结肠脾曲癌的手术方式选择及淋巴结清扫范围

Splenic flexure cancer:surgical procedures and extent of lymphadenectomy

结肠脾曲癌较其他部位结肠癌的发生率低, 但通常分期较晚, 更易发生急性肠梗阻。由于其特殊的双向供血特征, 其淋巴回流可同时流向肠系膜上血管及肠系膜下血管周围。较高的血管变异率带来对支配血管及主要淋巴回流方向判断的不确定性。目前对其淋巴结转移分布, 尤其是主淋巴结转移规律及清扫价值的研究病例数较少, 因而难以形成手术方式及淋巴结清扫范围方面的共识。充分游离结肠对满足足够的切缘和两侧供血血管的根部结扎尤其重要。未来应结合影像学三维重建、CT血管造影技术及术中淋巴结荧光显像等技术, 积极开展多中心研究, 为脾曲癌根治手术方式及淋巴结清扫范围的选择, 提供更充足的循证医学证据。

Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites.It is also associated with more advanced disease and higher rate of acute obstruction.The splenic flexure receives blood supply from both superior and inferior mesenteric arteries(SMA and IMA),and therefore has lymphatic drainage to both areas.The blood supply is also highly variable,causing difficulties in determining the main feeding vessels and the main direction of lymph drainage.Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread,especially the main lymph node status and the value of its dissection.The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy.Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA.Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration,with the use of modern techniques,including CT 3D reconstruction of the colon and angiography,as well as intraoperative fluorescent real-time imaging of lymph nodes.