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1.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 920-925, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630487

RESUMO

The theory of membrane surgery actually holds the same concepts as that of traditional cancer surgery, which believes that tumor spread is regarded as an isotropic process but the tumor is confined by the block of the membrane. Therefore, the radical resection can be achieved by complete mesentery excision along the membrane plane. The surgical practice derived from these conceptions is extended excision and lays emphasis on tumor-free margins. But the theory is controversial in the view of the existence of mesorectal fascial envelope and the feasibility of complete excision of mesorectum along the "holy plane". Based on ontogenetic anatomy, the compartment theory suggeststhat tumor spread is not isotropic, and it is locally confined within the ontogenetic compartment derived from a common primordium for a relatively long phase during their natural course. Local tumor is suppressed by the boundary instead of fascia. The anatomical territory developing from each anlage primordium may be separated morphologically. Consequently, ontogenetic compartment theory states that optimal local control of cancer is achieved by whole compartment resection, irrespective of margin width. The compartment model of tumor spread provides explanations for total mesorectal excision (TME) which excises the complete rectum compartment including the rectum and its surrounding vascular and ligamentous mesenteries. The compartment theory may set up the new principles for surgical tumor treatment, namely the resection of the tumor bearing compartment rather than target organ.


Assuntos
Mesentério/patologia , Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Colectomia/métodos , Colectomia/normas , Fáscia/patologia , Humanos , Margens de Excisão , Mesocolo/patologia , Mesocolo/cirurgia , Invasividade Neoplásica , Metástase Neoplásica , Protectomia/normas , Reto/anatomia & histologia , Reto/patologia
2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 926-931, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630488

RESUMO

Gastric cancer is a common malignant tumor of digestive system. D2 procedure is recognized as the standard operation for advanced gastric cancer at present. However, controversies still exist in the standardization and quality control of surgical procedures. Total mesorectal excision (TME) and complete mesocolic excision (CME) based on the membrane anatomy perfectly solve these problems in the treatment for colorectal cancer. However, the complexity of mesogastrium determines that TME and CME cannot be easily transplanted to the treatment of gastric cancer. The practical membrane anatomy in gastric cancer surgery is just emerging and its impact on the treatment of gastric cancer is immeasurable. By reviewing the evolution and embryonic development of digestive system, and combining with actual operation, this paper analyzes and redefines several key issues such as traditional Toldt space, Gerota fascia and complete mesenteric excision. On this basis, we propose a novel and feasible surgical procedure named regional en bloc mesogastrium excision (rEME) for distal gastric cancer. The concept of en bloc mesogastrium excision (EME) based on membrane anatomy may have some influences on the lymph node grouping from the 'Japanese Classification of Gastric Carcinoma'. Performance of EME may reduce the controversies about the group of lymph nodes and their borders. EME in the infra-pyloric region weakens the significance of subdivision of No.6 lymph nodes into No.6a, No.6v and No.6i. More studies are needed in the construction of a mature theoretical system for practical membrane anatomy in gastric surgery.


Assuntos
Gastrectomia/métodos , Excisão de Linfonodo/métodos , Mesentério/patologia , Mesentério/cirurgia , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Gastrectomia/normas , Humanos
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 932-936, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630489

RESUMO

In recent years, the incidence of adenocarcinoma of esophagogastric junction (AEG) keeps increasing. Siewert type II and type III AEG invades at 2-4 cm in the lower esophagus, and it has a higher rate of lower mediastinal lymph node metastasis. Lower mediastinal lymph node clearing through the abdomino-transhiatal (TH) approach is preferred, which can be accomplished by entering the lower mediastinum through the hiatus and mobilize the esophagus upward and the surrounding lymph and connective tissue for approximately 6.5 cm. Using the infracardiac bursa (IBC) as an anatomical landmark improves the safety and operability of the thorough dissection of the lower mediastinum. Total resection of the mesenterium at the esophagogastric junction can entirely dissect the lower mediastinal lymph nodes, which conforms to the safety principles in oncology.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgia , Excisão de Linfonodo/métodos , Mesentério/cirurgia , Adenocarcinoma/patologia , Neoplasias Esofágicas/patologia , Junção Esofagogástrica/patologia , Humanos , Mediastino/patologia , Mediastino/cirurgia , Mesentério/patologia
4.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 943-948, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630491

RESUMO

The neurovascular bundle (NVB) starts at the lateral angle of the seminal vesicle (the initial part), passes posterolateral of the prostate gland (the main part), and ends at the cavernous body of the penis (the cavernous part). In low rectal surgery, different transabdominal and transanal perspectives result in different NVB injury risks. In the perspective of transabdominal operation, the separation between the initial part of NVB and Denonvilliers fascia and the anatomical variation of the two lateral sides of Denonvilliers fascia increases the risk of NVB injury, and conformation separation may take into account the convenience of separationand the protection of NVB. In the perspective of transanal operation, when separating the main part with NVB and mesorectum, the perspective of the transanal, unidirection traction and excessive dissection increase the risk of NVB main exposure. Clear anatomical identification helps the protection of NVB in the transanal operation. At present, the medical evidence on the difference of NVB injury in different perspectives of transabdominal and transanal approach is still in need of relevant clinical researches.


Assuntos
Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Colectomia/métodos , Dissecação , Fáscia/anatomia & histologia , Humanos , Masculino , Mesentério/anatomia & histologia , Mesentério/irrigação sanguínea , Mesentério/inervação , Neoplasias Retais/patologia , Reto/anatomia & histologia , Reto/irrigação sanguínea , Reto/inervação
5.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(8): 724-728, 2019 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-31422609

RESUMO

Whether the transanal total mesorectal resection (taTME) techniques increase the risk of anastomotic failure is inconclusive. This paper discusses the anastomotic problems of taTME from different aspects including anatomical factors and technical characteristics. In terms of the anatomic and physiological characteristics of the lower rectum, the Hiatal ligament and the density of the perirectal space is a disadvantage to the anastomosis of taTME, while the prolapse of the rectum may be a beneficial factor. Due to the unique technical characteristics of taTME, the main reason affecting its anastomosis at present is that the caudal space at the distal end is not sufficiently mobilized, especially for male and lower anastomosis. In addition, stapled anastomosis at the level of anorectal ring may cause more problems, while manual anastomosis at the lower level may bring better results.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Protectomia/efeitos adversos , Protectomia/métodos , Reto/cirurgia , Canal Anal/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Masculino , Mesentério/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle
6.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(8): 781-785, 2019 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-31422618

RESUMO

Objective: To evaluate the feasibility and safety of transanal lateral lymph node dissection for mid-low rectal cancer. Methods: A descriptive case series research method was used. Clinical and pathological data of 5 mid-low rectal cancer patients who underwent transanal lateral lymph node dissection at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from November 2018 to May 2019 were retrospectively collected and analyzed. Of 5 cases, 4 were male and 1 was female with mean age of (43.2±13.2) years and mean body mass index of (21.2±2.6) kg/m(2); the mean diameter of tumor was (3.2±2.4) cm; the mean distance between tumor and anus was (6.3±2.5) cm; 3 received preoperative neoadjuvant chemotherapy. In preoperative TNM staging, 2 cases were T3N1M0, 1 was T3cN2aM0, 1 was T3cN2bM0, and 1 was T2N1M0. All the patients had no intestinal obstruction before operation. Surgical methods: (1) total mesorectal excision: using general transanal and transabdominal methods to mobilize and resect total mesorectum, and dissect No.252, No.253 lymph nodes; (2) transanal lateral lymph node dissection: dissect the adipose lymphoid tissue on the surface of the iliococcygeal muscle, the coccygeal muscle, and the obturator muscle (the No.283 lymph nodes) upward, and dissect No.263d and No.263p lymph nodes with fat tissue sequentially till the bifurcation of the internal and external iliac artery; (3) take out the specimen from anus, and make anastomosis between proximal colon and anal canal. Intraoperative and postoperative variables was observed. Results: All the 5 patients completed surgery successfully, and no patient needed to convert to open approach. The mean operative time was (295.6±97.7) minutes, and the median intraoperative blood loss was 70 (50-500) ml. The mean length of specimen was (12.9±3.0) cm, and the mean number of harvested lymph node was 30.4±9.9. The positive lateral lymph nodes were founder in 4 patients. The median distance between tumor and distal resection margin was 1.5 (1.2-8.0) cm. The resection margin in all the patients was negative. The mean time to postoperative flatus was (4.2±1.6) days, the mean postoperative spontaneous urination was (3.0±1.9) days, time to drainage tube removal was (5.6±1.9) days, and the mean postoperative hospital stay was (9.4±2.1) days. The postoperative TNM staging by pathology was 1 case with T1N0M0, 1 with T2N1M0, 1 with T3N2bM0, and 2 with T3N2M0. Five patients were moderately differentiated adenocarcinoma. Only 1 patient developed postoperative abdominal bleeding, who was healed after conservative treatment. The other 4 patients did not develop any perioperative complications, such as incision infection, presacral abscess, pelvic abscess, anastomotic leakage, or anastomotic stricture. Four patients underwent postoperative chemotherapy. All the patients were followed up for 2 to 28 weeks after surgery and they all felt well. The patients with stoma had fluent bowel. Conclusions: Transanal lateral lymph node dissection is feasible and safe in the treatment of mid-low rectal cancer, which can achieve the purpose of extended radical resection of mid-low movement rectal cancer. Moreover, this procedure is a new method to treat rectal cancer patients with lateral lymph node metastasis.


Assuntos
Adenocarcinoma/cirurgia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Protectomia/métodos , Neoplasias Retais/cirurgia , Adenocarcinoma/patologia , Adulto , Canal Anal/cirurgia , Anastomose Cirúrgica , Colo/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Laparoscopia , Linfonodos/cirurgia , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Estudos Retrospectivos
7.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(7): 668-672, 2019 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-31302966

RESUMO

Objective: To investigate the feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure. Methods: A retrospective cohort study was performed. Clinical data of 157 colorectal cancer patients undergoing the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure at Gastrointestinal Surgical Department of Guangdong Provincial People's Hospital from July 2015 to June 2018 were retrospectively analyzed. Of 157 cases, 17 were transverse colon cancer, 94 were descending colon cancer, 25 were sigmoid cancer and 21 were rectal cancer; 89 were male and 68 were female; mean age was (61.8±10.3) years and mean body mass index was (23.2±3.7) kg/m(2). The medial approach "four-step method" in the laparoscopic mobilization of splenic flexure was performed as follows: (1) The root vessels were treated with the "provocation" technique to expand the Toldt's gap. This expansion was extended from the lateral side to the peritoneum reflex of left colonic sulcus, from the caudal side to the posterior rectal space, and from the cephalad side to the lower edge of pancreas. (2) The left colonic sulcus was mobilized, converging with the posterior Toldt's gap. Mobilization was carried out from cephalad side to descending colon flexure, freeing and cutting phrenicocolic ligament and splenocolic ligament, and from caudal side to peritoneal reflex. (3) Gastrocolic ligament was moblized. Whether to enter the great curvature of stomach omentum arch when the gastrocolic ligament was cut, that was, whether to clean the fourth group of lymph nodes, should be according to the tumor site and whether serosal layer was invaded. (4) Transverse mesocolon was moblized and transected at the lower edge of the pancreatic surface, merging with the posterior Toldt's gap, and from lateral side to lower edge of the pancreatic body, merging with the lateral left paracolonic sulcus. Safety and short-term clinical efficacy of this surgical procedure was summarized. Results: All the patients completed this procedure. During operation, 3 cases were complicated with organ injury, including 1 case of colon injury, 1 case of spleen injury and 1 case of pancreas injury. No operative death and conversion to open surgery was found. The average operation time was (147.5±35.1) minutes, the average intra-operative blood loss was (40.8±32.7) ml and the average number of harvested lymph node was (16.1±5.8), including (4.0±2.3) of positive lymph nodes. The first exhaust time after surgery was (41.3±20.6) hours, the fluid intake time was (1.5±1.3) days, the postoperative hospital stay was (5.2±2.3) days. Eight (5.1%) cases developed postoperative complications, and all were improved and discharged after conservative treatments. According to the TNM classification system, postoperative pathology revealed that 31 patients were stage I, 51 were stage II, 53 were stage III, 22 were stage IV. Conclusion: The medial approach "four-step method" is safe and feasible, which can effectively decrease the operation difficulty of the laparoscopic mobilization of the splenic flexure.


Assuntos
Colectomia/métodos , Colo Transverso/cirurgia , Neoplasias do Colo/cirurgia , Laparoscopia/métodos , Neoplasias Retais/cirurgia , Idoso , Anastomose Cirúrgica , Estudos de Viabilidade , Feminino , Humanos , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Peritônio/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
8.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 507-513, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238630

RESUMO

Neoadjuvant chemoradiotherapy plus total mesorectal excision (TME) is the standard care for locally advanced middle-low rectal cancer. Some patients could benefit from neoadjuvant chemoradiotherapy to achieve clinical complete response (cCR). Therefore, in recent years, for patients with cCR after neoadjuvant therapy, the "watch and wait" strategy has been widely recommended by their doctors to let them enter "waiting period" without surgery, so that the quality of life is improved. However, the "watch and wait" strategy also has many practical problems that have not been resolved. Firstly, the diagnostic criteria for cCR and pathologic complete response (pCR) are not uniform and different significantly. Secondly, some cCR patients have found tumor regrowth and subsequently underwent salvage surgery during the "watch and wait" period. Thirdly, there is no clinical consensus on the adjuvant therapy for patients during the "watch and wait" period. Fourthly, the role of surgery in patients with cCR is controversial. Finally, we need to accumulate more clinical evidence to confirm whether the "watch and wait" strategy can be selected immediately after achieving cCR for rectal cancer. At the same time, we should find novel molecular markers that can predict the efficacy of chemoradiotherapy. Only rational choice of "watch and wait" strategy will allow more patients with rectal cancer to benefit from chemoradiotherapy.


Assuntos
Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Protectomia/métodos , Neoplasias Retais/terapia , Terapia Combinada , Humanos , Mesentério/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Qualidade de Vida , Neoplasias Retais/patologia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
9.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 527-533, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238633

RESUMO

Neoadjuvant chemoradiotherapy is the current standard of care for locally advanced rectal cancer. However, this modality is facing more and more challenges. The research progress on this issue around the world can be summarized into three aspects. The first is to increase the intensity of treatment to obtain better tumor regression, such as adding a second drug during the neoadjuvant chemoradiotherapy, prolonging the interval and receiving sufficient chemotherapy before surgery. Current research data are not sufficient to support strategies for adding drugs or receiving sufficient chemotherapy before surgery, but it may be worth looking forward to adding irinotecan during neoadjuvant chemoradiotherapy, and an appropriate extension of the interval before surgery may also be a good option. Secondly, we can reduce the intensity of treatment to improve the quality of life of patients with a non-inferior clinical outcome, such as non-surgical approach, local excision rather than total mesorectal excision and removal of preoperative radiotherapy. The data of the International Watch & Wait Database (IWWD) suggest that patients with a Watch & Wait strategy have similar long-term survival outcomes as those who have undergone surgery and have pathologic complete response, meanwhile the data are still inadequate to support using local excision instead of total mesorectal excision, or removal of preoperative radiotherapy strategies. Finally, to achieve a precise individual treatment, some potential biomarkers are investigated via genomics, metabolomics and radiomics. But so far, there is no recognized biomarker for clinical treatment in the field of neoadjuvant therapy for rectal cancer. This article summarizes the clinical research progress of locally advanced rectal cancer in recent years from the above three aspects.


Assuntos
Quimiorradioterapia Adjuvante/normas , Terapia Neoadjuvante/normas , Neoplasias Retais/terapia , Quimiorradioterapia Adjuvante/métodos , Terapia Combinada , Humanos , Mesentério/cirurgia , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Protectomia/métodos , Qualidade de Vida , Radioterapia Adjuvante , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
10.
Chirurgia (Bucur) ; 114(2): 268-277, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31060660

RESUMO

Background: Mobilization of the colonic splenic flexure (SFM) is an essential surgical step of the restorative rectal resections. However, the surgical procedures are technically complex thereby overcoming the learning curve may not be an easy process. Looking for improved expertise and better outcomes, in 2016, we have decided to routinely perform SFM as a first step of all the laparoscopic or robotic sigmoid and rectal resections. The aim of this paper is to describe the technique of laparoscopic splenic flexure mobilization and to discuss the advantages of using it as the first surgical step in colorectal rectal resection analyzing our last 12 months experience (2018). Method: A detailed description of the laparoscopic surgical technique for SFM is performed. There are four routes for SFM: two from medial to lateral, one starting from the splenic vein the other one from the promontory, a superior to inferior approach and a lateral to medial approach. However, the combination of different maneuvers for an easier, safer approach decreases the morbidity and is saving surgical time. Results: Between January and December 2018, 47 patients had SPM as a first step of the performed colorectal procedure in our institution. There were 30 patients with rectal cancer, 10 with sigmoidal tumors, five with sigmoidal resection for diverticulitis and Hartmann reversal was indicated in two. The robotic approach has been used in 40% (16 patients). No intraoperative incidents were associated with the SFM. No colorectal fistula was encountered. No early cancer recurrence, deaths or major complication were encountered. The mean follow-up for these patients is 7 months (range, 4-12 months). Conclusions: In our perspective, the routine mobilization of the splenic flexure as a first step of the colorectal restorative resections associate many advantages and these strategies should be largely used. There is a learning curve involved in such procedure and it can easily be overcome in high volume centers.


Assuntos
Colectomia/métodos , Doenças do Colo/cirurgia , Laparoscopia/métodos , Protectomia/métodos , Doenças Retais/cirurgia , Anastomose Cirúrgica , Colo Sigmoide/cirurgia , Doenças do Colo/diagnóstico , Humanos , Curva de Aprendizado , Mesentério/cirurgia , Peritônio/cirurgia , Doenças Retais/diagnóstico , Reto/cirurgia , Procedimentos Cirúrgicos Robóticos , Resultado do Tratamento
11.
Chirurgia (Bucur) ; 114(2): 278-283, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31060661

RESUMO

Transanal total mesorectal excision (TaTME), first introduced in 2010, represents a relatively new approach in the surgical treatment of rectal cancer. A case of a 65-years-old patient diagnosed with moderately differentiated adenocarcinoma of the middle rectum (cT2N0M0) is presented. Taking into consideration patient's characteristics and tumour features, the surgical team decided to use transanal total mesorectal excision technique. The surgical technique, as well as potential postoperative complications and oncological issues are discussed in the article. Patient selection and extensive experience in minimally invasive colorectal surgery are the bases for an optimal technique implementation. Although further studies are required in order to confirm its superiority over the laparoscopic total mesorectal excision, TaTME seems to be a safe and feasible option in the surgical approach of rectal cancer.


Assuntos
Adenocarcinoma/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Cirurgia Endoscópica Transanal/métodos , Idoso , Canal Anal , Anastomose Cirúrgica/métodos , Estudos de Viabilidade , Feminino , Humanos , Laparoscopia/métodos , Mesentério/cirurgia , Resultado do Tratamento
12.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 401-405, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104421

RESUMO

Membrane anatomy is in broad sense the anatomy of the mesentery and its bed, both of which are consisted of fascia membrane or/and serous membrane. Although the traditional mesentery has the definition of mesentery, people unconsciously identify them according to their "fan-shaped" and "free" characteristics. The "generalized mesentery" we propose refers to the fascia and/or serosa, envelope-like organs and their blood vessels, suspending to the posterior wall of the body, regardless of its shape, free or not. So the main points of the anatomy are as follows.(1) Organs or tissues with their feeding structures are enveloped by the fascia membrane or/and serous membrane, suspending to posterior wall of the body, to form different shapes of the mesentery in broad sense, and most of them are buried in the mesentery bed. (2) Cancer metastasis type V of in the gut moves in the envelop of the mesentery in broad sense.(3) Intraoperative breach of the envelop membrane not only results in intraoperative bleeding, but also cancer cell leakage from the mesentery. (4) The cancer of gut can be divided into cancer in the mesentery, cancer out of the mesentery and cancer at edge of the mesentery based on this anatomy. Radical tumor resection is effective for cancer in the mesentery, which should not be artificially breached into those of cancer out of the mesentery. The essence of neoadjuvant chemoradiation is to push cancer at edge of the mesentery back inside the mesentery.(5) Based on such anatomy, radical gut tumor operations are divided into D2/D3 procedure, without emphasizing the integrity of the mesentery during lymphatic dissection; CME procedure, which emphasizes the integrity of the mesentery but does not strictly define the extent of lymphatic dissection; D2/D3 + CME procedure, which strictly defines the integrity of the mesentery and the extent of lymphatic dissection.(6)For gastrointestinal tumors of the same T stage, shorter mesentery indicates worse prognosis.(7) For gastrointestinal tumors with the same T stage and the same length of mesentery, the more mesentery buried in the mesentery bed, the worse prognosis. (8) The above seven principles are universal in the organs of the body cavity (and even all internal organs).Membrane anatomy, unlike traditional "plane surgery" , is completely different from the "anatomy of the membrane..." described by Japanese scholars, but mainly bases on generalized mesentery and mesentery bed, meanwhile inherent life events can be accurately defined and confirmed.


Assuntos
Antineoplásicos/farmacologia , Neoplasias do Sistema Digestório/patologia , Neoplasias do Sistema Digestório/cirurgia , Mesentério/patologia , Antineoplásicos/uso terapêutico , Dissecação , Fáscia/patologia , Humanos , Mesentério/anatomia & histologia , Mesentério/efeitos dos fármacos , Mesentério/cirurgia , Estadiamento de Neoplasias , Prognóstico , Membrana Serosa/patologia
13.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 406-412, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104422

RESUMO

During the past 20 years, the development of minimally invasive surgery had developed through three stages: organ excision, radical organ excision centered on arteries and functional radical organ excision based on membrane anatomy.While high-definition laparoscopy was gaining more popularity, surgeons gradually observed the fascial spaces and fascial structures which could not be recognized by naked eye during open surgery. With the development of membrane anatomical architecture, we discovered several fascial spaces and fascial structures that had never been recognized before. Inspired with the anatomical concept, proposed by Professor Gong Jianping, we systematically observed and expounded the laparoscopic radical surgery for colorectal cancer based on membrane anatomy, and explored the fascial anatomy structure and fascial space during operations for right semicolon, left semicolon and rectum through the high-definition visualization of the endoscope and robot in combination with clinical practice. Meanwhile, the membrane anatomy theory was systematically studied through repeated surgical operations and verified through practice. The fascial anatomy structures, such as "space between small intestine and ascending mesentery", "transverse mesocolon radix" and "terminal line of total mesorectal excision" were proposed. This theory can promote the stable development of "microbleeding" or "no blood" minimally invasive colorectal surgery.


Assuntos
Colectomia/métodos , Neoplasias do Colo/cirurgia , Laparoscopia , Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Fáscia/anatomia & histologia , Humanos , Mesentério/anatomia & histologia , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos Cirúrgicos Robóticos
14.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 413-417, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104423

RESUMO

The most common metastasis modality of gastric cancer is the perigastric lymph node metastasis. Complete dissection of regional lymph nodes of the stomach is the core surgical treatment strategy of gastric cancer, and is closely related to the prognosis of gastric cancer patients. Infrapyloric lymph node metastasis is common in gastric cancer,and its incomplete dissection is associated with tumor recurrence. Meanwhile, anatomical variations of vessels and complex mesentery layers of infrapyloric area increase the difficulty of lymphadenectomy during the operation. So, infrapyloric lymph node (No. 6) is an important station. Based on the theory of embryonic development and complete mesogastrium excision, operation across the anatomical space among mesentery layers can ensure en bloc resection of the infrapyloric lymph nodes.


Assuntos
Gastrectomia/métodos , Excisão de Linfonodo/métodos , Mesentério/patologia , Mesentério/cirurgia , Neoplasias Gástricas/cirurgia , Humanos , Excisão de Linfonodo/normas , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Mesentério/anatomia & histologia , Recidiva Local de Neoplasia/prevenção & controle , Piloro/patologia , Neoplasias Gástricas/patologia
15.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 418-422, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104424

RESUMO

Primary lesion removal and lymph node dissection are the main constituents of radical gastrectomy. However, the high recurrence rate after D2 radical gastrectomy for advanced gastric cancer has not improved. Recently, studies have found that discrete tumor deposits in the mesogastrium may be an important factor affecting the prognosis of gastric cancer after surgery. With the development of laparoscopic equipment, the ever-expanding "submicroscopic vision" makes it possible to completely remove the mesogastrium. Professor Gong Jianping advocated "membrane anatomy" to optimize the concept of radical gastrectomy: D2- based complete mesenteric resection (CME), namely D2+CME procedure. To prevent the leakage of tumor cells into the surgical field, as histological barrier, the intact mesogastrium should be located. The essential difference between D2+CME and previous D2/D2+systematic mesogastrium excision (SME), en-bloc mesogastric excision (EME) is as follow: double-factor guiding (lymph nodes and discrete tumor deposits) vs. single factor guiding (lymph nodes only). After practicing dozens of radical gastrectomy (D2+CME) authors believe that its conceptual connotation (double factor guiding) and operational extension (above mesentery bed) cover D2. In D2+CME surgery, depending on the anatomical identification under the magnified field of view, the conformal space between gastric mesentery and mesenteric beds is unique operational plane with repeatability. These findings and considerations address one problem: where is the precise boundary of en bloc principle in radical gastrectomy? In author's opinion, with laparoscopy and "sub-microsurgery" progression and detection of discrete tumor deposit metastasis, survival benefit from definition of en bloc boundary in radical gastrectomy will be widely recognized. Meanwhile, D2+CME procedure is an appropriate way for study. Although the development of the "membrane anatomy" concept for gastric cancer still requires many further clinical and basic researches, it is reasonable to foresee that D2+CME surgery will guide a concept-optimized era for gastric cancer surgery.


Assuntos
Gastrectomia/métodos , Excisão de Linfonodo/métodos , Mesentério/cirurgia , Neoplasias Gástricas/cirurgia , Humanos , Laparoscopia , Metástase Linfática , Mesentério/anatomia & histologia , Mesentério/patologia , Prognóstico , Neoplasias Gástricas/patologia
16.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 427-431, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104426

RESUMO

Total mesorectal excision (TME) is the basic principle of surgery in rectal cancer which requires en bloc removal of the tumor and its regional lymph nodes. This conincides with the theory of membrane anatomy that emphasizes en bloc resection and avoids cancer leakage. The basis of membrane anatomy is the fusion of peritoneum and three key pointsare needed to understand the fusion and fusion fascia:(1) the fusion only occursin peritoneum; (2) the inside of fusion fascia cannot be separated; (3) the fusion can be diversiform. Only mastering these key points can we comprehend and apply this theory dialectically. The membrane anatomy in rectum is different from stomach or colon because of its specific location. The posterior space of rectum is filled with the loose connective tissue which is the degeneration of peritoneum fusion. In this space, the anterior lay of presacral fascia fuses with the proper fascia of rectum at the S4 level and separates the space into the retrorectal space and the supralevator space. Denonvilliers fascia is the fusion fascia in front of rectum, which forms the prerectal space and retroprostatic space, and extends to lateral pelvic wall with fusion of the parietal fascia of pelvis, covering the neurovascular bundle (NVB) together. The proper fascia of rectum surrounds the middle rectal artery, the pelvic plexus rectal branch and the adipose tissue to form the lateral rectal pedicle at 10 o'clock and 2 o'clock near the pelvic floor. At the level of levator ani hiatus, the fusion of levator ani muscle fascia and the proper fascia of rectum forms the Hiatal ligament, which fixs the anal canal and closes the levator ani hiatus.This article intends to discuss the above points from the perspective of membrane anatomy, in order to better guide surgeons to complete laparoscopic total mesorectal excision for rectal cancer.


Assuntos
Fasciotomia/métodos , Mesentério/cirurgia , Peritônio/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Fáscia/anatomia & histologia , Fáscia/patologia , Humanos , Laparoscopia , Excisão de Linfonodo , Mesentério/anatomia & histologia , Mesentério/patologia , Peritônio/anatomia & histologia , Peritônio/patologia , Neoplasias Retais/patologia , Reto/patologia
17.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(5): 436-440, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31104428

RESUMO

According to multicenter randomized controlled trials, laparoscopic radical resection of colon cancer has the same short and long term clinical efficacy as traditional open surgery. In laparoscopic radical resection of right semicolon cancer, it is important to separate the embryonic plane of the root, and to ligate and cut off the central vascular roots. Only by separation along the membrane space can one achieve minimally invasive operation with no bleeding, and ensure the integrity of the excision of the mesangium and avoid damage of internal fascia and other organs. The mesangial distribution of the right semicolon is adjacent to the mesangium of the stomach and is connected to the mesentery of the small intestine. The pancreaticoduodenum locates between the right semicolon mesentery and the retroperitoneal subperitoneal fascia. In particular, the relationship between the anterior and posterior Treitz fascia of the pancreaticoduodenum and the Toldt space is complex, which is closely related to the feasibility of complete mesocolic excision(CME). This article introduces the distribution of intermembranous space and mesangial bed in the right semicolon, presenting the problem in CME surgery. In addition, there are key points in identifying the gap between the membranes based on the author's experience and we propose a new evaluation criteria for membrane surgical specimens, which has certain guiding significance for radical CME surgery for right semicolon cancer.


Assuntos
Colectomia/métodos , Neoplasias do Colo/cirurgia , Mesentério/anatomia & histologia , Mesentério/cirurgia , Mesocolo/anatomia & histologia , Mesocolo/cirurgia , Neoplasias do Colo/patologia , Fáscia/anatomia & histologia , Fáscia/patologia , Fasciotomia , Humanos , Laparoscopia , Mesentério/patologia , Mesocolo/patologia , Peritônio/anatomia & histologia , Peritônio/patologia , Peritônio/cirurgia
18.
Dis Colon Rectum ; 62(5): 568-578, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30964794

RESUMO

BACKGROUND: Definitive surgery with total mesorectal excision is the mainstay of treatment for locally advanced rectal cancer. Multimodality therapy improves long-term survival. Current standards advise neoadjuvant chemoradiation followed by radical surgery and adjuvant chemotherapy. Nationally, compliance with adjuvant chemotherapy is only 32%. New research evaluates the effectiveness of total neoadjuvant therapy: complete chemotherapy and chemoradiation before surgery. OBJECTIVE: The aim of this study is to determine the favored treatment for locally advanced rectal cancer by comparing the cost-effectiveness of total neoadjuvant therapy and the current standard of care. DESIGN: Decision analytical modeling using long-term costs and 5-year disease-free survival was performed to determine the cost-effectiveness after total neoadjuvant therapy and the current standard of care. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters. SETTINGS: Centers for Medicare & Medicaid Services billing data perspective was adopted and outcomes modeled according to local and national databases and literature consensus. PATIENTS: Adult patients with stage II or III rectal cancer were selected. MAIN OUTCOME MEASURES: Cost-effectiveness in disease-free life-years, incremental cost-effectiveness ratio, and net monetary benefit were determined over a 5-year posttreatment period. The favored strategy was determined based on cost-effectiveness and sensitivity analyses. RESULTS: Cost-effectiveness for total neoadjuvant therapy was 40,708 $/life-year, and, for conventional therapy, cost-effectiveness was 44,248 $/life-year. Sensitivity analysis showed that, for an estimated total neoadjuvant therapy completion rate of 90%, total neoadjuvant therapy would remain the dominant strategy for any adjuvant chemotherapy completion rate of less than 93%. LIMITATIONS: The samples used to calculate completion rates are small, and survival probabilities are based on existing literature, local database values, and consensus estimates. The model encompasses a 5-year time period from diagnosis. CONCLUSIONS: Cost-effectiveness analysis shows that a strategy of total neoadjuvant therapy followed by radical surgery is favored over the current standard of care for locally advanced rectal cancer. Sensitivity analysis shows that a low rate of adjuvant chemotherapy administration plays a key role in decreasing the cost-effectiveness of the current standard of care. See Video Abstract at http://links.lww.com/DCR/A942.


Assuntos
Quimiorradioterapia/métodos , Quimioterapia Adjuvante/métodos , Terapia Neoadjuvante/métodos , Protectomia/métodos , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias Retais/terapia , Quimiorradioterapia/economia , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Intervalo Livre de Doença , Custos de Cuidados de Saúde , Humanos , Mesentério/cirurgia , Terapia Neoadjuvante/economia , Estadiamento de Neoplasias , Protectomia/economia , Neoplasias Retais/economia , Neoplasias Retais/patologia , Estados Unidos
20.
Dis Colon Rectum ; 62(5): 639-641, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30964796

RESUMO

INTRODUCTION: Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction. TECHNIQUE: We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer. RESULTS: The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia. CONCLUSIONS: The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.


Assuntos
Vias Autônomas/anatomia & histologia , Fáscia/anatomia & histologia , Mesentério/cirurgia , Pelve/anatomia & histologia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/anatomia & histologia , Vias Autônomas/lesões , Cadáver , Disfunção Erétil/etiologia , Disfunção Erétil/prevenção & controle , Humanos , Laparoscopia , Masculino , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Protectomia/efeitos adversos , Transtornos Urinários/etiologia , Transtornos Urinários/prevenção & controle
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