Management of lateral pelvic lymph nodes in rectal cancer:Is it time to reach an Agreement?

In this editorial,we proceed to comment on the article by Chua et al,addressing the management of metastatic lateral pelvic lymph nodes(mLLN)in stage II/III rectal cancer patients below the peritoneal reflection.The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians,albeit with a higher degree of convergence in recent years.The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries.In contrast,in the West,preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy,that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision.In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy,the risk of lateral local recurrence increases,suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile.Despite the heterogeneous and retrospective nature of studies addressing this area,an international consensus is necessary to approach this clinical scenario uniformly.

Feasibility and limitations of combined treatment for lateral pelvic lymph node metastases in rectal cancer

Colorectal cancer ranks among the most commonly diagnosed cancers globally,and is associated with a high rate of pelvic recurrence after surgery.In efforts to mitigate recurrence,pelvic lymph node dissection(PLND)is commonly advocated as an adjunct to radical surgery.Neoadjuvant chemoradiotherapy(NACRT)is a therapeutic approach employed in managing locally advanced rectal cancer,and has been found to increase the survival rates.Chua et al have proposed a combination of NACRT with selective PLND for addressing lateral pelvic lymph node metastases in rectal cancer patients,with the aim of reducing recurrence and improving survival outcomes.Nevertheless,certain studies have indicated that the addition of PLND to NACRT and total mesorectal excision did not yield a significant reduction in local recurrence rates or improvement in survival.Consequently,meticulous patient selection and perioperative chemotherapy may prove indispensable in ensuring the efficacy of PLND.

Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer

Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases(mLLN)in patients with low rectal cancer.The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented.However,the adequacy of pelvic lymph node dissection(PLND)or neoadjuvant chemoradiation(NACRT)alone in addition to total mesorectal excision(TME)have recently come into question,due to the relatively high incidence of lateral local recurrences following PLND and TME,or NACRT and TME alone.Recently,a more selective approach to PLND has been suggested,involving a combination of neoadjuvant therapy,followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events.A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging,such as nodal size,appearance,and size reduction following neoadjuvant therapy.However,no consensus has been reached regarding the optimal criteria for a selective approach to PLND,partly due to the heterogeneity and retrospective nature of most of these studies.This review aims to provide an overview of recent evidence with regards to the diagnostic challenges,considerations for,and outcomes of the current management strategies for mLLN in rectal cancer patients.

Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer

BACKGROUND As one effective treatment for lateral pelvic lymph node(LPLN)metastasis(LPNM),laparoscopic LPLN dissection(LPND)is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery.With regard to improving the accuracy and completeness of LPND as well as safety,we tried an innovative method using indocyanine green(ICG)visualized with a near-infrared(NIR)camera system to guide the detection of LPLNs in patients with middle-low rectal cancer.AIM To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer.METHODS A total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision(TME)and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group.Clinical characteristics,operative outcomes,pathological outcomes,and postoperative complication information were compared and analysed between the two groups.RESULTS Compared to the non-ICG group,the ICG group had significantly lower intraoperative blood loss(55.8±37.5 mL vs 108.0±52.7 mL,P=0.003)and a significantly larger number of LPLNs harvested(11.5±5.9 vs 7.1±4.8,P=0.017).The LPLNs of two patients in the non-IVG group were residual during LPND.In addition,no significant difference was found in terms of LPND,LPNM,operative time,conversion to laparotomy,preoperative complication,or hospital stay(P>0.05).CONCLUSION ICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

Short term outcomes of minimally invasive selective lateral pelvic lymph node dissection for low rectal cancer

BACKGROUND Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment(CRT),and one of the most common areas of recurrence is in the lateral pelvic lymph nodes.Hence,there is a possible role for lateral pelvic lymph node dissection(LPND)in rectal cancer.AIM To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery.Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans.METHODS From October 2016 to November 2019,22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND.These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery.All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans,defined as lymph nodes larger than 7 mm in long axis measurement,or abnormal radiological morphology.LPND was only performed on the involved side.RESULTS Majority of the patients were male(18/22,81.8%),with a median age of 65 years(44-81).Eighteen patients completed neoadjuvant CRT pre-operatively.18 patients(81.8%)had unilateral LPND,with the others receiving bilateral surgery.The median number of lateral pelvic lymph nodes harvested was 10(3-22)per pelvic side wall.8 patients(36.4%)had positive metastases identified in the lymph nodes harvested.The median pre-CRT size of these positive lymph nodes was 10 mm.Median length of stay was 7.5 d(3-76),and only 2 patients failed initial removal of their urinary catheter.Complication rates were low,with only 1 lymphocele and 1 anastomotic leak.There was only 1 mortality(4.5%).There have been no recurrences so far.CONCLUSION Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas.A pre-CRT lymph node size of≥10 mm is suggestive of metastases.LPND may be performed safely with minimally invasive surgery.

Prophylactic lateral pelvic lymph node dissection in stage Ⅳ low rectal cancer

AIM To assess the clinical significance of prophylactic lateral pelvic lymph node dissection (LPLND) in stage Ⅳ low rectal cancer.METHODS We selected 71 consecutive stage Ⅳ low rectal cancer patients who underwent primary tumor resection,and enrolled 50 of these 71 patients without clinical LPLN metastasis.The patients had distant metastasis such as liver,lung,peritoneum,and paraaortic LN.Clinical LPLN metastasis was defined as LN with a maximum diameter of 10 mm or more on preoperative pelvic computed tomography scan.All patients underwent primary tumor resection,27 patients underwent total mesorectal excision(TME) with LPLND(LPLND group),and 23 patients underwent only TME(TME group).Bilateral LPLND was performed simultaneously with primary tumor resection in LPLND group.R0 resection of both primary and metastatic sites was achieved in 20 of 50 patients.We evaluated possible prognostic factors for 5-year overall survival (OS),and compared 5-year cumulative local recurrence between the LPLND and TME groups.RESULTS For OS,univariate analyses revealed no significant benefit in the LPLND compared with the TME group (28.7% vs 17.0%,P = 0.523); multivariate analysis revealed that R0 resection was an independent prognostic factor.Regarding cumulative local recurrence,the LPLND group showed no significant benefit compared with TME group (21.4% vs 14.8%,P = 0.833).CONCLUSION Prophylactic LPLND shows no oncological benefits in patients with Stage Ⅳ low rectal cancer without clinical LPLN metastasis.

Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer

BACKGROUND The procedure for lateral lymph node(LLN)dissection(LLND)is complicated and can result in complications.We developed a technique for laparoscopic LLND based on two fascial spaces to simplify the procedure.AIM To clarify the anatomical basis of laparoscopic LLND in two fascial spaces and to evaluate its efficacy and safety in treating locally advanced low rectal cancer(LALRC).METHODS Cadaveric dissection was performed on 24 pelvises,and the fascial composition related to LLND was observed and described.Three dimensional-laparoscopic total mesorectal excision with LLND was performed in 20 patients with LALRC,and their clinical data were analyzed.RESULTS The cadaver study showed that the fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side in a medial-lateral direction constituting the dissection plane for curative rectal cancer surgery,and the last three fasciae formed two spaces(Latzko's pararectal space and paravesical space)which were the surgical area for LLND.Laparoscopic LLND in two fascial spaces was performed successfully in all 20 patients.The median operating time,blood loss and postoperative hospitalization were 178(152-243)min,55(25-150)mL and 10(7-20)d,respectively.The median number of harvested LLNs was 8.6(6-12),and pathologically positive LLN metastasis was confirmed in 7(35.0%)cases.Postoperative complications included lower limb pain in 1 case and lymph leakage in 1 case.CONCLUSION Our preliminary surgical experience suggests that laparoscopic LLND based on fascial spaces is a feasible,effective and safe procedure for treating LALRC.

Lateral pelvic lymph nodes for rectal cancer:A review of diagnosis and management

The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node(LPLN)metastasis of rectal cancer are described in this review.Magnetic resonance imaging(MRI)is recommended for the diagnosis of LPLN metastasis.A LPLN-positive status on MRI is a strong risk factor for metastasis,and evaluation by MRI is important for deciding treatment strategy.LPLN dissection(LPLD)has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications;therefore,LPLD may not be appropriate for cases that are less likely to have LPLN metastasis.Radiation therapy(RT)and chemoradiation therapy(CRT)have limited effects in cases with suspected LPLN metastasis,but a combination of preoperative CRT and LPLD may improve the treatment outcome.Thus,RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.

Spleen-preserving splenic lymph node dissection in radical total gastrectomy

Radical gastrectomy has been recognized as the standard surgical treatment for advanced gastric cancer, and essentially applied in a wide variety of clinical settings. The thoroughness of lymph node dissection is an important prognostic factor for patients with advanced gastric cancer. Splenic lymph node dissection is required during D2 radical gastrectomy for upper stomach cancer. This is often accompanied by removal of the spleen in the past few decades. A growing number of investigators believe, however, that the spleen plays an important role as an immune organ, and thus they encourage the application of a spleen- preserving method for splenic hilum lymph node dissection.

T1 rectal mucinous adenocarcinoma with bilateral enlarged lateral lymph nodes and unilateral metastasis:A case report

BACKGROUND There are a few cases of lateral lymph node(LLN)metastasis(LLNM)of T1 rectal cancer.Moreover,LLNM is easily missed,especially in patients with early-stage rectal cancer.To our knowledge,the possibility of bilateral LLNM before surgery has not been reported in previous studies.CASE SUMMARY A 36-year-old woman underwent endoscopic submucosal dissection at a local hospital owing to a clinical diagnosis of a rectal polyp.The pathology report showed a diagnosis of T1 rectal mucinous adenocarcinoma.She was considered to have bilateral LLNM after the examination at our hospital.Laparoscopic total mesorectal excision plus bilateral LLN dissection was performed and the pathological outcomes indicated unilateral LLNM.The patient received longcourse adjuvant chemoradiotherapy with no recurrence or metastasis observed during the 1-year follow-up period.CONCLUSION T1 rectal cancer could lead to LLNM and possibly,bilateral LLNM.Therefore,adequate clinical evaluation is essential for these patients.

New classification system for radical rectal cancer surgery based on membrane anatomy

BACKGROUND Total mesorectal excision along the“holy plane”is the only radical surgery for rectal cancer,regardless of tumor size,localization or even tumor stage.However,according to the concept of membrane anatomy,multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection.AIM To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery.METHODS A three-dimensional template of the member anatomy of the pelvis was established,and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation.Then,we suggested a new and simple classification system for rectal cancer surgery.For simplification,the classification was based only on the lateral extent of resection.RESULTS The fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces(medial,middle and lateral),and blood vessels and nerves are precisely positioned in the fascia or space.Three types of radical surgery for rectal cancer are described,as are a few subtypes that consider nerve preservation.The surgical planes of the proposed radical surgeries(types A,B and C)correspond exactly to the medial,middle,and lateral spaces,respectively.CONCLUSION Three types of radical surgery can be precisely defined based on membrane anatomy,including nerve-sparing procedures.Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

Technical feasibility of laparoscopic extended surgerybeyond total mesorectal excision for primary or recurrentrectal cancer

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer.Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.

基于MRI探索用于术前预测直肠癌侧方淋巴结转移的短径截断值

目的:探讨基于侧方淋巴结(lateral pelvic lymph node, LPLN)短径预测术前进行新辅助治疗和未进行新辅助治疗的直肠癌患者LPLN转移的诊断标准。方法:回顾性收集分析自2012年01月至2019年12月中国侧方淋巴结协作组的机构数据库中行全直肠系膜切除术(total mesorectal excision, TME)+侧方淋巴结清扫术(lateral pelvic lymph node metastasis, LPLND)的临床怀疑LPLN肿大的直肠癌患者的临床病理资料。结果:共纳入446例患者,根据不同术前治疗策略,将所有患者分为新辅助治疗组和无新辅助治疗组。新辅助治疗组患者病理pCR/T1(9.0%vs 2.7%,P=0.013)和N0(41.9%vs 55.3%,P<0.001)的比例与无新辅助治疗组患者差异明显。此外,相比于无新辅助治疗组患者,新辅助治疗组患者手术时间明显延长(300.7 vs 277.4 min,P=0.018)。新辅助治疗组与无新辅助治疗组分别有40例(25.8%)和78例(26.8%)患者病理诊断为LPLN转移。髂内淋巴结是新辅助治疗组(16.1%)和无新辅助治疗组(15.8%)患者最常见的LPLN转移位置。新辅助治疗组患者平均转移LPLN短径(1.0 vs 1.4 mm,P=0.015)和无转移LPLN短径(0.6 vs 0.8 mm,P=0.005)明显短于无新辅助治疗组。无新辅助治疗组和新辅助治疗组患者分别以9 mm和7 mm作为LPLN截断值时,AUC值分别为0.817和0.745,有着较好的一致性。结论:接受新辅助治疗和未接受新辅助治疗的患者分别以7 mm和9 mm作为LPLN截断值时,有着最佳的预测LPLN转移的能力。

四步法保留左结肠动脉用于腹腔镜下直肠癌根治术的效果

目的分析四步法保留左结肠动脉(LCA)用于腹腔镜下直肠癌根治术的效果。方法选择2020年5月至2022年5月在上海交通大学医学院苏州九龙医院进行治疗的102例择期行腹腔镜下直肠癌根治术的患者为研究对象,按照随机数字表法将其分为观察组和对照组,各51例。观察组采用“四步法”在保留LCA基础上进行手术,对照组在不保留LCA的基础上进行手术。比较两组手术和淋巴结清扫情况、手术前后肿瘤标志物、并发症发生情况,以及1年随访情况。结果两组手术时间、术中出血量、术后排气时间、肠鸣音恢复时间、住院时间、淋巴结清扫总数、NO.253淋巴结清扫数目比较,差异无统计学意义(P>0.05)。术后两组肿瘤标志物水平较术前降低(P<0.05),两组肿瘤标志物水平比较,差异无统计学意义(P>0.05)。观察组并发症总发生率低于对照组(P<0.05)。两组术后1年癌细胞转移发生率比较,差异无统计学意义(P>0.05)。结论将四步法保留LCA用于腹腔镜下直肠癌根治术患者对其手术时间、术中出血量、淋巴结清除率,以及肿瘤标志物水平无明显影响,但保留LCA可降低并发症发生风险。

腹腔镜结肠癌根治术治疗结肠癌的疗效及对胃肠道功能的影响分析

目的探讨在结肠癌的治疗中采用腹腔镜手术的临床效果及对患者胃肠道功能的影响。方法选取58例结肠癌患者,采用随机数字表法分成对照组和研究组,每组29例。对照组采用传统开放手术治疗,研究组采用腹腔镜结肠癌根治术治疗。对比两组围手术期相关指标、淋巴结清扫数量、血清炎性指标、血清应激指标及并发症发生率。结果研究组术中出血量(87.63±6.24)ml、术后引流量(24.32±2.05)ml较对照组的(122.25±9.52)、(30.23±2.63)ml少,手术时间(136.15±7.16)min、术后排气时间(3.14±0.26)d、肠鸣音恢复时间(2.34±0.43)d、恢复饮食时间(68.74±4.23)h、住院时间(10.42±1.16)d均较对照组的(141.05±8.75)min、(4.25±0.55)d、(3.58±0.75)d、(87.36±5.52)h、(15.27±1.44)d短(P<0.05)。两组肿瘤分期Ⅰ、Ⅱ期淋巴结清扫数量无显著差异(P>0.05);研究组肿瘤分期Ⅲ期淋巴结清扫数量、阳性淋巴结清扫数量、左半结肠淋巴结清扫数量、右半结肠淋巴结清扫数量分别为(25.11±2.02)、(21.06±2.14)、(18.87±1.42)、(24.23±2.14)个,均多于对照组的(17.58±1.36)、(12.25±1.23)、(16.25±1.26)、(18.54±1.52)个(P<0.05)。术后,对照组白细胞介素-6(IL-6)为(28.85±2.12)pg/ml,C反应蛋白(CRP)为(12.36±1.42)mg/L;研究组IL-6为(17.96±1.63)pg/ml,CRP为(8.64±1.15)mg/L,研究组IL-6、CRP较对照组低(P<0.05)。术后,对照组肾上腺素为(99.87±7.58)pg/ml,去甲肾上腺素为(176.52±9.36)pg/ml,皮质醇为(24.63±2.14)pg/ml;研究组肾上腺素为(64.25±4.31)pg/ml,去甲肾上腺素为(87.56±5.15)pg/ml,皮质醇为(13.54±1.63)pg/ml,两组较术前均有所升高,而研究组肾上腺素、去甲肾上腺素、皮质醇均较对照组低(P<0.05)。研究组并发症发生率(6.90%)较对照组(31.03%)低(P<0.05)。结论在结肠癌治疗中采用腹腔镜结肠癌根治术治疗可提高淋巴结清扫数量,缩短术后胃肠功能的恢复时间,改善血清炎性指标水平,减少应激反应,术后并发症发生率较低,有利于术后机体的康复,建议临床广泛应用。

机器人手术系统在低位直肠癌根治术联合侧方淋巴结清扫术中的应用

目的:评估机器人手术系统在低位直肠癌根治术(TME)联合侧方淋巴结清扫术(LLND)中的可行性及安全性。方法:选取2016年3月至2020年6月郑州大学第一附属医院收治的低位直肠癌合并侧方淋巴结肿大的患者187例,其中46例接受机器人手术系统辅助下TME+LLND(机器人组),141例接受腹腔镜下TME+LLND(腹腔镜组)。随访至2022年3月。比较2组的疗效和安全性指标。结果:2组患者均顺利完成手术。与腹腔镜组相比,机器人组保肛率高(71.7%vs 54.6%),手术时间短[(242.61±44.99) min vs(300.64±58.78) min],LLND时间短[(89.78±21.86) min vs(119.01±24.36) min],出血量少[(134.13±59.58) mL vs(371.21±181.11) mL],排气时间短[(2.96±0.82) d vs(3.75±1.10) d],术后住院时间短[(10.63±1.64) d vs(13.63±1.73) d],淋巴瘘发生率低(21.7%vs 38.3%)(P均<0.05);机器人组术后性功能及排尿功能评分均优于腹腔镜组(P<0.05)。机器人组侧方淋巴结清扫数多于腹腔镜组[(7.87±2.28)vs(5.69±2.39)](P<0.05)。2组患者总生存期、无病生存期差异均无统计学意义(P>0.05)。结论:机器人手术系统辅助下TME+LLND治疗低位直肠癌合并侧方淋巴结肿大安全、可行。

完整结肠系膜切除治疗结肠癌的临床疗效及安全性分析

目的分析完整结肠系膜切除(CME)治疗结肠癌的临床效果与安全性。方法整理本院收治的42例结肠癌患者(2018年1月~2022年12月)信息,在随机数字表下分为对照组(21例,传统根治术治疗)和观察组(21例,CME治疗);比较两组淋巴结清除情况、围术期指标、并发症及肠道菌群数量。结果观察组术中平均淋巴结清除数量(25.46±2.13)枚、阳性转移淋巴结清除数量(18.33±1.12)枚及左半结肠淋巴结清除数量(8.17±1.62)枚、右半结肠淋巴结清除数量(8.62±1.42)枚均较对照组的(17.22±2.31)、(11.45±1.06)、(6.92±1.33)、(5.67±1.05)枚更多(P<0.05)。两组手术时间对比无差异(P>0.05);观察组术中出血量(121.26±15.33)ml较对照组的(172.33±17.26)ml更少,术后拔管时间(8.10±1.24)d、肛门排气时间(32.12±5.64)h、排便时间(3.46±0.57)d、经口进食时间(3.26±0.90)d、住院时间(9.12±1.32)d均较对照组的(12.11±2.23)d、(46.25±7.12)h、(4.11±0.69)d、(4.11±1.12)d、(12.33±1.35)d更短(P<0.05)。观察组并发症发生率为4.76%,低于对照组的19.05%,但无差异性(P>0.05)。术后3 d,观察组双歧杆菌数量(7.02±1.20)cfu/ml、乳酸杆菌数量(6.89±1.02)cfu/ml、屎肠球菌数量(5.72±0.70)cfu/ml均多于对照组的(6.23±0.91)、(6.23±0.72)、(4.87±0.42)cfu/ml,大肠杆菌数量(8.02±1.03)cfu/ml少于对照组的(9.22±1.20)cfu/ml(P<0.05)。结论完整结肠系膜切除治疗结肠癌效果显著,可提升淋巴结清除数量,减少并发症,加快患者术后恢复进程,维持其肠道菌群稳定性。

全直肠系膜切除术联合侧方淋巴结清扫术治疗中低位直肠癌侧方淋巴结转移的疗效

目的:探讨侧方淋巴结清扫术(lateral lymph node dissection,LLND)对侧方淋巴结(lateral lymph node,LLN)转移直肠癌患者的治疗价值和LLN转移位置对生存预后的影响。方法:自2015年01月至2020年01月,回顾性收集分析在中国医学科学院肿瘤医院行全直肠系膜切除术(total mesorectal excision,TME)+LLND的临床怀疑LLN转移的中低位直肠癌患者与同时期行TME根治性切除的直肠癌患者的资料。根据手术方式,分为TME+LLND组(n=129)与TME组(n=362)。倾向得分匹配后,两组各有125例患者成功匹配。本研究的长期随访终点是3年局部复发率(local recurrence,LR)和3年无复发生存率(recurrence-free survival,RFS)。结果:TME+LLND组手术时间明显长于TME组(356.1 vs 244.8 min,P<0.001),而术后并发症并无明显增加(16.0 vs 12.0,P=0.362)。预后方面,TME+LLND与TME两组间3年LR率无明显差异(10.7%vs 8.8%,P=0.817),然而,TME+LLND组患者术后远处转移明显较高(15.2%vs 7.2%,P=0.044)。根据淋巴结状态与分期对患者进行亚组分析,髂内与闭孔转移患者3年RFS与N2期患者相似(57.1%vs 55.3%,P=0.613)。髂外与髂总转移患者预后与IV期患者3年RFS相似(49.1%vs 22.5%,P=0.302),且显著劣于N2期患者(49.1%vs 55.3%,P=0.044)。结论:LLN转移直肠癌患者可以通过LLND获得令人满意的局部控制效果。局限于髂内和闭孔淋巴结转移的患者可以通过LLND取得生存获益,可视作局部淋巴结转移进行管理与治疗。髂外和髂总转移患者通过LLND治疗效果不理想,预后劣于N2期,略优于IV期患者,此类患者应谨慎选择LLND。

102例直肠癌侧方淋巴结转移患者临床病理特点及生存预后分析

目的探讨侧方淋巴结清扫术(LPLND)在侧方淋巴结(LPLN)转移患者中的治疗效果及预后意义。方法回顾性分析2012年1月—2020年12月在中国医学科学院肿瘤医院和北京大学第一医院行全直肠系膜切除术(TME)联合LPLND术后病理证实LPLN转移的直肠癌患者的临床病理资料。探讨LPLN转移患者临床病理特点与转移规律,同时进行预后分析。结果共纳入102例病理证实LPLN转移的直肠癌患者。LPLN常见转移部位依次为髂内淋巴结(n=68,66.7%)、闭孔淋巴结(n=44,43.1%)和髂总/髂外淋巴结(n=12,11.8%)。10例(9.8%)患者出现双侧LPLN转移,平均LPLN转移数量为2.2±2.4,其中16例(15.7%)患者LPLN转移数量≥2。LPLN转移至髂外/髂总淋巴结的患者3年总体生存率(OS)(66.8%vs.7.7%,P<0.001)与无瘤生存率(DFS)(39.1%vs.10.5%,P=0.012)明显低于转移至髂内/闭孔淋巴结转移的患者。多因素分析显示LPLN转移至髂外/髂总是影响OS(HR=3.53;95%CI:1.50~8.31;P=0.004)和DFS(HR=2.40;95%CI:1.05~5.47;P=0.037)的共同独立危险因素。结论LPLN转移主要位于髂内血管与闭孔区域。转移至髂外或髂总淋巴结患者的生存预后无法通过LPLND改善,全身性综合治疗往往是此类患者的最佳治疗选择。

幽门下淋巴结清扫在腹腔镜右半结肠癌根治术中的临床应用

目的探讨幽门下淋巴结清扫在腹腔镜右半结肠癌根治术中的应用效果。方法选取2019年1月至2022年2月萍乡市人民医院收治的50例右半结肠癌患者作为研究对象,根据疾病类型分为对照组与观察组,每组25例。对照组为非横结肠近肝曲的右半结肠癌患者,观察组为横结肠近肝曲的右半结肠癌患者,两组均采用幽门下淋巴结清扫术治疗,比较两组围手术期指标、肿瘤标志物、淋巴结阳性率及术后并发症发生率。结果观察组手术时间、中央淋巴结清扫时间均长于对照组,术中出血量、淋巴结清扫数及幽门下区淋巴结数量均多于对照组,差异有统计学意义(P<0.05)。术后7d,两组血管内皮生长因子(VEGF)、结肠癌特异性抗原2(CCSA-2)及可溶性细胞黏附分子-1(sICAM-1)水平均低于术前,且观察组低于对照组,差异有统计学意义(P<0.05)。观察组术后淋巴结阳性率低于对照组,差异有统计学意义(P<0.05);两组术后并发症发生率比较差异无统计学意义。结论幽门下淋巴结清扫用于腹腔镜右半结肠癌根治术中手术创伤较小,能改善患者肿瘤标志物水平,降低淋巴结阳性率,且未增加术后并发症发生率,值得临床推广应用。