Complete mesocolic excision: Lessons from anatomy translating to better oncologic outcome

Since the introduction of complete mesocolic excision(CME) for colon cancer, the oncologic outcome of patients has been greatly improved, which has led to a longer survival and a lower recurrence, just like the total mesorectum excision for rectal cancer. Despite the fact that the exact anatomy of the organ is one of the most vital things for surgeons to conduct surgery, no team has really studied the exact structure of the mesocolon and related attachments for CME, until the mesocolonic anatomy was first formally characterized in 2012. Therefore, this article mainly focuses on the anatomy development of the mesocolon and the achievement in this field. Meanwhile, we introduce the latest progress in laparoscopic surgery for colon cancer achieved by our team.

Laparoscopic complete mesocolic excision: West meets East

Complete mesocolic excision is a relatively new concept in western literature. It follows the same concept of total mesorectal excision and units' routinely performing complete mesocolic excisions have good pathological results as well as good improvements in overall survival, disease free survival and local recurrence. And yet unlike total mesorectal excision, uptake in the West has been relatively slow with many units sceptical of the true benefits gained by taking up a more technically challenging and potentially more morbid procedure when there is a paucity of literature to support these claims. This article reviews complete mesocolic excision for colon cancer, attempting to identify the risks and benefits of the technique and particularly looking at the reasons why its uptake has not been universal. It also discusses the similarities of a complete mesocolic excision to a colon resection with a D3 lymphadenectomy as well as the role of a laparoscopic approach to this technique. Considering a D3 lymphadenectomy has been the standard of care for stage Ⅱ and Ⅲ colon cancers in many of our Asian neighbours for over 20 years, combining this data with data on complete mesocolic excision may provide enough evidence to support or refute the need for complete mesocolic excisions. Maybe there might be lessons to be learnt from our colleagues in the east.

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer:A comprehensive review

Aim of the study is to comprehensively review the latest trends in laparoscopic complete mesocolic excision(CME) with central vascular ligation(CVL) for the multimodal management of right colon cancer. Historical and up-to-date anatomo-embryological concepts are analyzed in detail,focusing on the latest studies of the mesenteric organ,its dissection by mesofascial and retrofascial cleavage planes,and questioning the need for a new terminology in colonic resections. The rationale behind Laparoscopic CME with CVL is thoroughly investigated and explained. Attention is paid to the current surgical techniques and the quality of the surgical specimen,yielded through mesocolic,intramesocolic and muscularis propria plane of surgery. We evaluate the impact on long term oncologic outcome in terms of local recurrence,overall and disease-free survival,according to the plane of resection achieved. Conclusions are drawn on the basis of the available evidence,which suggests a pivotal role of laparoscopic CME with CVL in the multimodal management of right sided colonic cancer: performed in the right mesocolic plane of resection,laparoscopic CME with CVL demonstrates better oncologic results when compared to standard non-mesocolic planes of surgery,with all the advantages of laparoscopic techniques,both in faster recovery and better immunological response. The importance of minimally invasive mesoresectional surgery is thus stressed and highlighted as the new frontier for a modern laparoscopic total right mesocolectomy.

Complete mesocolic excision: Techniques and outcomes

Complete mesocolic excision(CME) for the treatment of colon cancer was first introduced in the West in 2008. The first aim of this procedure is to remove the afflicted colon and its accessory lymphovascular supply by resecting the colon and mesocolon in an intact envelope of visceral peritoneum, which holds potentiallyinvolved lymph nodes. The second component of CME is a central vascular tie to remove completely all lymph nodes in the central(vertical) direction. In its original iteration, CME was performed via laparotomy, although many centers preferentially perform laparoscopic surgery, with its associated benefits and similar oncolo-gical outcomes, as the standard treatment for colonic cancer. Here, we present the surgical techniques for CME in open and laparoscopic surgery, as well as the surgical, pathological and oncological outcomes of the procedure that are available to date. Because there are no randomized control trials comparing CME to "standard" colon surgery, the principles underlying CME seem anatomical and logical, and the results published from the Far East, reporting an 80% 5-year survival rate for Stage III cancer, should guide us.

Post-operative computed tomography scan – reliable tool for quality assessment of complete mesocolic excision

BACKGROUND Quality control in colon cancer surgery is an ongoing debate ever since standardization proved to be highly efficient in improving survival in rectal cancer. Complete mesocolic excision(CME) is widely acclaimed as the new goldstandard in colon cancer resections, thus it is imperative to establish quality criteria of CME in order to make it easily understood and verified by surgeons worldwide. One simple and reproducible tool could be the measurement of arterial stumps postoperatively and a straightforward way to test its reliability is to test it in a comparative study between CME and non-CME surgery.AIM To validate arterial stump measurement as a surgical quality tool by comparing CME with conventional radical colectomies.METHODS This was a retrospective study, carried out on a prospective database. We collected data from two groups of patients, divided according to standard CME with D2 central vascular ligation(group A) and non-standardized surgery(group B). The two groups were compared with regard to the arterial stump length after right-and left-sided colectomies for colon cancer. The actual stump lengths of the ileocolic artery(ICA) and inferior mesenteric artery(IMA) were compared with their theoretical best D2 position of predicted ligation levels(D2 PLLs) for calculating the potential for improvement. Measurements on follow-up computed tomography scans were carried out by three observers. Pathological data were recorded(specimen length, lymph node yield) and correlated with stump length.RESULTS We analysed 58 colectomies. The stump lengths(mean ± SD) in group A were16.97 ± 4.77 mm for ICA and 31.70 ± 15.71 mm for IMA, whereas group B had 49.93 ± 20.29 mm for ICA and 67.24 ± 28.71 mm for IMA. Shorter lengths were obtained in group A, by a mean difference of 35.66 mm(χ~2 = 27.38, P < 0.001),which was significant for all types of colectomies. Except for a 5.85 ± 4.71 mm difference for right colectomies, all the ligations from group A significantly reached their potential height(0.26 ± 12.18 mm from D2 PLL; χ~2 = 0.005, P = 0.944).Apart from three left colectomies, group B failed to reach D2 PLL, by a mean difference of 32.14 ± 26.15 mm(χ~2 = 21.77, P < 0.001). The calculated improvement potentials were significantly shorter in group A than in group B, by a mean of 31.88 mm(χ~2= 22.13, P < 0.001). The large spread of results in group B showed that there is significant variability(P = 0.004) when compared to standard surgery. Significant correlations were found between stump length, specimen length and number of lymph nodes(P = 0.018 and P = 0.008 respectively). No statistical difference was found between observers' measurements(P = 0.866).CONCLUSION Arterial stump monitoring is a significant step in defining surgical quality, as longer stumps contain residual mesocolic tissue and correlate with major prognostic factors.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis

AIM To compare the effectiveness of laparoscopic complete mesocolic excision(CME) with central vascular ligation(L-CME) with its open(O-CME) counterpart. METHODS We conducted an electronic search of the Pub Med/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, Sci ELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials(RCTs) and controlled clinical trials(CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen(lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individualstudies.RESULTS A total of one RCT and eleven CCTs(four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes(MD =-1.06, 95%CI:-3.65 to 1.53, P = 0.42), and tumor to high tie distance(MD = 14.26 cm, 95%CI:-4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group(MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions(OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall(OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free(OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival. CONCLUSION The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.

Laparoscopic complete mesocolic excisions for colonic cancer in the last decade:Five-year survival in a single centre

AIM To analyse clinical and long-term oncologic results after laparoscopic complete mesocolic excision(CME) for colonic cancer over a 10-year period.METHODS Consecutive patients who received laparoscopic CME at our hospital from 2007 to 2017 were prospectively registered and retrospectively analysed. In total, 341 patients were included with tumour-nodal-metastasis(TNM) stages 0-Ⅲ.RESULTS The mean age of the patients was 71.9 years. The median length of stay was 5 d. The mean lymph node harvest was 17.8. The mortality rate was 1.2%. Fifteen patients were reoperated on for anastomotic leaks. The local recurrence rate was 2.3%. Five-year TTR and cancer-specific survival CSS were 83.1% and 90.3%. The location of the tumour was not a significant variable for survival in unadjusted and adjusted survival analysis. TNM stage and anastomotic leaks were significant variables with respect to survival.CONCLUSION Laparoscopic CME results in acceptable complication rates and long-term oncologic results. It is important to avoid anastomotic leaks because of their negative effect on survival.

Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision?

BACKGROUND Complete mesocolic excision(CME)with central vascular ligation(CVL)was proposed by Hohenberger in 2009.The CME principle has gradually become the technical standard for colon cancer surgery.How to achieve CME with CVL in laparoscopic right hemicolectomy(LRH)is controversial,and a unified standard approach is not yet available.In recent years,the authors’team has integrated the theory of membrane anatomy,tried to combine the cephalic approach with the classic medial approach(MA)for technical optimization,and proposed a cranialmedial mixed dominant approach(CMA).AIM To explore the feasibility of operational approaches for LRH with CME.METHODS In this retrospective cohort study,the clinical data of 57 patients with right-sided colon cancer(TNM stage I,II,or III)who underwent LRH with CME from January 2016 to June 2020 were collected and summarized.There were 31 patients in the traditional MA group and 26 in the CMA group.RESULTS There were no significant differences in baseline data between the two groups.The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group,but there was no significant difference in the number of positive lymph nodes,intraoperative blood loss,postoperative exhaust time,feeding time,postoperative hospital stay or postoperative complication incidence.CONCLUSION Our study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.

Historical development of mesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic excision

Although total mesorectal excision has now become the‘gold standard’for the surgical management of rectal cancer,this is not so for colon cancer.Recent data,provided by Hohenberger and West et al.and others,have demonstrated excellent oncological outcomes when mesenterectomy is extensive(as is implicit in the concept of a‘high tie’)and the mesenteric package not violated.Such studies highlight the importance of understanding the basics of the mesenteric organ(including the small intestinal mesentery,mesocolon,mesosigmoid and mesorectum)and of abiding to principles of planar surgery.In this review,we first offer classic descriptions of the mesocolon and then detail contemporary thinking.In so doing,we provide an anatomical basis for safe and effective complete mesocolic excision(CME)in the management of colon cancer.Finally we list opportunities associated with the new anatomical paradigm,demonstrating benefits across multiple disciplines.Perhaps most importantly,we feel that a crystallized view of mesenteric anatomy will overcome factors that have hindered the general uptake of CME.

腹腔镜CME手术与开腹CME手术在根治性右半结肠癌中的近期和远期疗效比较

目的探讨腹腔镜全结肠系膜切除(CME)手术与开腹CME手术在根治性右半结肠癌中的近期和远期疗效差异。方法选取本院2017年1月—2018年8月收治的右半结肠癌患者84例,采用随机数字表法分为微创组(42例)和开腹组(42例)。微创组给予腹腔镜CME手术治疗,开腹组给予开腹CME手术治疗,比较2组患者手术相关指标(术中出血量、手术时间、淋巴结清扫数量、术后进食时间、术后排气时间)、应激反应相关指标[促肾上腺皮质激素(ACTH)、皮质醇(COR)、肾上腺素(E)]、术后并发症、术后生存率及复发率、术后生活质量。结果微创组术后进食时间、术后排气时间短于开腹组,术中出血量均少于开腹组,差异有统计学意义(P<0.05)。术后,2组患者ACTH、COR、E水平升高,但微创组低于开腹组,差异均有统计学意义(P<0.05)。微创组术后并发症发生率为4.76%,低于开腹组的23.81%,差异有统计学意义(P<0.05)。微创组术后1年生存率、3年生存率及3年复发率分别为97.62%、83.33%、19.05%,开腹组1年生存率、3年生存率及3年复发率分别为95.24%、80.95%、21.43%,组间差异无统计学意义(P>0.05)。术后6个月及术后12个月,2组患者生活质量评分升高,且微创组高于开腹组,差异均有统计学意义(P<0.05)。结论腹腔镜下CME手术与开腹CME手术远期预后均较好,但腹腔镜下CME术后应激反应轻,恢复快,且并发症少,可优先选择。

尾侧中间联合入路在腹腔镜结肠癌完整结肠系膜切除术患者中的应用效果

目的:观察尾侧中间联合入路在腹腔镜结肠癌完整结肠系膜切除术患者中的应用效果。方法:回顾性分析2020年1月至2021年12月该院收治的60例右半结肠癌并不完全性肠梗阻患者的临床资料,根据手术入路不同将其分为对照组和研究组各30例。两组均行腹腔镜结肠癌完整结肠系膜切除术治疗,对照组采用头侧中间联合入路,研究组采用尾侧中间联合入路,两组术后均随访1年。比较两组手术相关指标(手术时间、术中出血量、排便时间、排气时间、术后住院时间)水平,手术前后应激指标[促肾上腺皮质激素(ACTH)、皮质醇(Cor)、去甲肾上腺素(NE)、肾上腺素(E)]水平、炎性指标[肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、C反应蛋白(CRP)]水平、肿瘤标志物[癌胚抗原(CEA)、糖类抗原125(CA125)、糖类抗原19-9(CA19-9)]水平,并发症发生率和1年生存率。结果:研究组手术时间、排便时间、排气时间、术后住院时间均短于对照组,术中出血量少于对照组,差异有统计学意义(P<0.05);术后1 d,研究组ACTH、Cor、NE、E、CRP、TNF-α、IL-6水平均低于对照组,差异有统计学意义(P<0.05);术后3d,研究组CEA、CA125、CA19-9水平均低于对照组,差异有统计学意义(P<0.05);两组并发症发生率和1年生存率比较,差异均无统计学意义(P>0.05)。结论:尾侧中间联合入路应用于腹腔镜结肠癌完整结肠系膜切除术患者可改善手术相关指标水平,降低术后应激指标、炎性指标和肿瘤标志物水平,效果优于头侧中间联合入路。

结肠癌患者CME术后化疗联合DC-CIK细胞免疫治疗的临床疗效和安全性

目的:探讨结肠癌患者完整结肠系膜切除(complete mesocolic excision,CME)术后化疗联合DC-CIK细胞免疫治疗的临床疗效和安全性。方法:收集2012年6月至2013年12月河北省沧州中西医结合医院肿瘤外科的82例Ⅲ期结肠癌患者,随机分为两组,均接受CME手术。单纯化疗组(n=42)采用Cape OX方案,给予6周期化疗;DC-CIK细胞免疫治疗联合化疗组(联合治疗组,n=40)除采用Cape OX方案化疗外,同时给予负载自身肿瘤抗原的DC肿瘤疫苗和细胞因子诱导的杀伤细胞(CIK)进行细胞免疫治疗。观察两组患者治疗前后CEA的变化、细胞免疫指标(外周血CD3^+、CD4^+、CD8^+、CD19^+、CD56^+及CD4^+CD25^+FOXP3^+Treg细胞的百分比)、治疗期间的药物毒副作用以及比较两组2年肿瘤复发率。结果:两组患者术后2周CEA数值较术前均有明显下降(P<0.05)。两组患者治疗前、后及术后1年的CEA数值差异无统计学意义(P>0.05)。单纯化疗组术后2年的CEA数值与治疗后及与联合治疗组相比均明显升高(均P<0.05)。单纯化疗组化疗后CD8^+和Treg细胞的百分比明显下降(P<0.05),余指标变化无统计学意义。联合治疗组治疗后CD3^+、CD4^+、CD8^+、CD19^+、CD3^+ CD56^+细胞的百分比显著提高(P<0.05),Treg细胞的百分比明显下降(P<0.05)。联合治疗组患者的骨髓抑制、恶心呕吐、腹泻、外周神经毒性及手足综合征等药物毒副作用的发生率均明显降低(均P<0.05)。单纯化疗组的2年肿瘤复发率为23.81%,联合治疗组为7.5%,差异有统计学意义(P<0.05)。结论:DC-CIK细胞免疫治疗联合化疗可以提高结肠癌患者术后的机体免疫功能,改善生活质量,减少化疗药物的毒副作用,并明显降低肿瘤2年的复发率。

国产图迈■内窥镜手术机器人辅助右半结肠癌根治术的应用分析

目的:初步探讨图迈■内窥镜手术机器人辅助右半结肠癌根治术的安全性及可行性。方法:收集甘肃省人民医院普外科一病区于2022年04月至06月收治的6例右半结肠癌患者的临床病例资料,其中男性4例,女性2例,中位年龄57岁,范围37~68岁;患者均行图迈■内窥镜手术机器人辅助右半结肠癌根治术,即右半结肠D3+全结肠系膜切除术。结果:6例患者均顺利完成手术;平均手术时间204.16 min,术中出血量108.31 mL,术后下床活动时间为3.16 d,术后胃肠功能恢复时间为4.16 d,术后进食流质食物时间为5 d,腹腔引流管引流时间8 d,淋巴结清扫数目为23.33枚,术后住院时间9.5 d;术中、术后均无器械相关的不良事件发生;6例患者均行全身静脉化疗,方案为FOLFOX,疗程为6~8个周期;1年总体生存率为100%。结论:图迈■内窥镜手术机器人辅助右半结肠癌根治术安全、可行,临床疗效良好;该机器人系统有望成为国内辅助根治结肠癌的主要手段。

基于CME理念的腹腔镜与开腹右半结肠癌根治术疗效对比

目的:比较采用完整结肠系膜切除术(CME)理念的腹腔镜下右半结肠癌根治术与开放右半结肠癌根治术的临床应用价值及安全性。方法:选取接受腹腔镜下右半结肠癌根治手术的33例结肠癌患者的临床资料,该组均采用经中间入路,完整结肠系膜切除的手术方式。并选取同期由同一手术组以开放途径,采取CME手术方式施行右半结肠癌根治术的47例患者作为对照组,比较两组患者的短期疗效和手术安全性。结果:腹腔镜组33例患者均在腹腔镜下完成手术。腹腔镜组平均手术时间较开腹组延长[(198.6±45.2)min比(134.9±33.3)min,P<0.05]。平均出血量,平均清扫淋巴结个数,术后并发症发生率与开放手术比较,差异有统计学意义(P<0.05)。平均术后住院日及术后排气时间少于对照组[(7.9±1.2)天比(8.2±2.3)天,(2.9±1.2)天比(3.1±1.1)天,P<0.05]。结论:基于CME理念的腹腔镜右半下结肠癌根治术难度较高,但未增大手术风险及术后并发症发生率,技术可行,患者恢复快,术后短期效果良好。

Quality assessment of surgery for colorectal cancer:Where do we stand?

Quality assurance in surgery has been one of the most important topics of debate among colorectal surgeons in the past decade.It has produced new surgical standards that led in part to the impressive oncological outcomes we see in many units today.Total mesorectal excision,complete mesocolic excision(CME),and the Japanese D3 lymphadenectomy are now benchmark techniques embraced by many surgeons and widely recommended by surgical societies.However,there are still ongoing discrepancies in outcomes largely based on surgeon performance.This is one of the main reasons why many countries have shifted colorectal cancer surgery only to high volume centers.Defining markers of surgical quality is thus a perquisite to ensure that standards and oncological outcomes are met at an institutional level.With the evolution of CME surgery,various quality markers have been described,mostly based on measurements on the surgical specimen and lymph node yield,while others have proposed radiological markers(i.e.arterial stumps)measured on postoperative scans as part of the routine cancer follow-up.There is no ideal marker;however,taken together and assembled into a new score or set of criteria may become a future point of reference for reporting outcomes of colorectal cancer surgery in research studies and defining subspecialization requirements both at an individual and hospital level.

CME联合术中动脉灌注及腹腔内间质缓释剂化疗的研究

目的:探讨CME联合术中动脉灌注及腹腔内间质缓释剂化疗的安全性及疗效。方法:选取行CME联合术中动脉灌注并腹腔内间质缓释剂化疗的结肠癌患者104例为试验组,98例行结肠癌根治术患者为对照组。检测患者术前、术后血常规、肝肾功能,记录术后不良反应、并发症发生率。检测试验组癌组织、癌旁组织、术后引流液以及外周血5-FU浓度。随访3年,记录两组患者局部复发率、肝脏转移率、无疾病进展生存率及总生存率。结果:两组术前、术后血常规、肝肾功能,术后不良反应、并发症发生率无显著性差异(P>0.05)。试验组癌组织中5-FU浓度明显高于癌旁组织。试验组患者术后第3天腹腔内引流液5-FU浓度显著升高,同时外周血5-FU浓度达到峰值。试验组淋巴结转移率、肝脏转移率、无疾病进展生存率及3年总生存率均明显优于对照组,差异具有统计学意义(P<0.05)。结论:试验组患者的治疗安全有效,明显提高无疾病进展生存率和3年总生存率,且能显著降低结肠癌的淋巴结转移率和肝脏转移率。

腹腔镜下CME对右半结肠癌患者术后血清学指标及免疫的影响

目的:探讨腹腔镜下完整肠系膜切除术(CME)及传统开腹CME手术对右半结肠癌患者血清炎性应激指标、肿瘤学指标及免疫功能的影响。方法:选取106例右半结肠癌患者,依据手术方式分为开腹组与腹腔镜组,各53例。术后比较2组患者血清炎性应激指标、肿瘤标志分子水平及全血T淋巴细胞亚群比例。结果:术后2组患者血清C反应蛋白(CRP)、白介素-6(IL-6)、单核细胞趋化因子蛋白-1(MCP-1)、高迁移率族蛋白-1(HMGB-1)、血糖(GLU)等炎性应激指标水平均较术前有明显升高(P<0.05),且术后开腹组显著高于腹腔镜组(P<0.05);术后开腹组血清结肠癌特异性抗原-2(CCSA-2)、3’sulfo-Lewis、膜联蛋白(Annexin-A5)、中期因子(MK)、人多效生物因子(PTN)水平均显著高于腹腔镜组(P<0.05);术后腹腔镜组Th1细胞比例显著高于开腹组,而Th2、Th17及Treg细胞比例显著低于开腹组(P<0.05)。结论:腹腔镜CME较开腹CME创伤小,有助于减轻患者术后炎性应激反应,减少肿瘤标志分子的释放并保护术后机体细胞免疫功能。

完整结肠系膜切除术(CME)在进展期结肠癌手术中的临床应用

目的探讨完整结肠系膜切除术(CME)在进展期结肠癌手术中的临床应用。方法选取进展期结肠癌患者共100例,随机分为实验组和对照组,实验组患者采用CME术治疗,而对照组患者采用传统根治术治疗。结果实验组患者的淋巴结清扫总数明显多于对照组患者,差异有统计学意义(P<0.05);2组患者的术后3天内腹腔引流量差异有统计学意义(P<0.05),术后3天内实验组患者的腹腔引流量明显多于对照组患者;2组患者的术中出血量、术后住院日与住院费用差异均无统计学意义(P>0.05);术后2组患者出现肠梗阻、淋巴瘘与切口裂开等不良反应情况差异均无统计学意义(P>0.05)。结论 CME在某一程度上为结肠癌手术技术上的一次创新,是有效、安全、可行的治疗手段。

BMI对开腹与腹腔镜下CME术治疗Ⅲ期右半结肠癌的临床效果与预后的影响

目的:探讨体重指数(BMI)对开腹与腹腔镜下完整结肠系膜切除(CME)术治疗Ⅲ期右半结肠癌临床效果与预后的影响。方法:回顾性分析2014年1月—2016年6月接受CME术治疗的126例III期右半结肠癌患者的临床资料。根据手术方式不同分为腹腔镜组(n=67)与开腹组(n=59)。根据中国成人肥胖标准,将腹腔镜组再分为BMI正常组(A组,BMI<28)和BMI超标组(B组,BMI≥28);将开腹组再分为BMI正常组(C组,BMI<28)和BMI超标组(D组,BMI≥28)。比较腹腔镜组与开腹组、A组与B组、C组与D组的手术时间、术中出血量、淋巴结清除数量、术后排气时间、术后并发症、住院时间,术前和术后炎症指标(外周血内IL-6、IL-8、CRP)、免疫功能指标(外周血内CD3^+、NK细胞所占比例及CD4^+/CD8^+比值)和肿瘤标志物(CEA及CA19-9)水平,以及术后3年内肿瘤复发、转移和肿瘤相关死亡情况。结果:与开腹组相比,腹腔镜组手术时间显著延长,术中出血量显著减少,术后排气时间及住院时间显著缩短,总并发症发生率显著降低;与A组相比,B组手术时间、术后排气时间及住院时间均显著延长,术中出血量显著增多;与C组相比,D组术中出血量显著增多;以上各指标差异均有统计学意义(P<0.05)。腹腔镜组术后IL-6、IL-8、CRP水平显著低于开腹组,CD3^+、NK细胞所占比例及CD4^+/CD8^+比值均显著高于开腹组;A组术后IL-6、IL-8、CRP水平显著低于B组,CD3^+、NK细胞所占比例及CD4^+/CD8^+比值均显著高于B组;以上各指标差异均有统计学意义(P<0.05)。C组和D组术后炎症(IL-6、IL-8、CRP)和免疫功能(CD3^+、NK细胞所占比例及CD4^+/CD8^+)指标比较,差异均无统计学意义(P>0.05)。所有患者术后1个月的CEA、CA19-9水平较术前均显著降低,差异有统计学意义(P<0.05);但腹腔镜组与开腹组、A组与B组、C组与D组术后1个月的CEA、CA19-9水平比较,差异均无统计学意义(P>0.05)。腹腔镜组与开腹组、A组与B组、C组与D组术后3年内肿瘤复发、远处转移及肿瘤相关死亡发生率比较,差异均无统计学意义(P>0.05)。结论:腹腔镜下CME术治疗Ⅲ期右半结肠癌患者安全、可靠,近远期疗效均达到开腹CME的效果,且患者创伤小、出血少、康复快。BMI超标即肥胖增加腹腔镜下CME手术操作的难度,术中出血多,术后恢复慢,但对患者临床疗效及预后均无明显影响。

CME理念在腹腔镜右半结肠癌根治术中的应用

结肠癌是严重威胁人类健康及生命安全的常见的恶性肿瘤,手术仍是目前最有效的治疗手段。相对于传统的右半结肠癌根治术,全结肠系膜切除术(CME)理念下腹腔镜根治术结合了腹腔镜手术微创性的同时也保证了肿瘤的根治性。了解CME理念下右半结肠癌根治术的适应证与禁忌证、手术入路、解剖结构以及术中注意事项等对于顺利完成腹腔镜右半结肠CME根治术至关重要。深入了解CME下右半结肠癌根治术目前存在的问题以及发展的方向,可提高患者的生存率,改善患者的生活质量。