腹腔镜右半结肠癌CME与D3根治质量对照研究

doi:10.3877/cma.j.issn.2095-3224.2014.04.08

目的

比较腹腔镜下CME与开腹D3根治在右半结肠癌根治中外科肿瘤学质量。

方法

选取山西省人民医院2010年2月至2013年10月间收治的右半结肠腺癌患者共87例，前瞻性非随机实施腹腔镜全系膜切除术(Laparoscopic complete mesocolon excision，L-CME，n＝45)和同期开腹D3根治术(Laparotomy D3 resection，L-D3R，n＝42)，根据术中外科平面和结肠标本量化评估外科质量。

结果

L-CME组外科平面分级略高于D3组但统计学差异不显著(84.4%v73.8%，P>0.05)，但获取淋巴结(28.73v24.43，P<0.01)，切除系膜面积(14592.49v10953.42mm²，P<0.01)及结肠切除(24.33v18.33cm，P<0.01)均高于D3组。

结论

两种手术都有较好系膜切除平面，但L-CME更符合系膜平面解剖学特点，从而提高了外科质量参数。

关键词: 腹腔镜, 结直肠肿瘤, 淋巴结切除术, 全结肠系膜切除, 外科质量

Objective

To compare the surgical quality betweenlaparoscopic complete mesocolon excision and open D3 lymphadenectomy in right-sided colon cancer.

Methods

The clinical data of 87 patients with right-sided colon adenocarcinoma who underwent either L-CME(45cases)or open D3 lymphadenectomy(42cases)from February 2010 to October 2013 were collected .The surgical quality of anatomic planes and completeness of excised mesocolon were assessed through the surgical specimens obtained.

Results

L-CME was slightly higher but not significant in mesocolic plane dissection rate(84.4%vs 73.8%, P>0.05). L-CME removed longer bowel(24.33 cm vs 18.33cm, P<0.01), more mesocolon(14592.49mm²vs 10953.42mm², P<0.01)and more lymph nodes(28.73vs 24.43, P<0.01). The distancefrom artery ligationsite to closest intestinal wall or tumor in L-CMEgroupwas significantly longer(89.69 mm vs 79.55 mm, P<0.01; 111.82 mm vs 102.31mm, P<0.01).

Conclusion

Bothsurgical methods showed good mesocolic plane dissection rate.But L-CME increased the completeness of mesocolon excised andquality of lymphadenectomy.L-CME was surgically superior to D3 lymphadenectomyand might be a standard procedure for colon cancer.

Key words: Laparoscopy, Colorectal neoplasms, Lymph node excision, Complete mesocolon excision, Surgical quality

表1 患者基本资料比较表

分组(Total＝87)		L-CME(n＝45)	L-D3R(n＝42)	t	P
年龄(year)		57.84±9.148	60.60±9.061	1.40	0.163
BMI(Kg/m²)		20.68±1.94	20.75±2.256	0.17	0.865
手术时间(min)		151.977±39.19	164.809±38.39	1.54	0.127
失血量(ml)		149.55±95.87	86.666±71.41	56.20	0.049
性别		?	?	?	?
?	女	26(57.8%)	23(54.8%)	?	?
?	男	19(42.2%)	19(45.2%)	49(56.3%)38(43.7%)	0.080
cTNM-stage		45(100%)	42(100%)	87(100%)	?
?	I	8(17.8%)	5(11.9%)	13(14.9%)	?
?	II	5(11.1%)	7(16.7%)	12(13.8%)	0.610
?	III	32(71.1%)	30(71.4%)	62(71.3%)	?

表1 患者基本资料比较表

分组(Total＝87)		L-CME(n＝45)	L-D3R(n＝42)	t	P
年龄(year)		57.84±9.148	60.60±9.061	1.40	0.163
BMI(Kg/m²)		20.68±1.94	20.75±2.256	0.17	0.865
手术时间(min)		151.977±39.19	164.809±38.39	1.54	0.127
失血量(ml)		149.55±95.87	86.666±71.41	56.20	0.049
性别		?	?	?	?
?	女	26(57.8%)	23(54.8%)	?	?
?	男	19(42.2%)	19(45.2%)	49(56.3%)38(43.7%)	0.080
cTNM-stage		45(100%)	42(100%)	87(100%)	?
?	I	8(17.8%)	5(11.9%)	13(14.9%)	?
?	II	5(11.1%)	7(16.7%)	12(13.8%)	0.610
?	III	32(71.1%)	30(71.4%)	62(71.3%)	?

图1 腹腔镜下全结肠系膜切除术外科质量控制相关因素图像

图2 L-CME组与L-D3R组结肠系膜质量分级及标准量化比较柱状图

表2 结肠系膜平面质量分级比较表

组别	MMP	IMP	MCP	Total
L-D3R	2(4.8%)	9(21.4%)	31(73.8%)	42(48.3%)
L-CME	3(6.7%)	4(8.9%)	38(84.4%)	45(51.7%)
Total	5(5.7%)	13(14.9%)	69(79.3%)	P＝0.255

表2 结肠系膜平面质量分级比较表

组别	MMP	IMP	MCP	Total
L-D3R	2(4.8%)	9(21.4%)	31(73.8%)	42(48.3%)
L-CME	3(6.7%)	4(8.9%)	38(84.4%)	45(51.7%)
Total	5(5.7%)	13(14.9%)	69(79.3%)	P＝0.255

表3 两组外科质量比较

GPMD	L-D3R			L-CME
GPMD	MPP	IMP	MCP	MPP	IMP	MCP
MA	6954.00	8216.67	12006.16	9670.00	11198.00	15764.74
SD	832.97	844.61	2310.88	836.15	783.62	2182.01
L-total	10953.42±2706.23			14952.49±2798.43
?	F＝45.79，P＝0.000
LNs	15.00	18.78	21.26	19.00	26.25	29.76
SD	1.40	1.20	4.19	2.00	2.22	4.60
L-total	20.43±3.97			28.73±5.12
?	F＝70.71，P＝0.000
PD	10.00	14.44	20.00	17.67	19.00	25.42
SD	0.00	1.42	4.22	0.58	0.82	3.91
L-total	18.33±4.71			24.33±4.42
?	F＝37.53，P＝0.000
AI	77.50	72.22	81.81	74.00	76.75	92.29
SD	3.54	8.30	9.98	11.53	7.09	7.78
L-total	79.55±10.13			89.69±9.91
?	F＝22.29，P＝0.000
AT	91.50	100.00	103.58	102.33	96.00	114.24
SD	4.95	12.26	12.52	21.22	10.55	12.18
L-total	102.31±12.34			111.82±13.67
?	F＝11.55，P＝0.001

表3 两组外科质量比较

GPMD	L-D3R			L-CME
GPMD	MPP	IMP	MCP	MPP	IMP	MCP
MA	6954.00	8216.67	12006.16	9670.00	11198.00	15764.74
SD	832.97	844.61	2310.88	836.15	783.62	2182.01
L-total	10953.42±2706.23			14952.49±2798.43
?	F＝45.79，P＝0.000
LNs	15.00	18.78	21.26	19.00	26.25	29.76
SD	1.40	1.20	4.19	2.00	2.22	4.60
L-total	20.43±3.97			28.73±5.12
?	F＝70.71，P＝0.000
PD	10.00	14.44	20.00	17.67	19.00	25.42
SD	0.00	1.42	4.22	0.58	0.82	3.91
L-total	18.33±4.71			24.33±4.42
?	F＝37.53，P＝0.000
AI	77.50	72.22	81.81	74.00	76.75	92.29
SD	3.54	8.30	9.98	11.53	7.09	7.78
L-total	79.55±10.13			89.69±9.91
?	F＝22.29，P＝0.000
AT	91.50	100.00	103.58	102.33	96.00	114.24
SD	4.95	12.26	12.52	21.22	10.55	12.18
L-total	102.31±12.34			111.82±13.67
?	F＝11.55，P＝0.001

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Comparison of surgical quality between complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer

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Comparison of surgical quality between complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer