设为首页 | 加入收藏
| 欢迎光临本站!

消化内镜学分会官方网站

当前位置:文献追踪 > 国内外期刊

早期肠癌患者的治疗:太多的选择?

发布日期:2014-1-29 12:40:58 文章来源:GIE 作者次数:3390

    摘要

    针对内镜问题,两篇文章给出了一份关于早期结直肠癌微创手术治疗的详细比较,也是考虑日益普遍的早期结肠癌外科治疗走向的最佳时机。

    Kiriyama及其合作者代表着世界著名的实施内镜黏膜剥离手术(ESD)机构,他们对297例结直肠ESD进行了回顾性审核,同时也采用过去相似的10年内腹腔镜下结直肠外科手术(LAC)等手段对结直肠ESD进行了比较[1]。该结肠镜切除术仅适用于T1期癌症病人,这样两组至少在一定程度上有可比性,虽然也有很大的不同:例如在ESD组直肠病变比较多,而在LAC组晚期癌明显比较多。比较结果常是LAC组病人将会直观感觉-出现较多的并发症,尤其是伤口感染,而且也会发现病人住院天数更长。但不管怎样总会有一些值得评论的意外。ESD的手术时间远远短于腹腔镜手术的时间(106206分钟),尽管ESD组肿瘤平均大小为3.7cm。这或许表示:Tokyo组大规模和ESD经验比两种手术的内在优势更多。我有一个大胆的猜想:日本以外的多家癌症中心的手术时间恰恰相反,ESD120分钟到180分钟,腹腔镜检查需90分钟到150分钟。对直肠癌来说,特定差异在于ESD手术时间比直肠切除术所需时间更短,二者分别为129分钟和4小时以上。

    作者们得出结论:他们的研究显示,与腹腔镜结结肠切除术相比,结直肠ESD疗效高、成本低且安全,我认为根据所呈现的数量,这个结论是有效的;然而,凭心而论,事实是他们的结肠患者几乎都患有浸润性癌,因此他们不得接受ESD-也就是说,要达到疗效,必须得需一项更广泛、耗时且危险的手术-这样使得该说法在一定上具有欺骗性。阅读这篇文章的最好方法是,在一家中心(如:东京国家癌症中心的中心)发现,结直肠癌越具侵入性,其发病率和治疗成本也在逐步增加。

    对于这个问题,Korea也有一篇相似的文章[2],在他们的研究中,Drs ParkMin和他们的外科同事仅专注于早期直肠病变,比较了ESD与其他微创外科手术和经直肠内镜显微外科(TEM),提供了全层局部切除。在这篇文章中,尽管数量比较低,但是ESD的效果不错:从肿瘤学观点来看,其操作迅速、疼痛减弱且疗效相似。不像第一篇文章,两组所治疗的病变有很大的相似性。结直肠微创外科医师以他们自己提供了TEM而不是开放式或腹腔镜下直肠切除术为傲,因为TEM比开放式或腹腔镜下直肠切除术的侵入和所致病害低许多倍-现在他们已经是“完全获胜”。公平地说,TEM程序花费更长的时间,因为它是一项需闭合的全层修复。TEM也经常用作部分层切除手术,即粘膜下层切除手术,该情况下它比ESD更快。然而,TEM比较昂贵且不那么可用。外科医生选择用TEM来进行全层切除术,是因为他们想确定全层病理组织,而且常常也是为了取得直肠周围淋巴结样品,在某种情况下,为进行根治性切除术治疗T1期甚至T2期癌。

    我认为从这两篇文章可以得到两个重要的信息:第一个有点难以启齿,全世界绝大多数患有早期结直肠癌且受限于黏膜的病人接受的是腹腔镜或开放式结肠切除术。这是对医保财务资源的浪费,对于病人来说确实不是最佳的疗法。为了让所有的肿瘤病人能够得到“最好”的治疗,应从国际上推动外科医师和胃肠病专家加快使用ESD的速度。这些文章中点醒我的第二点是:到时候改变胃肠癌的治疗方法了,尤其是结直肠癌。从表面上来看,这篇文章像是采用传统的外科手术与内镜治疗疾病,这意味着如果外科医师收治病人,病人首先主要接受外科手术切除,但是如果是胃肠内视镜医师治疗这些病人,那么这些病人可能需接受内镜下切除术。这显然不是最佳的治疗。结直肠癌病人的治疗有很多选择:ESDTEM、腹腔镜结肠切除术、腹腔镜下腔内切除和开放式根治性切除,其中每一种都有特定病人适应症。该创新治疗趋势将只会增长:经自然腔道内镜手术(NOTES)结肠切除的临床经验正在增长[3],而且内镜下全层切除术正在研究之中[4];或许增加前哨淋巴结活检[5]会将器官保留手术的应用扩展至更大数量的早期癌症患者。将来,结直肠癌病人的最佳治疗将会在一家中心出现,这个中心所有这些方法的专业知识,在这里患者将被多学科团队评估,并给与最低伤害的疗法,以确保给与患者成本低且友好的癌症治疗和护理。


     

    Treatment of early colorectal cancers: too many choices?
    Oregon Health andScienceUniversity, Division of GI and Minimally Invasive Surgery, TheOregonClinic,Portland,Oregon,United States

    *                Abstract

    Two papers in this issue of Endoscopy bring us a head-to-head comparison of minimally invasive treatments of early colon and rectal cancers, offering a perfect opportunity to consider where we are going with the surgical treatment of the increasingly common finding of early colon cancer.

    Kiriyama and co-authors, representing the worlds pre-eminent institution for endoscopic submucosal dissection (ESD), present a retrospective review of 297 colorectal ESD procedures, comparing them with their cancer resections by means of laparoscopically assisted colorectal surgery (LAC) over a similar 10-year timeframe [1]. The colectomies were only those for T1 cancers, making the two groups at least somewhat comparable, though there were important differences: for example there were more rectal lesions in the ESD group and obviously more advanced cancers in the LAC group. The results of the comparison are in general what one would intuitively expect - more complications, particularly wound infections, in the LAC group, longer length of hospital stay in that group, etc. There were some surprises however that deserve comment.

    The mean operative time for ESD was significantly shorter than the laparoscopic surgery time (106 min vs. 206 min), in spite of a mean tumor size of3.7 cmin the ESD group. This probably says more about the large volume and experience with ESD of theTokyogroup than it does about inherent benefit of the two procedures. I would hazard a guess that in the majority of cancer centers outside ofJapanthe operative times would be exactly reversed, with ESD taking 120 to 180 min and the laparoscopic procedure taking 90 to 150 min. A particular difference was seen for rectal cancers where operative times were even shorter for the ESD (129 min) compared with rectal resections (more than 4 hours). The authors conclude that their study shows high efficacy, cost - effectiveness, and safety of colorectal ESD when compared with laparoscopic colectomy. I suppose that this is a valid conclusion based on the numbers presented; however, in all fairness, the fact that almost all of their colectomy patients had invasive cancers and therefore were not candidates for ESD - that is, to achieve a cure a more extensive, time-consuming, and dangerous procedure was inescapable - makes the argument somewhat deceptive. A better way to read this paper is that, at a center like theTokyoNationalCancerCenter, as colorectal cancers become more invasive the morbidity and cost of their treatment steadily increases.

    In this issue there is also a similar paper fromKorea[2]. In their study, Drs Park, Min and their surgical colleagues address only early rectal lesions, comparing ESD with another minimally invasive surgical treatment, transanal endoscopic microsurgery (TEM), which typically provides a full-thickness local resection. In this paper, albeit with lower numbers, ESD also comes out looking good: quicker, less painful, and equally effective from an oncologic standpoint. Unlike the first paper, there is a striking similarity between the two groups in the lesions treated. Minimally invasive colorectal surgeons pride themselves on offering TEM rather than open or laparoscopic rectal resection as it is many times less invasive and less morbid - now they have been “one-upped.” To be fair though, the TEM procedure took longer because it is a full-thickness repair which requires closure. TEM is also not infrequently performed as a partial thickness resection - a surgical submucosal excision - in which case it is much faster than ESD. It is still however, more expensive and less available. Surgeons elect to perform TEM full-thickness resection because they want to determine the full-thickness histopathology, and often in order to sample the perirectal lymph nodes, and in certain cases as a curative resection for T1 and even T2 cancers..

    I think that two major messages can be taken from these two papers. The first is that it is a shame that the vast majority of patients worldwide who have early cancers of the colon and rectum, confined to the mucosa, are subjected to laparoscopic or open colon resections. This is wasteful of healthcare financial resources and really is not optimal care for the patient. There should be an international drive to get surgeons and gastroenterologists up to speed on ESD, so that all patients have access to the “best” treatment for these tumors.  The second point that these articles highlighted to me is that it is time to change how we address gastrointestinal cancers, particularly colorectal cancers. Read superficially, the papers can sound like the traditional “surgery versus endoscopy” way of treating disease - meaning that if the surgeon gets to the patient first the patient will receive a major surgical resection, but if the gastrointestinal endoscopist sees them an endoscopic resection might happen. This is obviously not optimal care. There are many options for care of the colorectal cancer patient: ESD, TEM, laparoscopic colectomy, laparoscopically assisted endoluminal resection, and open radical resections, each with very specific patient indications. And this trend for innovative treatment will only increase: clinical experience with natural orifice transluminal endoscopic surgery (NOTES) colectomy is increasing [3], and full-thickness endoscopic resection is being investigated [4]; perhaps with the addition of sentinel node biopsy [5], this will broaden the application of organ-sparing surgery to an even greater number of early cancer patients. In the future, optimal care of the colorectal cancer patient will be take place in a center that offers expertise in all of these approaches, where patients will be assessed by a multidisciplinary team and assigned to the least invasive treatment modality, to ensure cost-effective, patient-friendly curative cancer care.

     

    (作者:)
相关评论
用户名: 登录