Inna Tulina教授专访
脾曲游离并非常规！仅约15%患者需行选择性脾曲游离
第19届上海国际大肠癌高峰论坛于2023年6月17日在上海顺利召开。本次会议汇集了多位院士及海内外结直肠癌学术领军专家，围绕结直肠癌诊疗最新研究进展和方向展开学术汇报，可谓是精彩纷呈。
【肿瘤资讯】小编亲临现场，特邀俄罗斯莫斯科国立谢东诺夫第一医科大学医院Dr.Inna Tulina接受专访，一同探讨结直肠癌外科手术中脾曲游离的适应症及应用价值。
中俄人群右半结肠血管分布存在解剖学差异
Inna Tulina：的确，我们这项研究旨在探究俄罗斯人群及中国人群右半结肠在解剖学上是否存在差异。这个课题的开展是因为有学者提出：相较于的标准治疗方式，右半结肠肿瘤的淋巴结清扫更为困难。例如，许多西方的外科医生认为，对于他们的患者进行扩大淋巴结清扫是不可能的，原因是西方患者的解剖结构与东方患者完全不同。因此，我们的研究目的即是探究两者是否具有差异。在试验中，我们进行了CT扫描，入组的俄罗斯人群及中国人群各为数百例。
结果发现，两者的确具有差异。例如，右结肠动脉（RCA）在中国人群中出现率更高。但更为重要的是肠系膜上动脉（SMA）和肠系膜上静脉（SMV）这两条血管穿插及走行位置的差异：在中国人群中，SMA常显现在SMV的腹侧。这意味着，在大多数中国人群中，若进行D3淋巴结清除术，清扫至肠系膜上动脉的淋巴结时，不需要清扫肠系膜上静脉的淋巴结。因此，相对而言会更“容易”一些。
但在西方人群中，肠系膜上动脉位于更远处，故仍需清除肠系膜上静脉和肠系膜上动脉之间的淋巴结。因此，在大多数西方患者中，右半结肠癌的D3淋巴结清扫术可能更为复杂。
总之，本研究结果表明，中国人群及俄罗斯人群在解剖学上存在着一些差异，但这些差异并非关键性的。即使是俄罗斯右半结肠癌患者，我们也可以对其进行完整的D3淋巴结清扫。
尽管有指南推荐，但脾区游离不应是常规操作
Inna Tulina：在大多数直肠癌手术中，结肠脾曲的游离均是常规操作，被美国、欧洲、俄罗斯、韩国等诸多国家的指南列为必要步骤，同时也是直肠癌手术众所周知的步骤。直肠癌手术的第一步是肠系膜下动脉（IMA）的高位结扎，外科医生将聚焦于乙状结肠的良好血供，同时进行脾区游离从而暴露降结肠进行吻合。
在明天的主题讲课中，我将介绍：脾区游离不应作为常规操作，而应作为选择性操作。在我们的医疗中心，我们并不常规游离脾曲；因为，在第一步操作时，我们通常不会在IMA起始处行高位结扎；而是正如在今天的主题讲课中我所提到，我们通常保留左结肠动脉并在其下方结扎肠系膜下动脉（IMA）。由于左结肠动脉的保留，降结肠和乙状结肠的血供得以保留，有助于进行乙状结肠-直肠吻合。
因此，除一些特殊情况外，我们将不会常规行脾区游离，这些特殊情况包括：患者有乙状结肠憩室病；患者有短肠综合征，没有过多的乙状结肠；或是其他可以进行选择性脾区游离的情况。这些仅占所有患者的15%。我们的决策是只对真正有治疗需求的患者行选择性脾区游离。正如你所提到，这一操作将导致脾脏损伤、手术时间延长、手术过程更复杂等风险，而选择性的决策将有效降低这些风险。
限制性结肠脾曲游离（LSFM）的应用前景
Inna Tulina：脾区游离的决策依赖于不同情境和不同患者特征。由于患者的解剖学差异，在某些患者中，我们需要行完全的脾曲游离；而在其他患者，正如你所引用的，我们需要行限制性脾区游离（LSFM）。因此，首先，是否行脾区游离、完全或限制性脾区游离取决于患者的解剖学特征；其次，取决于我们希望通过脾区游离暴露的结肠长度；再者，取决于肿瘤的部位：如果肿瘤位于乙状结肠，或许需要采用LSFM；如果肿瘤位于降结肠、脾曲，则需要完全脾曲游离。当然，中国学者提出的这个概念是颇具意义的。
Splenic flexure mobilization is not routine! Only about 15% of patients need selective splenic flexure mobilization
The 19th Shanghai International Colorectal Cancer Forum was successfully held in Shanghai on June 17, 2023. The Forum brought together many academicians and leading experts in colorectal cancer at home and abroad to present the latest research progress and direction of colorectal cancer diagnosis and treatment, which can be described as wonderful. Dr. Inna Tulina from I.M. Sechenov First Moscow State Medical University, Moscow,Russian was invited to be interviewed by Oncology News to discuss the indications and application value of splenic flexure mobilization in colorectal cancer surgery.
Anatomical differences in the distribution of right colon vessels in Russian and Chinese populations
Inna Tulina：Yes, we have made this analysis to investigate if there are anatomical differences in right colon between the Russian and Chinese populations. This topic was proposed because it was suggested that extended lymph node dissection of right colon is more difficult than the standard treatment. For example, many Western surgeons say that extended lymph node dissection is not possible in their patients because the anatomy of Western patients is completely different from Eastern patients. Therefore, the purpose of our study was to investigate whether there are differences between the two. In our trial, we performed CT scans in hundreds of cases in the Russian and Chinese populations.
The results showed that there were indeed differences. The right colonic artery (RCA) was found to be more prevalent in the Chinese population. What is more important, as to the difference in the location of the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV),in the Chinese population, the SMA is often seen ventral to the SMV. This means that in most Chinese populations, when performing D3 lymph node dissection, the lymph nodes of the superior mesenteric artery are cleared without clearing the lymph nodes of the superior mesenteric vein. Therefore, it is relatively "easier".
However, in the Western population, the superior mesenteric artery is more distal, so the lymph nodes between the superior mesenteric vein and the superior mesenteric artery still need to be cleared. Therefore, D3 lymph node dissection for right colon may be more complicated in most Western patients.
In conclusion, the results of this study suggest that there are some anatomical differences between the Chinese and Russian populations, but these differences are not critical. We can perform complete D3 lymph node dissection even in Russian patients with right colon cancer.
Despite guideline recommendations, splenic flexure mobilization should not be routine
Inna Tulina：In most rectal cancer surgeries, the mobilization of splenic flexure is routine and is listed as an obligatory step in many guidelines in the United States, Europe, Russia, Korea and other countries, and is also a well-known step in rectal cancer surgery. The first step in rectal cancer surgery is a high ligation of inferior mesenteric artery (IMA), and the surgeon focuses on the good blood supply to the sigmoid colon while performing a splenic flexure mobilization to expose the descending colon for anastomosis.
In tomorrow's lecture, I will demonstrate that splenic flexure mobilization cannot be a routine procedure, but a selective approach. In our clinic, we do not routinely splenic flexure mobilization because, in the first step, we do not usually perform a high ligation the origin of IMA.As I mentioned in today's lecture, we usually preserve the ICA and ligate the IMA below the ICA. Because the ICA is preserved, the blood supply to the descending colon and sigmoid colon is preserved, which facilitates the sigmoid-rectal anastomosis.
Therefore, we will not routinely perform splenic flexure mobilization routinely except in some special cases, which include: patients with sigmoid diverticulosis, patients with short bowel syndrome without excess sigmoid colon, or other cases in which selective splenic flexure mobilization can be performed. These represent only 15% of all patients. Our decision is to perform selective splenic flexure mobilization only in patients who really need it. As you mentioned, this operation would result in risks such as splenic injury, longer operative time, and more complicated procedures, and these risks can be diminished by selective approach.
Application prospect limited splenic flexure mobilization (LSFM)
Inna Tulina：The decision to splenic flexure mobilization depends on different contexts and different patient characteristics. Due to patient anatomic differences, in some patients we need to perform a complete splenic flexure release; in other patients, as you quoted, we need to perform a limited-splenic flexure mobilization (LSFM). So, first of all, whether to perform splenic flexure mobilization, complete or limited splenic flexure mobilization depends on the anatomic features of the patient. Secondly, it depends on the length of the colon that we want to expose by splenic flexure mobilization. And then, it depends on the site of the tumor, if the tumor is located in the sigmoid colon, perhaps LSFM is needed; if the tumor is located in the descending colon, splenic flexure, complete splenic flexure mobilization is needed. Of course, the concept proposed by Chinese scholars is of importance.
1. Efetov S, Jiang J, Liu Z, Tulina I,et al. Superior mesenteric vessel anatomy features differ in Russian and Chinese patients with right colon cancer: computed tomography-based study. Chin Med J (Engl). 2021 Jun 7;134(20):2495-2497. doi: 10.1097/CM9.0000000000001566. PMID: 34101634; PMCID: PMC8654426.
2.李赟,刁德昌,李洪明等.限制性结肠脾曲游离技术在腹腔镜直肠癌低位前切除术中的临床应用[J].中华结直肠疾病电子杂志,2020,9(01):46-50.
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