Wong Kar Yong, Tan Aloysius Mn
Colorectal Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore.
World J Gastrointest Surg. 2020 Apr 27;12(4):178-189. doi: 10.4240/wjgs.v12.i4.178.
Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment (CRT), and one of the most common areas of recurrence is in the lateral pelvic lymph nodes. Hence, there is a possible role for lateral pelvic lymph node dissection (LPND) in rectal cancer.
To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery. Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans.
From October 2016 to November 2019, 22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND. These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery. All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans, defined as lymph nodes larger than 7 mm in long axis measurement, or abnormal radiological morphology. LPND was only performed on the involved side.
Majority of the patients were male (18/22, 81.8%), with a median age of 65 years (44-81). Eighteen patients completed neoadjuvant CRT pre-operatively. 18 patients (81.8%) had unilateral LPND, with the others receiving bilateral surgery. The median number of lateral pelvic lymph nodes harvested was 10 (3-22) per pelvic side wall. 8 patients (36.4%) had positive metastases identified in the lymph nodes harvested. The median pre-CRT size of these positive lymph nodes was 10mm. Median length of stay was 7.5 d (3-76), and only 2 patients failed initial removal of their urinary catheter. Complication rates were low, with only 1 lymphocele and 1 anastomotic leak. There was only 1 mortality (4.5%). There have been no recurrences so far.
Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas. A pre-CRT lymph node size of ≥ 10 mm is suggestive of metastases. LPND may be performed safely with minimally invasive surgery.
尽管引入了全直肠系膜切除术和放化疗（CRT），直肠癌手术后盆腔复发仍然是一个重大问题，最常见的复发部位之一是盆腔外侧淋巴结。因此，盆腔外侧淋巴结清扫术（LPND）在直肠癌治疗中可能具有一定作用。
评估直肠癌手术期间接受微创LPND患者的短期结局。次要结局是根据术前扫描评估确定淋巴结转移的任何预测因素。
2016年10月至2019年11月，22例II期或III期直肠癌患者接受了微创直肠癌手术和LPND。这些患者均在多学科肿瘤委员会会议上进行了讨论，大多数患者在手术前接受了新辅助放化疗。所有患者在初始分期扫描时盆腔外侧淋巴结在影像学上呈阳性，定义为长轴测量大于7mm的淋巴结或异常的影像学形态。LPND仅在受累侧进行。
大多数患者为男性（18/22，81.8%），中位年龄为65岁（44 - 81岁）。18例患者术前完成了新辅助CRT。18例患者（81.8%）接受了单侧LPND，其他患者接受了双侧手术。每侧盆腔壁收获的盆腔外侧淋巴结中位数为10个（3 - 22个）。8例患者（36.4%）在收获的淋巴结中发现有阳性转移。这些阳性淋巴结在CRT前的中位大小为10mm。中位住院时间为7.5天（3 - 76天），只有2例患者首次拔除尿管失败。并发症发生率较低，只有1例淋巴囊肿和1例吻合口漏。仅1例死亡（4.5%）。目前尚无复发情况。
放化疗在完全根除侧壁转移方面并不充分，在准确诊断这些区域的转移方面仍存在技术限制。CRT前淋巴结大小≥10mm提示有转移。LPND通过微创手术可以安全进行。
