Clinical Indication of Laparoscopic Surgery for Colorectal Cancer: The Optimal Extent of Lymph Node Dissection based on Depth of Colorectal Cancer and Technical Feasibility of Laparoscopic Colorectal Surgery.

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Recently, laparoscopic colorectal surgery has been considered to be appropriate for colorectal cancer, and the feasibility of many laparoscopic techniques has been established; however, the indication for curative colorec-tal cancers is controversial. In this study, before laparoscopic procedure was performed on patients with colorectal cancers, 641 patients who had under-gone open laparotomy for colorectal cancer during the past 16 years were ev-aluated for the distribution of metastatic lymph nodes classified by depth of invasion. The results obtained were as follows: The rate of all lymph node metastasis of patients with pTis was 0%. The rate of intermediate lymph node (n2) metastasis of patients with pT1 and pT2 tumor was low (3.4% and 4.1% respectively) , however, in patients with pT3 and pT4 tumors, this rate was much higher (15.9% and 15.8% respectively) . Therefore, with re-gard to lymph nodes dissection for colorectal cancer it might be concluded that the intermediate lymph nodes metastases in patients with pT1 and pT2 tumors (less than 5%) were negligible. However, in patients with pT3 and pT4 tumors, for the purpose of performing a complete harvest of intermedi-ate lymph nodes, D3-dissection (including principal lymph node dissection) is required. it is questionable whether or not performance of the laparoscopic procedure for cancer achieves the same extent of lymph node dissection as compared with open laparotomy. Dissection was restricted to intermediate grade lymph node including the paracolic lymph nodes (D2) . Accordingly, patients with pT3 and pT4 tumor should be excluded from indication for laparoscopic procedure. Between October 1997 and November 1998, laparoscopic colorectal resec-actions were performed on a limited number of the above mentioned patients with Tis, Ti and T2 tumor. The grade of lymph node dissection was deter-mined by the results of a preoperative assessment of the depth of cancer in-vasion. With the exception of one patient, whose preoperative assessment for depth of cancer invasion was a limitation at the muscularis propria, but whose histological outcome had been pT3 tumor, all the other patients were able to undergo laparoscopic colorectal resection. The final histological results were as follows: 3 patients with pTis tumor, 6 pTl tumor, and 3 pT2 tumor. One of the pT3 patients alone was converted from a laparoscopic pro-cedure to open laparotomy because of the intraoperative proof of intermediate lymph node metastases, and subsequently this patient underwent principal lymph node dissection (D3-dissection) . With regard to the histological metas-tasis of harvested lymph nodes, no patients was found to have regional lymph node metastasis except for one patient only who had a pT3 tumor. Thus the histological findings were similar to those for conventional open laparotomy. In this study, it was concluded that by laparoscopic procedure a safe and complete dissection of intermediate lymph nodes including the paracolic lymph nodes (nl and n2) could be achieved. On the other hand, the true incidence of port site recurrence, and also its mechanism remain unknown to date. However, it is considered that the incidence of port site recurrence in patients with serosal invasion (T4 tumor) is higher than in those without (i.e., patients with pTis, pTl, pT2 and pT3 tumor) . We are also convinced that a number of patients with pTis, pTl and pT2 undergoing laparoscopic procedure were able to gain curative colorectal resection in terms of port site non-recurrence, and strongly believe that the application of laparoscopic col-orectal surgery for cancer might be acceptable.
札幌医科大学の論文

Clinical Indication of Laparoscopic Surgery for Colorectal Cancer: The Optimal Extent of Lymph Node Dissection based on Depth of Colorectal Cancer and Technical Feasibility of Laparoscopic Colorectal Surgery.

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