Colonic surgery for cancer: a new paradigm
Colonic surgery for cancer: a new paradigm
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结肠癌手术：新范例
DOI：
10.1111/j.1463-1318.2009.01793.x
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发表时间：
2009
影响因子：
3.4
通讯作者：
N. Haboubi
中科院分区：
文献类型：
--
作者：
N. Haboubi
在过去二十年左右的时间里，结肠直肠病界有理由庆祝直肠癌治疗的重大进展，包括全直肠系膜切除术（TME）、经肛门内窥镜显微手术、粘膜下切除术、迈尔斯一个世纪前首次描述的腹会阴切除术的原始方法的转世以及辅助放化疗等等。其中最重要的一项是 Heald 在 20 世纪 80 年代推广的 TME [1]。希尔德强调了几点，其中最重要的是胚胎发育过程中创建的解剖/手术平面中的解剖概念。这种方法与局部复发率低有关，这是手术等局部区域治疗的终点。 TME 也与病理学家相关。 Quirke 在他的经典研究中 [2]）表明，在切除标本中检查时，局部复发与圆周切除边缘的状态有关。手术和组织病理学方法相互补充，因为它们都反映了相同的病理特征，本质上是手术清除的程度。这是针对特定科学问题的多学科方法的胜利之一。虽然直肠癌取得了这些进展，但结肠癌的手术几乎没有受到影响。在本期中，我们发表了 Hohenberger 等人的一项大型研究的结果。来自德国埃尔兰根，其中直肠癌 TME 的相同原理已应用于结肠 [3]。他们将该技术称为完全结肠系膜切除术（CME）。这项重要的研究必须与另外两篇论文结合起来阅读，以完成观察、应用和验证的三位一体。其中第一个来自澳大利亚悉尼康科德医院的 Bokey 和同事 [4]，他们是第一个发表结肠癌手术平面和临床结果的数据的人，并对大肠的胚胎学进行了清晰的描述。作者报告了 867 名结肠癌患者接受了治愈性治疗，未接受新辅助化疗，随访时间中位数为 49 个月。他们将观察期分为两个时间段：1971-1979年，普通外科医生在没有统一或标准化技术的情况下对结肠癌进行手术；1980-1995年，手术技术被标准化以尊重“胚胎学/手术平面”。腹膜后易于识别的结肠“融合”筋膜的胚胎发育被认为类似于直肠固有筋膜。他们的手术技术原理包括切除结肠肿瘤及其淋巴管引流，同时保持融合筋膜层完整。该技术基于“沿解剖平面的精确解剖，促进手术不会损害或破坏结肠及其肠系膜的表面包膜”。在进行左或右半结肠切除术或乙状结肠切除术时，这些手术/胚胎学平面略有不同。病理学家将圆周切除边缘描述为受累或不受累。他们发现结肠癌手术的结果与切除的完整性和无腹膜受累直接相关。他们发现，引入标准化技术后，总体5年生存率从第一代的48.1%上升到63.7%，提高了15%。最近发表的第二项相关且重要的研究是 West 等人的研究。来自英国利兹[5]。这是首次尝试将结肠系膜 (MC) 切除的病理特征与采用医学研究委员会结直肠癌患者传统手术与腹腔镜辅助手术 (CLASICC) 研究 [6] 中的结肠手术质量和 CR07 试验的病理分级 [7] 的结果联系起来。这是一项对399例结肠癌的回顾性观察研究，对标本的前视图和后视图照片进行分析，特别参考MC切除的级别，并将结果与结果进行比较。作者根据解剖的手术平面（MP、IMC 和 MC）将病例分为三组或三级。固有肌层 (MP) 等级，手术平面被认为较差，标本显示少量结肠系膜，破坏延伸至 MP。第二级是结肠系膜间（IMC）平面，手术平面被认为是中等，标本显示中等数量的结肠系膜，有一些不规则性，但没有暴露MP。第三级为MC平面，认为手术平面良好，结肠系膜光滑，腹膜完整。该研究的优点之一是标本的照片记录，
Over the last two decades or so, the world of coloproctology has had cause to celebrate significant advances in the treatment of rectal cancer including total mesorectal excision (TME), trans-anal endoscopic microsurgery, Submucosal resection, the reincarnation of Miles’ original approach for abdomino-perineal resection first described a century ago and adjuvant chemo-radiotherapy to name but a few examples. One of the most important, was TME popularized by Heald in the 1980s [1]. Heald emphasized several points the most important being the concept of dissection in the anatomical ⁄ surgical planes created during embryological development. This approach has been associated with low rates of local recurrence which is the end point for a loco-regional treatment such as surgery. TME is also relevant to the pathologist. Quirke in his classical study [2]) has shown that local recurrence is related to the state of the circumferential resection margin when examined in the resected specimen. Both surgical and histopatological approaches compliment each other since they are both reflections of the same pathological feature which is essentially the degree of surgical clearance. This is one of the triumphs of the multidisciplinary approach to a given scientific problem. While these advances were being made in rectal cancer,, surgery for colonic cancer has been left almost untouched. In this issue we publish the results of a large study by Hohenberger et al. from Erlangen, Germany, in which the same principle of TME in rectal cancer has been applied to the colon [3]. They call the technique complete mesocolic excision (CME). This important study has to be read in conjunction with two other papers to complete the triad of observation, application and verification. The first of these is from Bokey and colleagues of the Concord Hospital, Sydney, Australia [4] who were the first to publish data on the surgical planes and clinical outcome of surgery for colon cancer with a clear description of the embryology of the large intestine. The authors reported 867 patients with colonic cancer treated with curative intent with no neo-adjuvant chemotherapy followed for a median of 49 months. They divided the observation period into two time periods;1971–1979 in which general surgeons carried out surgery on colon cancer with no unified or standardized technique and 1980–1995 during which the surgical technique was standardized to respect the ‘embryological ⁄ surgical planes’. The embryological development of the colonic ‘fusion’ fascia easily recognized retroperitoneally was regarded as analogous to the fascia propria of the rectum. The principle of their surgical technique involved removal of the colonic tumour and its lymphovascular drainage with the layer of the fusion fascia intact. The technique was based on ‘precise dissection along anatomic planes facilitating an operation that will not compromise or breach the facial envelope of the colon and its mesentery’ These surgical ⁄ embryological planes varied slightly when doing a left or right hemicoloectomy or a sigmoid colectomy. The pathologist described the circumferential resection margins as either involved or not involved. They found that the outcome of colonic cancer surgery was directly related to the completeness of excision and the absence of peritoneal involvement They found that the overall 5 years survival rose by 15% from 48.1% in the first era to 63.7 after the introduction of the standardized technique. The second relevant and important recently published study is that by West et al. from Leeds, UK [5]. This was the first attempt to relate pathological features of mesocolic (MC) excision to outcome adopting the quality of colon surgery from the Medical Research Council Conventional Versus Laproscopic Assisted Surgery in patients with Colorectal Cancer (CLASICC) study [6] and the pathological grading from the CR07 trial [7]. It was a retrospective observational study of 399 cases of colonic cancer in which the photographs of anterior and posterior views of the specimen were analysed with special reference to grade of MC excision and the results were compared with outcome. The authors divided their cases into three groups or grades according to the surgical plane of dissection (MP, IMC and MC). The muscularis propria (MP) grade in which the surgical plane was regarded as poor and the specimen showed little amount of mesocolon with disruption extending down to the MP. The second grade was the intermesocolic (IMC) plane in which the surgical plane was regarded as moderate and the specimen showed moderate amount of mesocolon with some irregularity but without exposure of the MP. The third grade was the MC plane in which the plane of surgery was regarded as good and the mesocolon was smooth with intact peritoneum. One of the strong points of the study was the photographic documentation of the specimens, which
影响因子：
9.6
作者：
HEALD, RJ;HUSBAND, EM;RYALL, RDH
通讯作者：
RYALL, RDH