Moriya Yoshihiro, Akasu Takayuki, Fujita Shin, Yamamoto Seiichirou, Inada Ryou, Takawa Masashi
Division of Colorectal Surgery, Tokyo, Japan.
Nihon Geka Gakkai Zasshi. 2011 Sep;112(5):325-9.
Lateral lymphatics of the rectum originate in the area where branches of the inferior hypogastric plexus and the middle rectal vessels from the internal iliac vessels enter the mesorectum below the level of the peritoneal reflection in the pelvis, then reach the bifurcation of iliac vessels along the internal iliac vessels. Among lateral lymph nodes, the middle rectal, obturator, and internal iliac lymph nodes are important from the viewpoint of both the incidence of metastais and treatment effects. Although total mesorectal excision (TME) had become the standard surgical treatment for rectal cancer by the 1990s, this technique does not treat lateral node metastasis. A randomized clinical trial of TME versus D3 lymphadenectomy (JCOG0212) was started in 2003, and the registration of 701 patients with lower rectal cancer was completed in August 2010. The results of this clinical trial are highly anticipated. In Japan, where the rate of local recurrence after surgery is low, patients at high risk of local recurrence such as those with lateral node metastasis, T4 disease, and multiple lymph node metastases in the mesorectum should be selected to receive preoperative chemoradiation. Japanese surgeons who treat rectal cancers are in an advantageous position because they have the additional measure of lateral node dissection along with TME and chemoradiotherapy.
直肠的外侧淋巴管起源于下腹下丛分支和来自髂内血管的直肠中血管进入盆腔腹膜返折水平以下直肠系膜的区域，然后沿髂内血管到达髂血管分叉处。在外侧淋巴结中，从转移发生率和治疗效果来看，直肠中、闭孔和髂内淋巴结很重要。尽管到20世纪90年代全直肠系膜切除术（TME）已成为直肠癌的标准手术治疗方法，但该技术并不能治疗外侧淋巴结转移。一项TME与D3淋巴结清扫术对比的随机临床试验（JCOG0212）于2003年启动，2010年8月完成了701例低位直肠癌患者的登记。该临床试验的结果备受期待。在日本，手术局部复发率较低，对于局部复发高危患者，如伴有外侧淋巴结转移、T4期病变以及直肠系膜内多发淋巴结转移的患者，应选择接受术前放化疗。治疗直肠癌的日本外科医生处于有利地位，因为他们除了TME和放化疗外，还有外侧淋巴结清扫这一额外手段。
