结肠肝曲癌的幽门下淋巴转移及清扫

Metastasis and dissection of infrapyloric lymph node in the colon cancer of hepatic flexure

结肠癌是最常见的消化道恶性肿瘤之一,最主要转移方式是淋巴结转移,彻底清扫区域淋巴结是右半结肠癌外科治疗的核心之一。D3根治术和完整结肠系膜切除术(CME)是目前较为公认的右半结肠癌的手术方法,可以提高手术的规范性和肿瘤切除的质量,并提供更多的淋巴结清扫数目。目前,部分研究发现结肠肝曲癌有可能出现幽门下淋巴结(No.206)转移,No.206淋巴结属于非区域淋巴结,清扫No.206淋巴结属于右半结肠癌扩大根治术。右半结肠癌扩大根治术涉及的血管变异多、周围解剖结构关系复杂。膜解剖理论给外科医生提供了解剖学基础,清晰认识幽门下区域解剖结构,是彻底清扫No.206淋巴结的重要理论基础,可以完整地切除肿块、相应区域淋巴结和脂肪结缔组织,实现无出血手术的目标。清扫No.206淋巴结,并非单纯切除肉眼可见淋巴结,而是把连同脂肪组织在内的、该区域整个淋巴结和淋巴管一并切除。右半结肠癌扩大根治术对手术技术要求较高,扩大清扫术带来的生存获益尚缺少高级别证据支持。而且关于结肠肝曲癌幽门下淋巴结清扫的远期疗效,目前研究资料尚少,缺乏具有说服力的临床研究,有待临床多中心前瞻性研究的开展,来证实结肠肝曲癌扩大根治术的疗效。

Colon cancer is one of the most common malignancies of the alimentary tract,and one main metastatic route is lymph node metastasis.Thorough dissections of regional lymph nodes is one of the core surgical treatment of right colon cancer.D3 lymphadenectomy and complete mesocolic excision(CME)are generally accepted surgical methods for right colon cancer,which can improve the standardization of surgery,improve the quality of tumor resection,and provide more lymph nodes dissectal.Colon cancer of hepatic flexure is likely to have metastasis of the infrapyloric lymph nodes(No.206),which are not regional lymph nodes.Lymph node dissection of No.206 group belongs to extended right hemicolectomy,which involves many vascular variations and complicated peripheral anatomical structure.The theory of fascial surgery provides surgeons with anatomic basis and a clear understanding of the anatomical structure of the infrapyloric region,which is an important theoretical basis for the thorough dissection of lymph nodes in No.206 group,and can completely remove the mass,regional lymph nodes and adipose connective tissue,so as to achieve the goal of non-bleeding surgery.Lymph nodes in No.206 group were dissected,not just the visible lymph nodes,but the entire lymph nodes and lymphatic vessels in the region,including adipose tissue.Extended right hemicolectomy requires higher surgical techniques.The survival benefits of extended right hemicolectomy are not supported by high-level evidence.It is still controversial whether the infrapyloric lymph node dissection should become routine for colon cancer of hepatic flexure.In this article,the metastasis and dissection of infrapyloric lymph node in colon cancer of hepatic flexure is elucidated.