Are Preoperative Localization Methods a Benefit to Tumor Resection Margin During Laparoscopic Anterior Resection?

對於腹腔鏡前位切除而言，術前定位是否對於腫瘤切除邊緣有幫助

林昌霖(Chang-Lin Lin) ； 陳周斌(Chou-Pin Chen) ； 陳周誠(Chou-Chen Chen) ； 蔣鋒帆(Feng-Fan Chiang) ； 陳明正(Ming-Cheng Chen) ； 陳志典(Chih-Tien Chen) ； 林俊余(Chun-Yu Lin) ； 鄭厚軒(Hou-Hsuan Zheng) ； 邵彥誠(Yen-Chen Shao)

《中華民國大腸直腸外科醫學會雜誌》 31卷2期 (2020/06) Pp. 109-116

https://doi.org/10.6312/SCRSTW.202006_31(2).10832

摘要

Purpose. Upon introduction of laparoscopic colon surgery over 20 years ago, the procedure became the standard treatment for colon cancer. Because a small colonic tumor may not easily be visualized or palpated during laparoscopic surgery, pre-operative localization of the lesion is very important. Many previously published articles have offered an opinion with regards to this, however the influence of localization on tumor resection margin has not yet been addressed in any available literature. Methods. We identified 214 patients who had undergone elective laparoscopic colorectal surgery, and an anterior resection over the previous three-year period. Data was collected with regards to preoperative localization methods, tumor staging, intraoperative colonoscopy, tumor resection margin, lymph node dissection amount, and time need for surgery. Results. One hundred fifty-nine (159) of 214 (74%) patients did not receive pre-operative localization. Twenty-five (25) of 214 (12%) patients underwent pre-operative localization through use of metallic clip placement. Thirty (30) of 214 (14%) patients underwent pre-operative localization via the tattoo method. The median resection margin of the non-localization group was 3 cm, which was significantly shorter than that of the localization group (4 cm, p = 0.013). Only 1 of 55 (2%) patients underwent an intra-operative colonoscopy in the localization group, which was significantly lower than the non-localization group (20 of 159, p = 0.04). In the locally advanced group (T stage 3 or 4), 115 of 214 (54%) patients were identified. The median resection margin of the non-localization group was 3 cm, with no significant difference seen when compared to the localization group (3.5 cm, p = 0.145). In subgroup analysis, we compared the endoscopic tattooing method to the metallic clip placement method. The resection margin, operation time, and LN dissection amount were shown not to be different between these two groups. Conclusions. Preoperative localization in a laparoscopic anterior resection can lead to better surgical planning and resection margin, while also diminishing the need for an intraoperative colonoscopy. The choice of using either the tattooing or metallic clip method is dependent upon the surgeon’s preference. More data and a longer follow-up period are still needed in order to provide a better progression free survival evaluation.

關鍵字

Colorectal cancer ； Laparoscopic ； Preoperative localization ； Tattoo ； Metallic clip

並列摘要

目的：大腸直腸腹腔鏡手術至今已經超過20多年，已經成為世界各地大腸直腸癌的標準治療方法。由於在腹腔鏡下，比較小的大腸病灶不容易用肉眼看到或是觸摸到，術前的定位就顯得非常重要。之前有不少文章對於術前定位有提供不少建議，但是對於腫瘤切除邊緣是否有幫助仍然沒有文章提及。方法：我們蒐集了台中榮民總醫院過去三年中，接受常規腹腔鏡前位切除手術的病人共215位。資料來源根據病歷紀載，蒐集了關於術前定位方法，腫瘤階段，是否使用術中大腸鏡，腫瘤切除邊緣長短，淋巴結廓清術輛，以及手術時間。結果：總共159位病人（74%）沒有接受術前定位，25位病人（12%）使用大腸鏡金屬止血夾定位，30位病人（14%）使用大腸鏡黏膜染色定位。沒有術前定位組的腫瘤切除邊緣中位數為3公分，統計上顯著比有定位組的短（4公分）。有定位組中只有1位病人（2%）接受術中大腸鏡檢查，統計上顯著比沒定位組的少（13%）。在這全部214位病人之中，分類屬於局部進階的腫瘤（T3-T4）有115位（54%）。在這群病人中沒有定位組的腫瘤切除邊緣中位數為3公分，統計上跟有定位組沒有差異（3.5公分）。我們還有比較使用大腸鏡黏膜染色定位或大腸鏡金屬止血夾定位之間的差異，結果在於腫瘤切除邊緣、淋巴廓清數量、手術時間都沒有統計上的差異。結論：對於腹腔鏡前位切除手術，術前定位能夠帶來更好的手術計畫和腫瘤切除邊緣，降低術中大腸鏡的使用。至於要使用哪種定位方法就根據外科醫師的個人偏好。在未來，我們需要更多的病人資料以及更長的追蹤時間來評估對於腫瘤預後有無影響。

並列關鍵字

大腸直腸癌 ； 腹腔鏡 ； 術前定位 ； 染色 ； 金屬夾

參考文獻

A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med 2015; 372:1324-1332

Kim SH, Milsom JW, Church JM, et al. Perioperative tumor localization for laparoscopic colorectal surgery. Surg Endosc 1997;11:1013-6.

Marco Montorsi, Enrico Opocher, Roberto Santambrogio, et al.Original Technique for Small Colorectal Tumor Localization During Laparoscopic Surgery. Dis Colon Rectum, 1999.

SAGES evidence-based guidelines for the laparoscopic resection of curable colon and rectal cancer. Surg Endosc. 2013

Role of endoscopy in the staging and management of colorectal cancer. ASGE Standards of Practice Committee. Gastrointest Endosc. 2013.