Buchmann P, Christen D, Moll C, Flury R, Sartoretti C
Chirurgische Klinik, Stadtspital Waid, Zürich.
Swiss Surg. 1996;Suppl 4:45-9.
In minimal invasive cancer surgery port-side metastases are observed. The most plausible theory of there development is by tumor cell contamination during the operation. This prospective controlled study was designed to evaluate the moment of liberation of cancer cells, frequency of implantation and follow up after laparoscopically assisted and open resections.
The peritoneal cavity is washed out 4 times with 200 mls of Ringer' solution (at the beginning of the operation, after central ligation of the vessels, after mobilisation of the cancer and at the end). The aspirate is centrifuged and stained by Papanicolaou. Follow up is by the protocol of the swiss cancer study group. Up to now 71 patients (35 laparoscopical, 4 conversions, 27 open, 5 peritoneal carcinomatosis) have entered the study.
Positive cytology was found in 4/35 laparoscopic and 5/27 open resections. Excluding the first wash out 1/35 (3%) and 3/27 (11%) respectively were positive, however, none at the end of operation. Only in 4/5 peritoneal carcinomatosis tumor cells were present in the final wash out. Median follow up of patients with positive cytology was 9,5 months [6-15] for laparoscopy and 8 months [2-11] for open surgery. Three from each group were followed more than 7 months. No recurrence or port-side metastasis was observed. In patients with negative cytology two cancer progressions were detected.
The significance of free tumor cells for the development of implantation metastases is unclear. In 8/13 patients cytology was positive at the beginning of the operation, and only patients with a peritoneal carcinomatosis demonstrated cancer cells in the final wash out. In laparoscopy no cells were found in the second and one in the third wash out, resulting in a 1/35 risk of cancer cell liberation. Whether this patient will develop a port-side metastasis is unknown. He is followed for 8 months without tumor progression. We believe that a positive cytology alone cannot be the reason for implantation metastases.
Using the minimal invasive technique for colorectal carcinoma resection liberation of cancer cells tends to be less compared with open surgery. For further conclusions the time of follow up is not yet long enough.
在微创癌症手术中可观察到端口侧转移。关于其发生最合理的理论是手术过程中肿瘤细胞污染。这项前瞻性对照研究旨在评估腹腔镜辅助切除和开放切除后癌细胞释放的时刻、种植频率及随访情况。
用200毫升林格氏液冲洗腹腔4次（手术开始时、血管中央结扎后、肿瘤游离后及结束时）。吸出物离心并用巴氏染色法染色。按照瑞士癌症研究组的方案进行随访。到目前为止，71例患者（35例腹腔镜手术、4例中转手术、27例开放手术、5例腹膜癌）进入研究。
在35例腹腔镜手术切除中有4例细胞学检查呈阳性，27例开放手术切除中有5例呈阳性。排除首次冲洗后，分别有1/35（3%）和3/27（11%）呈阳性，但手术结束时均无阳性。仅在5例腹膜癌患者中，最后冲洗液中有肿瘤细胞。细胞学检查呈阳性患者的中位随访时间，腹腔镜手术为9.5个月[6 - 15个月]，开放手术为8个月[2 - 11个月]。每组各有3例随访超过7个月。未观察到复发或端口侧转移。在细胞学检查呈阴性的患者中检测到2例癌症进展。
游离肿瘤细胞对种植转移发生的意义尚不清楚。13例患者中有8例在手术开始时细胞学检查呈阳性，只有腹膜癌患者在最后冲洗液中发现癌细胞。在腹腔镜手术中，第二次冲洗未发现细胞，第三次冲洗发现1例，癌细胞释放风险为1/35。该患者是否会发生端口侧转移尚不清楚。他已随访8个月，无肿瘤进展。我们认为仅细胞学检查呈阳性不能成为种植转移的原因。
与开放手术相比，采用微创技术进行结直肠癌切除时癌细胞释放往往较少。要得出进一步结论，随访时间还不够长。
