Liang Jin-Tung, Huang Kuo-Chin, Lai Hong-Shiee, Lee Po-Huang, Sun Chia-Tung
Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC.
Ann Surg Oncol. 2007 Jul;14(7):1980-90. doi: 10.1245/s10434-007-9368-x. Epub 2007 Apr 26.
Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach.
The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection.
The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6-76.9] months in the N0 group; 56.8 [48.3-65.2] months in N1; 46.8 [37.5-56.1] months in N2; and 43.9 [28.3-59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean +/- standard deviation, 27.4 +/- 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 +/- 44.5 mL), but at the expense of a long operation time (294.4 +/- 34.8 minutes).
The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.
许多日本外科医生常规进行扩大的D3淋巴结清扫术以治疗进展期乙状结肠癌，以期实现更好的肿瘤控制。然而，应用腹腔镜方法进行D3淋巴结清扫术一直具有挑战性。这项2期前瞻性研究旨在探索这种手术方法的肿瘤学结果。
考虑到中位随访时间>3年，该研究在6年期间进行。研究对象为经临床影像分期为肿瘤、淋巴结、转移系统III期的乙状结肠癌。D3清扫范围及术后淋巴结图谱绘制均遵循日本结直肠癌学会的指南。患者根据组织病理学证实的最高受累淋巴结水平进行分层，分为N0、N1、N2和N3组。该研究的主要终点为腹腔镜D3清扫术后癌症的估计复发时间和5年复发率。
估计的5年复发率（N0组为20%[n = 10]；N1组为25%[n = 44]；N2组为33.3%[n = 30]；N3组为42.8%[n = 14]）、复发时间（N0组平均[95%置信区间]为59.8[42.6 - 76.9]个月；N1组为56.8[48.3 - 65.2]个月；N2组为46.8[37.5 - 56.1]个月；N3组为43.9[28.3 - 59.4]个月）以及复发模式在N0、N1、N2和N3组之间无显著差异（所有P值>.05）。因此，通过腹腔镜广泛解剖清扫，有淋巴结受累的患者与无淋巴结转移的患者治疗效果相当。腹腔镜D3清扫有助于收集更多淋巴结（平均±标准差，27.4±4.2个）用于组织病理学检查。清扫淋巴结的图谱显示，18.2%（88例中的16例）患者存在跳跃性淋巴结转移。D3清扫使5例患者（5.1%）的癌症分期上调（从N0到N3）。然而，该手术导致77.5%的患者出现短暂性排尿功能障碍，91.7%的患者出现射精功能丧失。通过腹腔镜方法，D3淋巴结清扫术通过小切口安全进行，导致功能恢复快且失血仅为中度（324.8±44.5 mL），但手术时间较长（294.4±34.8分钟）。
良好的短期肿瘤学结果和快速康复意味着对于能够接受泌尿生殖系统功能障碍的III期乙状结肠癌患者，可推荐腹腔镜D3清扫术。
