Siani L M, Pulica C
Unit of General Surgery, Department of Surgery "Carlo Poma" Hospital, Mantua, Italy -
Minerva Chir. 2014 Aug;69(4):199-208.
Complete removal of mesocolon "as an envelope" (complete mesocolic excision, CME) with central vascular ligation and apical node dissection (CVL) in the surgical management of right sided colonic cancer is a novel technique focused on resection of the colon surrounded by its intact primitive dorsal mesentery containing the tumors and all the routes of initial cancerous diffusion; our aim was to evaluate quality of surgical specimens and the relative impact on long-term oncologic outcome when compared to less radical planes of surgery.
Data were collected in 159 staged I-IIIC right sided colon cancers operated on with the concept of CME and CVL, between 2008 and 2013.
Morbidity and mortality were 37.7% and 1.9% respectively. Overall and disease free survival were 80.5% and 69.8% at five years. Mesocolic, intramesocolic and muscolaris-mucosa planes of resection were achieved in 64.7%, 22.6% and 12.5% of cases, respectively: mesocolic plane of surgery impacted significantly on R0 resection rate (98%), CRM<1 mm (2.9%) and overall survival (81.5% at 5 years) when compared to muscolaris propria plane of surgery, with R0 resection rate and 5 years survival falling to 65% and 60%, respectively, and CRM<1 mm rising to 35%, being all statistically significant; statistical difference was also recorded for intramesocolic plane of resection, with survival, R0 resection rate and CRM<1 mm of 72.2%, 86.1% and 13.8%, respectively. Stratifying patients for stage of disease, CME with CVL significantly improved survival in stage II, IIIA/B and in a subgroup of IIIC patients, with not metastatically involved apical nodes.
CME with CVL follows the oncologic principle based on resection of the primitive embryological mesenterium as an intact envelope, along with central lymphadenectomy up to the apical nodes, translating in higher surgical specimens quality and significant impact on locoregional control and overall survival when compared to less radical planes of surgery.
在右侧结肠癌手术治疗中，采用中央血管结扎和顶端淋巴结清扫术（CVL）进行“包膜样”完整结肠系膜切除（完整结肠系膜切除术，CME）是一种新技术，其重点在于切除被包含肿瘤及其所有初始癌扩散途径的完整原始背侧系膜所环绕的结肠；我们的目的是评估手术标本的质量以及与不太彻底的手术层面相比，其对长期肿瘤学结局的相对影响。
收集了2008年至2013年间采用CME和CVL理念进行手术的159例I-IIIC期右侧结肠癌患者的数据。
发病率和死亡率分别为37.7%和1.9%。五年时的总生存率和无病生存率分别为80.5%和69.8%。分别有64.7%、22.6%和12.5%的病例实现了结肠系膜、结肠系膜内和肌层-黏膜层面的切除：与固有肌层手术层面相比，结肠系膜手术层面显著影响R0切除率（98%）、环周切缘＜1mm（2.9%）和总生存率（5年时为81.5%），R0切除率和5年生存率分别降至65%和60%，环周切缘＜1mm则升至35%，均具有统计学意义；结肠系膜内手术层面也有统计学差异，生存率、R0切除率和环周切缘＜1mm分别为72.2%、86.1%和13.8%。根据疾病分期对患者进行分层，CME联合CVL显著提高了II期、IIIA/B期以及IIIC期未发生顶端淋巴结转移亚组患者的生存率。
CME联合CVL遵循基于完整切除原始胚胎系膜包膜并进行直至顶端淋巴结的中央淋巴结清扫的肿瘤学原则，与不太彻底的手术层面相比，可提高手术标本质量，并对局部区域控制和总生存率产生显著影响。
