. J Colorectal Anal Surg, 2022, 28(5):449-455.
[28]	LE VOYER T E, SIGURDSON E R, HANLON A L, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089[J]. J Clin Oncol, 2003, 21(15):2912-2919. doi: 10.1200/JCO.2003.05.062 URL
[29]	LYKKE J, ROIKJAER O, JESS P, et al. The relation between lymph node status and survival in Stage Ⅰ-Ⅲ colon cancer: results from a prospective nationwide cohort study[J]. Colorectal Dis, 2013, 15(5):559-565. doi: 10.1111/codi.12059 URL
[30]	WONG S L, JI H, HOLLENBECK B K, et al. Hospital lymph node examination rates and survival after resection for colon cancer[J]. JAMA, 2007, 298(18):2149-2154. doi: 10.1001/jama.298.18.2149 URL
[31]	ISHIYAMA Y, MAEDA C, SHIMADA S, et al. Propensity-score-matched analysis of short- and long-term outcomes in patients with an ileocolic artery crossing anterior vs. posterior to the superior mesenteric vein during curative resection for right-sided colon cancer[J]. Surg Endosc, 2020, 34(12):5384-5392. doi: 10.1007/s00464-019-07333-5
[32]	YANG Y, MALAKORN S, ZAFAR S N, et al. Superior mesenteric vein-first approach to robotic complete mesocolic excision for right colectomy: technique and preliminary outcomes[J]. Dis Colon Rectum, 2019, 62(7):894-897. doi: 10.1097/DCR.0000000000001412 URL
[33]	KANEMITSU Y, KOMORI K, KIMURA K, et al. D3 lymph node dissection in right hemicolectomy with a no-touch isolation technique in patients with colon cancer[J]. Dis Colon Rectum, 2013, 56(7):815-824. doi: 10.1097/DCR.0b013e3182919093 URL
[34]	周乐其, 冯波, 苏浩, 等. 以肠系膜上动脉左侧为右半结肠癌D3根治术淋巴结清扫内侧界可行性研究[J]. 中国实用外科杂志, 2019, 39(7):712-715.
	ZHOU L Q, FENG B, SU H, et al. Surgical feasibility of laparoscopic D3 lymphadenectomy along the left of SMA for right colon cancer[J]. Chin J Gen Surg, 2019, 39(7):712-715.
[35]	ZHOU L, DIAO D, YE K, et al. The medial border of laparoscopic D3 lymphadenectomy for right colon cancer: results from an exploratory pilot study[J]. Dis Colon Rectum, 2021, 64(10):1286-1296. doi: 10.1097/DCR.0000000000002046 URL
[36]	THORSEN Y, STIMEC B V, LINDSTROM J C, et al. Stool dynamics after extrinsic nerve injury during right colectomy with extended D3-mesenterectomy[J]. Scand J Gastroenterol, 2021, 56(7):770-776. doi: 10.1080/00365521.2021.1918757 URL
[37]	LUZON J A, THORSEN Y, NOGUEIRA L P, et al. Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis[J]. Surg Endosc, 2022, 36(10):7607-7618. doi: 10.1007/s00464-022-09200-2
[38]	刁德昌, 万进, 易小江, 等. 腹腔镜下保留植物神经右半结肠癌D3根治术的可行性及应用价值[J]. 中华胃肠外科杂志, 2018, 21(8):908-912.
[39]	HASHIGUCHI Y, MURO K, SAITO Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer[J]. Int J Clin Oncol, 2020, 25(1):1-42. doi: 10.1007/s10147-019-01485-z
[40]	BENSON A B, VENOOK A P, AL-HAWARY M M, et al. Colon cancer, version 2.2021, NCCN clinical practice guidelines in oncology[J]. J Natl Compr Canc Netw, 2021, 19(3):329-359. doi: 10.6004/jnccn.2021.0012 URL
[41]	中华人民共和国国家卫生健康委员会. 中国结直肠癌诊疗规范(2020年版)[J]. 中华外科杂志, 2020, 58(8):561-585.
	National Health Commission of the People's Republic of China. Chinese protocol of diagnosis and treatment of colorectal cancer (2020 edition)[J]. Chin J Surg, 2020, 58(8):561-585.
[42]	KOTAKE K, MIZUGUCHI T, MORITANI K, et al. Impact of D3 lymph node dissection on survival for patients with T3 and T4 colon cancer[J]. Int J Colorectal Dis, 2014, 29(7):847-852. doi: 10.1007/s00384-014-1885-z URL
[43]	STORLI KE, SØNDENAA K, FURNES B, et al. Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages Ⅰ-Ⅱ[J]. Tech Coloproctol, 2014, 18(6):557-564. doi: 10.1007/s10151-013-1100-1 URL
[44]	PALMERI M, PERI A, PUCCI V, et al. Pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy?[J]. Updates Surg, 2022, 74(4):1327-1335. doi: 10.1007/s13304-022-01317-2
[45]	BERTELSEN C A, KIRKEGAARD-KLITBO A, NIELSEN M, et al. Pattern of colon cancer lymph node metastases in patients undergoing central mesocolic lymph node excision: a systematic review[J]. Dis Colon Rectum, 2016, 59(12):1209-1221. doi: 10.1097/DCR.0000000000000658 URL