合理把握直肠癌侧方淋巴结清扫适应证

Management of the lateral lymph node dissection in rectal cancer

直肠癌侧方淋巴结清扫手术难度高,术后排尿和性功能障碍等并发症发生率较高,在我国尚未常规开展。术前新辅助治疗、影像学评估和术式选择等均对侧方淋巴结清扫的效果具有重要影响。为直肠癌病人制定手术方案时,应合理把握侧方淋巴结清扫的适应证。对于腹膜返折以下的局部进展期(Ⅱ~Ⅲ期)直肠癌病人实施侧方淋巴结清扫可遵循以下原则:(1)术前应结合MRI检查进行综合判断。对于可根治性切除者,如术前检查提示侧方淋巴结短径≥5 mm,建议进行清扫,否则可不必进行清扫;而对于无法根治性切除者(如盆壁侵犯等),建议先行新辅助放化疗,治疗后如仍有侧方淋巴结短径≥5 mm者,须进行清扫,否则可不必进行清扫。(2)由于侧方淋巴结清扫易损伤盆腔神经丛,导致术后排尿和性功能障碍,一般建议对淋巴结肿大的一侧进行清扫,仅两侧均出现侧方淋巴结肿大时才考虑进行双侧清扫,清扫过程应注意保留盆腔自主神经。(3)对于有腹腔镜和机器人手术操作经验的医生,可采用微创技术。

Lateral lymph node dissection in rectal cancer, which is difficult in practice and has a high risk of postoperative urinal and sexual dysfunction, is not routinely performed in China. Neoadjuvant therapy, radiological evaluation and surgical method have great impact on the outcome of lateral lymph node dissection. It is better to beware of the management of lateral lymph node dissection, while planning the surgical intervention for the patients with rectalcancer. For patients with stage Ⅱand Ⅲ local advanced rectal cancer, which locates below the peritoneal reflection, the lateral lymph node dissection is suggested to perform under the following criteria. Firstly, the surgical plan should be made based on the preoperative MR examination. For patients with resectable tumor, it＇ s not necessary to perform the lateral lymph node dissection when no lateral lymph node with short axis larger than 5 mm is found in MR examination. The dissection should be performed when lateral lymph node with short axis larger than 5 mm is indicated. For patients with unresectable tumor, such as pelvic invasion, it＇ s better to provide neoadjuvant therapy first, and then the lateral lymph node should be evaluated again. If lateral lymph node with short axis larger than 5 mm is still detected, the lateral lymph node dissection should be performed. But it＇ s unnecessary to do the dissection while no lateral lymph node with short axis larger than 5 mm is found. Secondly, as postoperative urinary dysfunction and sexual dysfunction are often observed, which might result from the injury to the pelvic plexuses in the surgery, unilateral lymph node dissection is suggested. Only when enlarged lymph nodes are found in both sides, bilateral dissection is performed. As well, pelvic automatic nerve should be preserved carefully during the surgery. Thirdly, for surgeons who are skillful in robotic and laparoscopy surgery, minimally invasive surgery could be used.