Willaert Wouter, Ceelen Wim
Wouter Willaert, Wim Ceelen, Department of Surgery, Ghent University Hospital, B-9000 Ghent, Belgium.
World J Gastroenterol. 2015 Jan 7;21(1):132-8. doi: 10.3748/wjg.v21.i1.132.
Since the introduction of total mesorectal excision as the standard approach in mid and low rectal cancer, the incidence of local recurrence has sharply declined. Similar attention to surgical technique in colon cancer (CC) has resulted in the concept of complete mesocolic excision (CME), which consists of complete removal of the intact mesentery and high ligation of the vascular supply at its origin. Although renewed attention to meticulous surgical technique certainly has its merits, routine implementation of CME is currently unfounded. Firstly, in contrast to rectal cancer, local recurrence originating from an incompletely removed mesentery is rare in CC and usually a manifestation of systemic disease. Secondly, although CME may increase nodal counts and therefore staging accuracy, this is unlikely to affect survival since the observed relationship between nodal counts and outcome in CC is most probably not causal but confounded by a range of clinical variables. Thirdly, several lines of evidence suggest that metastasis to locoregional nodes occurs early and is a stochastic rather than a stepwise phenomenon in CC, in essence reflecting the tumor-host-metastasis relationship. Unsurprisingly, therefore, comparative studies in CC as well as in other digestive cancers have failed to demonstrate any survival benefit associated with extensive, additional or extra-mesenteric lymphadenectomy. Finally, routine implementation of CME may cause patient harm by longer operating times, major vascular damage and autonomic nerve injury. Therefore, data from randomized trials reporting relevant endpoints are required before CME can be recommended as a standard approach in CC surgery.
自从全直肠系膜切除术被引入作为中低位直肠癌的标准术式以来，局部复发率已大幅下降。对结肠癌（CC）手术技术给予类似关注后产生了完整结肠系膜切除术（CME）的概念，该术式包括完整切除完整的系膜并在其起始处高位结扎血管供应。尽管重新关注精细的手术技术确实有其优点，但目前尚无充分依据常规实施CME。首先，与直肠癌不同，CC中因系膜切除不完全导致的局部复发很少见，通常是全身疾病的一种表现。其次，尽管CME可能会增加淋巴结计数，从而提高分期准确性，但这不太可能影响生存率，因为在CC中观察到的淋巴结计数与预后之间的关系很可能不是因果关系，而是受到一系列临床变量的混淆。第三，有几条证据表明，CC中向区域淋巴结转移发生得很早，并且是一种随机而非逐步的现象，本质上反映了肿瘤-宿主-转移关系。因此，毫不奇怪，CC以及其他消化系统癌症的比较研究未能证明广泛、额外或系膜外淋巴结清扫术能带来任何生存益处。最后，常规实施CME可能会因手术时间延长、主要血管损伤和自主神经损伤而对患者造成伤害。因此，在CME被推荐作为CC手术的标准术式之前，需要来自报告相关终点的随机试验的数据。
