低位直肠癌侧方淋巴结清扫策略30年变迁:单中心289例治疗体会及预后分析  

Thirty years′changes of the strategy of lateral lymph node dissection in low rectal cancer:treatment experience and prognostic analysis of 289 cases in one single center

作　　者：汤坚强[1,2] 李华玉 刘涛 张峻岭[1] 左帅[1] 孙烈[1] 武颖超[1] 姜勇[1] 陈国卫[1] 吴涛[1] 万远廉[1] 汪欣[1] Tang Jianqiang;Li Huayu;Liu Tao;Zhang Junling;Zuo Shuai;Sun Lie;Wu Yingchao;Jiang Yong;Chen Guowei;Wu Tao;Wan Yuanlian;Wang Xin(Department of General Surgery,Peking University First Hospital,Beijing 100034,China;Department of Colorectal Surgery,National Cancer Center,National Clinical Research Center for Cancer,Cancer Hospital,Chinese Academy of Medical Science and Peking Union Medical College,Beijing 100021,China)

机构地区：[1]北京大学第一医院普通外科,100034 [2]国家癌症中心,国家肿瘤临床医学研究中心中心,医学科学院北京协和医学院肿瘤医院结直肠外科,北京100021

出　　处：《中华胃肠外科杂志》2021年第10期889-896,共8页Chinese Journal of Gastrointestinal Surgery

基　　金：北京市中医药科技发展资金项目(JJ2018-05)。

摘　　要：目的对于低位直肠癌侧方淋巴结清扫(LLND)的手术指征、清扫区域和处理原则,东西方国家一直存在较大争议。本研究通过回溯单中心LLND策略的30年变迁和分析侧方淋巴结转移患者的预后因素,旨在为侧方淋巴结清扫的合理实施提供依据。方法采用回顾性历史对照研究方法。收集1990-2019年30年间,北京大学第一医院普通外科行直肠癌根治术加LLND的289例患者的临床资料,按每10年为一个阶段,将患者分为3个组,其中1990-1999年组89例,2000-2009年组92例,2010-2019年组108例。观察指标:(1)患者基线资料;(2)手术及术后恢复情况;(3)LLND情况;(4)术后生存情况以及侧方淋巴结阳性患者的预后。结果 289例LLND手术患者占同期4 542例直肠癌患者的6.3%,3个时间段组患者的基线资料比较,除肿瘤距肛缘距离≤7 cm、溃疡型肿瘤以及新辅助放化疗者的比例逐年代增加;其余比较,差异均无统计学意义(均P>0.05)。腹腔镜手术占比和单侧LLND比率逐年代增加,手术时间、术中出血量、Ⅲ级以上并发症发生率、术后住院时间逐年代降低。289例患者共完成483次侧方清扫,其中单侧清扫组95例,双侧清扫组194例;侧方淋巴结转移率24.6%(71/289)。3组LLND同期占比逐年代降低[9.9%(89/898)比8.0%(92/1 154)比4.3%(108/2 490),χ^(2)=40.159,P<0.001]。髂内及闭孔区域淋巴结中位清扫数目逐年代增加(2比3比3,P<0.001),但髂总及髂外区域淋巴结中位清扫数目则明显减少(4比3比2,P=0.014)。71例(24.6%)患者侧方淋巴结阳性,2010—2019年组侧方淋巴结阳性率显著高于前两个年代组[37.0%(40/108)比16.9%(15/89)和17.4%(16/92),P=0.001]。侧方淋巴结阳性患者总体生存和无病生存显著劣于阴性患者(均P<0.001)。在侧方淋巴结转移患者中,单纯髂内动脉淋巴结转移单纯闭孔动脉淋巴结转移和髂外或髂总动脉淋巴结转移者5年总体生存率分别为30.9%、27.2%和0(P=0.028),5年无病Objective The surgical indications,resection extent and management principle of lateral lymph node dissection(LLND)in lower rectal cancer have been controversial between Eastern and Western countries.This study aims to provide a theoretical basis for the rational implementation of LLND by reviewing the changes of LLND strategy over the past 30 years in a single-center,and analyzing prognostic factors for the survival outcomes of patients with lateral lymph node metastasis(LLNM).Methods A retrospective observational study was performed.Clinical data of 289 patients with rectal cancer who received LLND at the Department of General Surgery of Peking University First Hospital from 1990 to 2019 were collected.Patients were divided into three groups based on decades.There were 89 cases in 1990-1999 group,92 cases in the 2000-2009 group,and 108 cases in the 2010-2019 group.Data analyzed:(1)patient baseline data;(2)surgery and postoperative recovery;(3)lateral lymph node dissection;(4)postoperative survival and prognosis of patients with positive lateral lymph nodes.The surgical methods and pathological results of LLND were compared between groups,and the prognostic risk factors of patients with LLNM were analyzed.Results A total of 289 patients underwent radical resection with LLND'accounting for 6.3%of the 4542 patients with rectal cancer during the same period in our hospital.Except decade-by-decade increase in tumors with distance from anal verge≤7 cm,the proportion of ulcerated tumors,and the proportion of neoadjuvant radiochemotherapy,the differences in other baseline data were not statistically significant among 3 decade groups(all P>0.05).The proportion of LLND in the 3 groups decreased decade by decade[9.9%(89/898)vs.8.0%(92/1154)vs.4.3%(108/2490),χ^(2)=40.159,P<0.001].The proportion of laparoscopic surgery and unilateral LLND increased,while the mean operative time,intraoperative blood loss,surgical complications above grade III and postoperative hospital stay decreased decade by decade.These 289 patients co

关 键 词：直肠肿瘤 侧方淋巴结清扫 侧方淋巴结转移 预后 

分 类 号：R735.37[医药卫生—肿瘤]