Feasible Analysis And Clinical Evaluation Of The Selective Extended Radical Rectal Cancer Surgery

Extended radical rectal cancer surgery is always the debated focus of the surgeons in recent years. The cleaning scopes of lymph nodes around rectal cancer are not the same in the standpoints of domestic and abroad, which mainly focus on the clearance of the N3 and N4 lymph nodes along the central direction of rectal cancer. At the present stage, TME has been the gold standard of the treatment method of rectal cancer. But the basic difference of TME and TSD is the lateral lymph nodes cleaning. Modern surgery has gradually transformed from the traditional operation excision conception to the functional surgery conception. The treatment mode of modern surgery has transformed to society- mentality-biology mode. People pay more attention to quality of life after operation than the effect of radical operation. Besides these, they also pay more attention to reduce operation injury and retain organ function, and so on. As for the operations at the present stage, a lot of surgeons wish to find a balance point between the radical effect and the quality of life. Our centre has focused on the lateral lymph nodes cleaning for many years. Basic on deeply researched on corpses, the traditional pelvic autonomic nerve preservation surgery operation were well carried out. With the development of laparoscopic colorectal-carcinoma surgery of our centre last year, extended radical rectal cancer surgery by using laparoscopic was further discussed and a new operation approach was determined by us. The viewpoint of our centre is that TME and TSD have their advantages and disadvantages, respectively, and they both have their unlimited vitality. How to choose the suitable method is the key point, which is based on the surgeon's grasp of patient's general objective information, clinicopathological features, tumor biology features and lymphatic metastasis rule. Then the optimal operation approach can be chosen.TSD is benefit for improving the radical effect of low rectal cancer surgery to some extent, which foundation is the anatomic characteristics of the fascias around rectum. This region is divide into:Level I, is the covering region of fascia propria of the rectum, LevelⅡ, is the inner side of fascia propria Japanese researches attach importance to lateral lymph nodes cleaning. They believe that Total Mesorectal Excision (TME) has some limitations. Though lateral lymph nodes arrive at N3, it only respects the local disease focus. Using TME method, lymph nodes of I region are cleaned, and lymph nodes of II and III regions are not cleaned. So this method can not replace the extended radical rectal cancer surgery. The upward lymph nodes and lateral lymph nodes should be clean. However, Western researchers believe that metastasis rate of lateral lymph nodes is low. If lateral lymph nodes are transferred, especially the obturator lymph nodes, it is the late period expression. The patients'survival rate can not be improved by operation. Moreover, the operation may increase the injury to nerve and blood vessel so the operation time and bleeding volume increased. It will produce a series of complications. With regard to lateral lymph nodes cleaning, there is no a large sample and multicenter clinical experiment to validate its practicability and dependability. And whether the patients'prognosis can be improved or not has not been determined. In order to propose our viewpoint, firstly, we summarized the experiences and results of lateral lymph nodes cleaning of our centre. For 114 patients, the results demonstrated that:all of the rectal cancer occur upward lymph nodes metastasis, while lateral lymph nodes metastasis mainly take place at。Lateral lymph nodes metastasis mainly takes place on the patients of Dukes stage C and Dukes stage D, or the patients of bad histopathological grading. At that time, lateral lymph nodes should be cleaned based on TME method. Lymph nodes around rectal cancer take place metastasis mainly in mesorectum lymph nodes, the metastasis rate of lymphadenectomy adjacent to inferior mesenteric artery root and lateral lymph nodes is low. Among 114 patients, there are 46 patients take place the lateral lymph nodes metastasis, total metastasis rate is 40.4% (46/114), among these, the metastasis rate of mesorectum lymph nodes is 39.5%(45/114), the metastasis rate of lymphadenectomy adjacent to inferior mesenteric artery root is 3.9% (2/51), the metastasis rate of lateral lymph nodes is 9.6%(11/114). Lateral lymph nodes is divide into anterior lymph nodes of vena cava, left and right iliac lymph nodes, left and right obturator lymph nodes and sacral lymph nodes, whose metastasis rate is 7.1%,2.6%,7.8%, 3.0%,2.8%,6.3%, respectively. We did not find the metastasis rule of each lateral lymph nodes group, because of the low metastasis rate of lateral lymph nodes and the small number of lateral lymph nodes metastasis.In the last year, with the development of laparoscopic technology of our centre, we discussed lateral lymph nodes cleaning by using laparoscopic. We make full use of the large function of laparoscopic and good hemostasia effect of cusa. In the laparoscopic operation, the autonomic nervous direction and its tiny branch and can be identified clearly. Moreover, the protection effect of pelvic autonomic nerve of laparoscopic operation is better than that of traditional operation. Moreover, the laparoscopic operation can also reduce postoperative complications. According to the above research results, we believe that the extended radical rectal cancer surgery is feasible at the present stage, the patients can sustain it.Surgery mainly focuses on the patients'operation results. In order to validate the feasible and practicality of lateral lymph nodes cleaning, we summarized the recent prognosis of the patients. Whether using the laparoscopic radical resection or using traditional operation for rectal cancer patients, all patients are not presacral venous plexus hemorrhage, and their ureter, obturator nerve and pelvic nerve are not injured. There are no dead patients. The traditional laparotomy time is (150±40) min, the bleed volume is (300±50) mL. The average hospital stay is (18±6) days. the average laparoscopic radical resection time is (200±80) min, the bleed volume is (150±30) mL. However, as to the first four cases, the average operation time is longer than 4 h. The rest of cases operation time ranges from 2 h to 4 h. The average bleed volume is (150±30) mL. The average recovery time of bowel function is 3±2 days. The average hospital stay is 9±4 days.In order to evaluate the patients'injured condition after operation, we use flow cytometry to detect the patients'preoperative and postoperative immune function, respectively. We compared the patients'preoperative immune function and postoperative immune function respectively using traditional laparotomy and TME. The results demonstrated that the patients'immune function is bad before operation. After operation, T-lymphocyte subsets (CD3+,CD4+,CD4+/CD8+), NKT cells, NK cells of traditional laparotomy group and TME group were decreased obviously.1 day,3 days,5 days after surgery, T-lymphocyte subsets (CD3+, CD4+, CD4+/CD8+), NKT cells, NK cells of the traditional laparotomy group and the TME group did not have significant differences. The influence of the patients'cell immune function by using the traditional laparotomy and the TME did not have significant differences. Therefore, we should choose the suitable operation method according to immune condition, staging and grading cancer.Furthermore, we compared the preoperative immune function and the postoperative immune function by using laparoscopic radical resection for rectal cancers and traditional laparotomy, respectively. The results demonstrated that:1 day after operation, T-lymphocyte subsets (CD3+, CD4+, CD4+/CD8+), NK cells of laparoscopic group significantly increased than those of the traditional laparotomy. The differences between the two groups had statistical significance.3 days after operation, NK cells in laparoscopic group were significantly higher than those of traditional laparotomy group. The differences between the two groups had statistical significance. The postoperative index (1 day after operation) was compared with the preoperative index. The results demonstrated that each index of the traditional laparotomy group reduced significantly. However, as to laparoscopic group, only NKT cells and NK cells reduced significantly. The conclusions are:The operation makes the gerontal patients' immune function reduced, while the laparoscopic radical resection for rectal cancer has the smaller influence.The metastasis rate of lateral lymph nodes is low, which is always one of the reasons that the cleaning of lateral lymph nodes is not agreed with many surgeons. We believe that conventional pathology detection method has its limitation. A lot of tiny and occult metastasis can not be detected by the conventional pathology detection method. The detection indexes of specific expression in rectal cancer, including AE1/AE3, CK20, CDX2 and villin, are chosen, and detect the lymph nodes around rectal cancer of 40 patients using immunohistochemistry method. The results are:The combined detection of four indexes could improve the detectable rate of lymph nodes around rectum tumor. For middle and low rectal cancer patients who were in Dukes B and C period, due to micro-metastasis of lateral lymph nodes, the pelvic autonomic nerve preservation should be held during extended radical rectal cancer operation.More sensitive detective method for micro-metastasis was employed. Synthetical CK20,CDX2 was used for the detection of frost fresh rectal carcinoma tissue, paracancerous tissues, healthy rectal tissue, lateral lymph nodes and preoperative peripheral blood by RT-PCR method. The detection results showed there was no expression of CK20 in healthy rectal tissue, but in rectal carcinoma and paracancerous tissues which was expressed at different levels, especially in the former, high level was found. Meantime, expression of CDX2 in rectal carcinoma tissue, paracancerous tissue and healthy rectal tissue was also detected; more high level expression was found in healthy rectal tissue compared to the other two tissues. The RT-PCR method was proved that it could improve the micro-metastasis of lateral lymph nodes. The extended radical rectal cancer surgery currently could also play an important role for the treatment of middle and low rectal cancer patients who were in Dukes B and C period. The detection results of CK20,CDX2 in preoperative peripheral blood would further guide the postoperative treatment or rehabilitation to the patients before or after the surgery.Based on above analysis, it is conclude that extended radical rectal cancer surgery has the feasibility in clinical application, which could help detect and kick out the occult metastases of lymph nodes thoroughly. But it does not recommend that all patients should take the radical rectal cancer operation, which depends on the preoperative evaluation of the patients'general information (such as age, trophic state, immune state, etc.); preoperative detection of TRUS, the CT and MRI of rectum, even PET-CT; meantime, the surgeon's grasp of patient's lymph node enlargement biology features (such as morphology, amount, color etc.) could help the final decision making. Only when the surgeon totally mastered the patient's general objective information, clinicopathological features, tumor biology features and lymphatic metastasis rule, the optimal operation approach could be chosen, and patients could benefit to a maximum.This dissertation focused on the following parts,1. Reviewed and analyzed the metastasis patterns, rules and clinicopathological features of lateral lymph nodes by the traditional extended radical resection with nerve-preservation for rectal cancer, to further discuss the significance of lateral lymph node dissection in current state.2. The analysis of the operation mode and approach of low extended radical resection with autonomic nerve-preservation in the aid of peritoneoscope was conducted. The feasibility, safety and clinical application experience of peritoneoscope aided extended radical resection with nerve-preservation was also discussed.3. The effects on immune function of both extended radical resection with autonomic nerve-preservation(extended radical rectal cancer surgery and laparoscopic colorectal-carcinoma surgery) and TME approach (extended radical rectal cancer surgery and laparoscopic colorectal-carcinoma surgery)were investigated.4. In order to prove the significance of lateral lymph node dissection, the micro-metastasis was employed for the detection of lateral lymph nodes. AE1/AE3,CK20, CDX2,villin were used together to conduct the detection of immunohistochemistry for rectal cancer structure and lymph node metastasis; CK20,CDX2 was used for the detection of frost fresh rectal carcinoma tissue, paracancerous tissues, healthy rectal tissue, lateral lymph nodes and preoperative peripheral blood by RT-PCR method to further prove the lateral lymph node dissection still has important realistic significance and clinical application value in current state.5. Summarize two cases of patients got neoadjuvant chemotherapy before surgery, and detect condition of micrometastasis.The research achievements are:1 The lymph nodes metastasis mainly takes place at the mesorectum around tumor. The metastasis rate of the lymph nodes inferior mesenteric artery and lateral lymph nodes are lower. However, the possibility of lateral lymph nodes metastasis increased significantly of the patients who were in Dukes C and D period and had poorly differentiated tumor. At the present stage, extended radical rectal cancer surgery is feasible.2 Extended radical operations in low rectal cancer by using laparoscopic can arrive at the effect of the traditional laparotomy. This technology not only has reliable security and feasibility, but also has the advantage of slight trauma, mild pain and early recovery. It is worthy of clinical application and popularization.3 The rectal cancer patients' immune function is low before operation. Compared with TME, extended radical rectal cancer surgery did not make the patients undergo any other attack. There are no significant differences for the patients' cell immune function between the two methods. After operation, the patients' immune function recovered gradually. The influence of patients' immune function of laparoscopic radical resection is smaller than that of traditional laparotomy. The recovery time of laparoscopic operation is shorter than that of traditional laparotomy.4 AE1/AE3,CK20,CDX2,villin can act as the detection indexes for micrometastasis, because they are expressed in various degrees in cancer tissue and metastatic lymph nodes. Combined detection can improve the detected rate of lymph nodes of rectal cancer patients. Especially for the patients who were in Dukes C and D period and middle and low rectal cancer patients, the micrometastasis rate of the lymph nodes inferior mesenteric artery and lateral lymph nodes is high. These patients should deal with autonomic nerves-preservation extended radical rectal cancer operation. 5 Synthetical CK20,CDX2 was used for the detection of frost fresh rectal carcinoma tissue, paracancerous tissues, healthy rectal tissue, lateral lymph nodes and preoperative peripheral blood by RT-PCR method, so as to improve the detectable rate of metastasis. And the metastasis was detected indeed in patients'blood sample and lymph nodes. That means the probability rate of micro-metastasis of lateral lymph nodes was increased for the middle and low rectal cancer patients who were in Dukes B and C period.6 Treatment pattern of rectal cancer has changed to subjects combination pattern and MTD team cooperation treatment will be the main direction. The core of MTD team is chirurgeon, and surgery always being the main treatment to cure rectal cancer. Radical resection for rectal cancer is of practicability and clinical value to some patients, thus to choose the adaptive treatment and opportunity is crucial to cure rectal cancer.