Reply to: Right hemicolectomy with central vascular ligation in colon cancer
Reply to: Right hemicolectomy with central vascular ligation in colon cancer
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回复：结肠癌右半结肠切除中央血管结扎术
DOI：
10.1007/s00464-011-1892-x
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发表时间：
2012
期刊：
影响因子：
--
通讯作者：
D. Ignjatovic
中科院分区：
文献类型：
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作者：
M. Spasojevic;S. Kiil;B. Stimec;D. Ignjatovic
我们感谢韦伯和霍亨伯格医生的善意评论[1]；然而，我们想强调一些有趣的问题。结肠动脉解剖的差异是一个公认的事实，并已被很好地指出，这可能是由于所使用的定义、人群检查或方法[2]。数字并不重要；更重要的是，外科医生要意识到个别的变异，特别是那些可能会使手术过程复杂化的变异。我们的印象也是右结肠动脉在手术中并不像放射科那样经常被发现。有时，在手术前的MDCT血管造影中看到的右结肠动脉是如此小的口径，以至于在手术中可以成功地烧灼。然而，这并不意味着在其附近没有淋巴结或血管。此外，文献中有盲肠和升结肠癌向回结肠中央、右结肠和中结肠转移率分别为11.1%、5.0%和6.1%的数据[3]。根据最近的数据，这一点变得更加重要，因为有微转移和采集的淋巴结内分离的癌细胞的患者(在5-26%的阴性淋巴结中发现)存活率较低[4]。这就是为什么我们开始了一项随机对照试验(临床试验。GOV)通过术前多层螺旋CT血管成像，探讨右半结肠癌D3切除的安全性。我们D3切除(或CME)的手术技术与Hohenberger等人的有所不同[5]。在挪威，人们普遍倾向于采取中间途径。解剖始于在回肠末端静脉上方分割内脏腹膜，并切开肠系膜上静脉(SMV)的血管鞘。分离继续向肠系膜上动脉的左侧，然后向颅侧，跟随它到胃绞痛主干的水平。同时(在手术室)使用我们文章中提到的Osirix软件对血管进行三维重建(图1)。脂肪组织从SMV向患者右侧剥离；发现回结肠和右结肠动脉(如果存在)并在起始处分离。不分割结肠中动脉，但切除结肠中动脉起始处周围的脂肪组织，向患者右侧解剖，保持标本完整和完整。结肠中动脉的右支被分开。根据动脉的位置，动脉被拉向SMV的右手侧，前或后，右结肠静脉在其与胃结肠干的汇合处被分开。我们有一名血管外科医生在场(SK)。然后对切断血管的标本进行侧向移位。如果以这种方式进行解剖，人们会注意到一条通往下腔静脉的沟槽，它与结肠系膜一起被抬起。最后切除SMV后的血管鞘。最后，我们想说的是，接受D3切除的患者术后腹泻不是问题
We thank Doctors Weber and Hohenberger for their kind comments [1]; however, we would like to stress some points of interest. The variance of colon arterial anatomy is an established fact and has been well pointed out that it can be due to definitions used, population examined, or methodology [2]. The numbers are not crucial; it is more important that the surgeon be aware of the individual variants, especially those that can complicate surgical procedures. We also have had the impression that the right colic artery is not found at surgery as often as with radiology. On occasion, a right colic artery seen at preoperative MDCT angiography was of such a small caliber that it could be successfully cauterized at surgery. However, this does not imply that there are no lymph nodes or vessels in its vicinity. Moreover, there are data in the literature about metastasis in cecal and ascending colon cancer to the central ileocolic, right colic, and middle colic nodes at rates of 11.1, 5.0, and 6.1%, respectively [3]. This becomes even more important in light of recent data suggesting that patients with micrometastasis and isolated cancer cells within harvested lymph nodes (found in 5–26% of negative nodes) have lower survival rates [4]. This is why we have started a randomized controlled trial (ClinicalTrials. gov) to study safe D3 resection in right-sided colon cancer through the help of preoperative MDCT angiography. Our operative technique for D3 resection (or CME) differs somewhat from that of Hohenberger et al.[5]. A medial approach is generally preferred in Norway. Dissection begins by dividing the visceral peritoneum over the terminal ileal vein and opening the vascular sheath of the superior mesenteric vein (SMV). The dissection continues toward the left-hand side of the superior mesenteric artery, and then cranially, following it to the level of the gastrocolic trunk. This is simultaneously followed (in the operating room) by a 3D reconstruction of the vessels using the Osirix software mentioned in our article (Fig. 1). The fatty tissue is dissected from the SMV toward the patient’s right side; the ileocolic and right colic arteries are found (when present) and divided at their origin. The middle colic artery is not divided, but the fatty tissue around the origin of the middle colic artery is removed, dissecting it toward the right side of the patient and keeping the specimen intact and en bloc. The right branch of the middle colic artery is divided. The arteries are drawn toward the right-hand side of the SMV anterior or posterior depending on their position, and the right colic vein is divided at its confluence with the gastrocolic trunk. We have a vascular surgeon present in this segment of the procedure (SK). Lateral mobilization of the devascularized specimen is then performed. If the dissection is done in this manner, one will notice a gutter toward the vena cava that is lifted together with the mesocolon. The resection of the vascular sheath posterior to the SMV is performed last. Finally, we would like to say that postoperative diarrhea was not an issue in patients who underwent a D3 resection