腹腔镜下直肠癌根治术中淋巴结清扫的争议与进展

doi:10.3760/cma.j.issn.1007-1245.2024.19.003

摘要/Abstract

摘要：

腹腔镜下直肠癌根治术是目前直肠恶性肿瘤的主要治疗方式。淋巴结的清扫是决定手术根治性的重要因素。淋巴结清扫范围以及淋巴结的清扫方式是手术的关键。本文结合国内外指南、文献以及刁德昌教授团队的实践经验，对腹腔镜下直肠癌根治术中淋巴结清扫的争议与进展进行论述。为临床直肠癌淋巴结清扫选择提供参考，以更好地平衡肿瘤治疗效果和患者功能保护。

关键词:

直肠恶性肿瘤, 肠系膜下动脉, 左结肠动脉, 侧方淋巴结清扫, 进展

Abstract:

Laparoscopic rectal cancer surgery has become the primary treatment method for malignant tumors of the rectum. Lymph node dissection plays a crucial role in determining the curative intent of the procedure. The extent and technique of lymph node clearance are pivotal factors in achieving successful outcomes. In this article, we discuss the controversies and recent advancements related to lymph node dissection during laparoscopic rectal cancer surgery. Our aim is to provide references for selecting an optimal approach for rectal cancer lymph node dissection, and balancing oncological treatment efficacy and functional preservation in the patients.

Key words:

Rectal neoplasms, Inferior mesenteric artery, Left colic artery, Lateral lymph node dissection, Progress

任佳琪刁德昌张雪阳.

腹腔镜下直肠癌根治术中淋巴结清扫的争议与进展 [J]. 国际医药卫生导报, 2024, 30(19): 3180-3184.

Ren Jiaqi, Diao Dechang, Zhang Xueyang.

Controversies and progress of lymph node dissection during laparoscopic radical rectal cancer surgery [J]. International Medicine and Health Guidance News, 2024, 30(19): 3180-3184.

参考文献

[1] 郑荣寿,陈茹,韩冰峰,等. 2022年中国恶性肿瘤流行情况分析[J]. 中华肿瘤杂志, 2024, 46(3): 221-231. DOI: 10.3760/cma.j.cn112152-20240119-00035.
[2] Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence? [J]. Br J Surg, 1982, 69(10): 613-616. DOI: 10.1002/bjs.1800691019.
[3] Dworkin MJ, Allen-Mersh TG. Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon [J]. J Am Coll Surg, 1996, 183(4): 357-360.
[4] Seike K, Koda K, Saito N, et al. Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery [J]. Int J Colorectal Dis, 2007, 22(6): 689-697. DOI: 10.1007/s00384-006-0221-7.
[5] 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.
[6] Chin CC, Yeh CY, Tang R, et al. The oncologic benefit of high ligation of the inferior mesenteric artery in the surgical treatment of rectal or sigmoid colon cancer [J]. Int J Colorectal Dis, 2008, 23(8): 783-788. DOI: 10.1007/s00384-008-0465-5.
[7] Matsuda K, Yokoyama S, Hotta T, et al. Oncological outcomes following rectal cancer surgery with high or low ligation of the inferior mesenteric artery [J]. Gastrointest Tumors, 2017, 4(1-2): 45-52. DOI: 10.1159/000477805.
[8] Rao X, Zhang J, Liu T, et al. Prognostic value of inferior mesenteric artery lymph node metastasis in cancer of the descending colon, sigmoid colon and rectum [J]. Colorectal Dis, 2018, 20(6): O135-O142. DOI: 10.1111/codi.14105.
[9] Wang L, Hirano Y, Heng G, et al. Prognostic utility of apical lymph node metastasis in patients with left-sided colorectal cancer [J]. In Vivo, 2020, 34(5): 2981-2989. DOI: 10.21873/invivo.12129.
[10] 唐俊伟,王晓伟,李扬,等. 中低位直肠癌患者第253组淋巴结转移特点及其影响因素分析(附2 316例报告)[J]. 中华消化外科杂志,2022,21(6):773-778. DOI:　10.3760/cma.j.cn115610-20220411-00198.
[11] 赵富强,周雷,杜晓辉,等. 降结肠、乙状结肠癌及直肠癌第253组淋巴结转移影响因素及预后分析的多中心研究[J]. 中华外科杂志,2023,61(9):760-767. DOI: 10.3760/cma.j.cn112139-20230331-00132.
[12] 王治杰, 刘骞. 直肠和乙状结肠癌区域淋巴结清扫的规范化开展[J]. 中华胃肠外科杂志, 2022, 25(4): 309-314. DOI:10.3760/cma.j.cn441530-20220104-00007.
[13] Kim JC, Lee KH, Yu CS, et al. The clinicopathological significance of inferior mesenteric lymph node metastasis in colorectal cancer [J]. Eur J Surg Oncol, 2004, 30(3): 271-279. DOI: 10.1016/j.ejso.2003.12.002.
[14] Kanemitsu Y, Hirai T, Komori K, et al. Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery [J]. Br J Surg, 2006, 93(5): 609-615. DOI: 10.1002/bjs.5327.
[15] Lee SH, Lee JL, Kim CW, et al. Oncologic significance of para-aortic lymph node and inferior mesenteric lymph node metastasis in sigmoid and rectal adenocarcinoma [J]. Eur J Surg Oncol, 2017, 43(11): 2076-2083. DOI: 10.1016/j.ejso.2017.08.014.
[16] Leggeri A, Roseano M, Balani A, et al. Lumboaortic and iliac lymphadenectomy: what is the role today? [J]. Dis Colon Rectum, 1994, 37(2 Suppl): S54-S61. DOI: 10.1007/BF02048433.
[17] Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908) [J]. CA Cancer J Clin, 1971, 21(6): 361-364. DOI: 10.3322/canjclin.21.6.361.
[18] 武颖超,汪欣,刘玉村,等. 直肠癌肠系膜下动脉根部淋巴结转移规律的研究[J]. 中华普通外科杂志,2013,28(8):586-589. DOI: 10.3760/cma.j.issn.1007- 631X. 2013.08.006.
[19] Hu S, Li S, Teng D, et al. Analysis of risk factors and prognosis of 253 lymph node metastasis in colorectal cancer patients [J]. BMC Surg, 2021, 21(1): 280. DOI: 10.1186/s12893-021-01276-2.
[20] Huang YQ, Liang CH, He L, et al. Development and validation of a radiomics nomogram for preoperative prediction of lymph node metastasis in colorectal cancer [J]. J Clin Oncol, 2016, 34(18): 2157-2164. DOI: 10.1200/JCO.2015.65.9128.
[21] Surtees P, Ritchie JK, Phillips RK. High versus low ligation of the inferior mesenteric artery in rectal cancer [J]. Bri J Sur, 1990, 77(6): 618-621.
[22] Uehara K, Yamamoto S, Fujita S, et al. Impact of upward lymph node dissection on survival rates in advanced lower rectal carcinoma [J]. Dig Surg, 2007, 24(5): 375-381. DOI: 10.1159/000107779.
[23] Pezim ME, Nicholls RJ. Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer [J]. Ann Surg, 1984, 200(6): 729-733. DOI: 10.1097/00000658-198412000-00010.
[24] Mari GM, Crippa J, Cocozza E, et al. Low ligation of inferior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary dysfunction: results from a randomized controlled trial (HIGHLOW trial) [J]. Ann Surg, 2019, 269(6): 1018-1024. DOI: 10.1097/SLA.0000000000002947.
[25] Cirocchi R, Farinella E, Trastulli S, et al. High tie versus low tie of the inferior mesenteric artery: a protocol for a systematic review [J]. World J Surg Oncol, 2011, 9: 147. DOI: 10.1186/1477-7819-9-147.
[26] Komen N, Slieker J, de Kort P, et al. High tie versus low tie in rectal surgery: comparison of anastomotic perfusion [J]. Int J Colorectal Dis, 2011, 26(8): 1075-1078. DOI: 10.1007/s00384-011-1188-6.
[27] Wang C, Zhou ZG, Yu YY, et al. Patterns of lateral pelvic lymph node metastases and micrometastases for patients with lower rectal cancer [J]. Eur J Surg Oncol, 2007, 33(4): 463-467. DOI: 10.1016/j.ejso.2006.09.015.
[28] Zhang X, Deng X, Wei M, et al. A modified technique of laparoscopic lateral lymph node dissection combining fascia-oriented dissection and routine upfront distal visceral vessels ligation for mid- to low-lying rectal cancer [J]. Dis Colon Rectum, 2021, 64(4): e67-e71. DOI: 10.1097/DCR.0000000000001950.
[29] Wang Z, Loh KY, Tan KY, et al. The role of lateral lymph node dissection in the management of lower rectal cancer [J]. Langenbecks Arch Surg, 2012, 397(3): 353-361. DOI: 10.1007/s00423-011-0864-x.
[30] Ogura A, Konishi T, Beets GL, et al. Lateral nodal features on restaging magnetic resonance imaging associated with lateral local recurrence in low rectal cancer after neoadjuvant chemoradiotherapy or radiotherapy [J]. JAMA Surg, 2019, 154(9):e192172. DOI: 10.1001/jamasurg.2019.2172.
[31] Nakanishi R, Yamaguchi T, Akiyoshi T, et al. Laparoscopic and robotic lateral lymph node dissection for rectal cancer [J]. Surg Today, 2020, 50(3): 209-216. DOI: 10.1007/s00595-020-01958-z.
[32] Christou N, Meyer J, Combescure C, et al. Prevalence of metastatic lateral lymph nodes in Asian patients with lateral lymph node dissection for rectal cancer: a meta-analysis [J]. World J Surg, 2021, 45(5): 1537-1547. DOI: 10.1007/s00268-021-05956-1.
[33] Benson AB, Venook AP, Al-Hawary MM, et al. Rectal cancer, version 2.2022, NCCN clinical practice guidelines in oncology [J]. J Natl Compr Canc Netw, 2022, 20(10): 1139-1167. DOI: 10.6004/jnccn.2022.0051.
[34] Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage Ⅱ/Ⅲ lower rectal cancer (jcog0212): a multicenter, randomized controlled, noninferiority trial [J]. Ann Surg, 2017, 266(2): 201-207. DOI: 10.1097/SLA.0000000000002212.
[35] Kusters M, Beets GL, van de Velde CJ, et al. A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence [J]. Ann Surg, 2009, 249(2): 229-235. DOI: 10.1097/SLA.0b013e318190a664.
[36] Sugihara K, Kobayashi H, Kato T, et al. Indication and benefit of pelvic sidewall dissection for rectal cancer [J]. Dis Colon Rectum, 2006, 49(11): 1663-1672. DOI: 10.1007/s10350-006-0714-z.
[37] 李文娟,刁德昌,林佳鑫,等. 基于膜解剖的"三面包抄式"关键技术应用于中低位直肠癌腹腔镜侧方淋巴结清扫术的可行性[J]. 中华胃肠外科杂志,2023,26(10):968-976. DOI: 10.3760/cma.j.cn441530-20230525-00181.
[38] Moriya Y, Sugihara K, Akasu T, et al. Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer [J]. Eur J Cancer, 1995, 31A(7-8): 1229-1232. DOI: 10.1016/0959-8049(95)00164-e.
[39] 孙轶,张锡朋. 直肠癌侧方淋巴结清扫术的研究进展[J]. 结直肠肛门外科, 2021, 27(3): 207-210. DOI: 10.19668/j.cnki.issn1674-0491.2021.03.005.
[40] 刘海龙, 李阿健, 王文超, 等. 基于膜解剖的低位直肠癌侧方淋巴结"两间隙"清扫术安全性研究[J]. 中国实用外科杂志, 2020, 40(8): 950-956. DOI: 10.19538/j.cjps.issn1005-2208.2020.08.11.
[41] 练磊,谢明颢. 从"两面三道"浅谈直肠癌手术侧方淋巴结清扫的技巧——复杂问题简单化的一个思考[J]. 中华胃肠外科杂志, 2019, 22(6): 597-600.
DOI: 10.3760/cma.j.issn.1671?0274.2019.06.016.