John Goligher Colorectal Unit, St. James's University Hospital, Leeds, UK.
RPA Institute of Academic Surgery, University of Sydney, 145-147 Missenden Road, Camperdown, NSW, 2050, Australia.
Int J Colorectal Dis. 2020 May;35(5):869-880. doi: 10.1007/s00384-020-03541-x. Epub 2020 Feb 28.
Tenets of 'good quality' colon cancer surgery include mesocolic plane dissection to preserve an intact mesocolic fascia/peritoneum, and excision of sufficient mesocolon for adequate lymphadenectomy. However, it remains controversial what clinicopathological factors determine 'good quality' surgery, and whether quality of surgery influences morbidity/mortality. This study documents the quality of colon cancer surgery at a quaternary referral centre and identifies factors that influence quality of surgery and post-operative outcomes.
Consecutive patients who underwent resection for colon adenocarcinoma at St. James's University Hospital, Leeds, UK (2015-2017), were included. Primary outcome measures included (i) plane of mesocolic dissection, prospectively assessed; and (ii) tissue morphometry (area of mesentery and vascular pedicle length). Other histopathological data were extracted from a prospective database. Clinical data were obtained from the National Bowel Cancer Audit and individual records.
Four hundred five patients were included (mean 69.6 years). The majority (67.4%) of specimens were mesocolic plane dissections. Median area of mesentery excised was 12,085.4 mm. Median vascular pedicle length was 89.3 mm. Post-operative complication was recorded in one-third of patients. Mesocolic plane excision was associated with open surgery (OR 1.80, 95% CI 1.05-3.09), especially in emergency colectomy. Open resections also had a greater mesentery excised (P = 0.002), but incurred more post-operative complication (OR 2.11, 95% CI 1.12-3.99). Post-operative complication was not associated with plane of excision or tissue morphometry.
Majority of resections were 'optimal' mesocolic plane dissections. Open resections yielded better quality specimens, but incurred more morbidity. There is room for improvement in the quality of laparoscopic colon cancer surgery, particularly those performed as emergency.
结肠癌手术“高质量”的原则包括横结肠系膜平面解剖，以保留完整的横结肠系膜筋膜/腹膜，并切除足够的横结肠系膜以进行充分的淋巴结清扫。然而，目前仍存在争议的是，哪些临床病理因素决定了“高质量”的手术，以及手术质量是否会影响发病率/死亡率。本研究记录了一家四级转诊中心的结肠癌手术质量，并确定了影响手术质量和术后结果的因素。
纳入 2015 年至 2017 年在英国利兹圣詹姆斯大学医院接受结肠癌切除术的连续患者。主要观察指标包括：（i）前瞻性评估的横结肠系膜平面解剖；和（ii）组织形态计量学（肠系膜面积和血管蒂长度）。其他组织病理学数据从一个前瞻性数据库中提取。临床数据来自国家结直肠癌审计和个人记录。
共纳入 405 例患者（平均年龄 69.6 岁）。大多数（67.4%）标本为横结肠系膜平面解剖。切除的肠系膜面积中位数为 12085.4mm。血管蒂长度中位数为 89.3mm。三分之一的患者出现术后并发症。横结肠系膜切除与开放性手术相关（OR 1.80，95%CI 1.05-3.09），尤其是在紧急结肠切除术。开放性手术切除的肠系膜也更大（P=0.002），但术后并发症更多（OR 2.11，95%CI 1.12-3.99）。术后并发症与切除平面或组织形态计量学无关。
大多数切除术是“最佳”的横结肠系膜平面解剖。开放性手术可获得更高质量的标本，但发病率更高。腹腔镜结肠癌手术，特别是紧急手术，还有改进的空间。
