摘要
近年来，我国结直肠癌外科领域取得了长足的进步。诸如经肛全直肠系膜切除术、机器人手术等技术的创新，全程新辅助治疗、新辅助免疫治疗的探索，等待-观察策略、局部切除策略的应用，使得结直肠外科正逐步实现手术操作微创化。肿瘤治疗高效化以及器官保留个体化。针对这些热点和创新，近年来涌现了许多高质量的循证医学证据，本文将对此进行回顾和总结。
我国结直肠癌的发病率和死亡率位居所有肿瘤的第二位和第五位，是严重危害国民健康的一类疾病。近年来，随着手术技术、药物研发、治疗理念等多方面的发展，结直肠癌的诊治取得了长足的进步[1]。本文将对近年来结直肠癌外科领域的最新进展和热点进行总结。
新技术新设备层出不穷
微创一直是结直肠外科的重要发展方向。近年来，经肛全直肠系膜切除术（transanal total mesorectal excision，taTME）和机器人结直肠手术等新兴微创技术快速发展，并有高质量的研究结果发表，结果令人振奋。
（一）经肛全直肠系膜切除术
机器人手术器械及技术的发展与推广已经带领结直肠外科进入新的时代。随着《机器人结直肠癌手术中国专家共识》的发布，机器人结直肠癌手术的开展日趋规范化、标准化和同质化[13]。在未来，手术机器人结合5G、人工智能技术，在远程控制、智能导航等领域拥有更广阔的应用前景。
综合治疗应用效果彰显
目前，放化疗联合免疫治疗的研究主要以Ⅱ期研究为主，且缺乏远期生存数据的报道。NRG-GI002和VOLTAGE-A研究的远期结局报道提示免疫治疗可能带来潜在的生存获益，该结论仍需要更多证据支持[29-30]。而随着免疫治疗的疗效凸显，新辅助放化疗联合免疫治疗最佳方案组合，器官保留策略的应用以及获益人群的筛选将是未来探索的方向。
个体化精准化治疗日趋完善
新辅助治疗后进行局部切除可作为另一项器官保留策略。GRECCAR2研究结果共纳入了186例T2-3N0-1的直肠癌患者，对145例反应良好的患者实施LE或TME手术。结果显示两者在远期肿瘤结局方面并无差异[34］。TAU-TEM研究纳入173例T2/3abN0M0期直肠癌患者，随机分至新辅助治疗后经肛内镜切除（CRT-TEM）组或TME组，CRT-TEM 治疗获得更高的pCR率（45.3%比21%）和更低的并发症发生率（20.7%比50.6%）[35]。针对W&W策略过程中出现再生的部分患者，局部切除亦可能成为诊断或者器官保留的机会。然而，需要指出的是，LE同样会带来手术相关并发症风险，术后瘢痕也可能增加补救性TME手术并发症的发生率，而无法清扫淋巴结则可能成为潜在的肿瘤风险因素。因此采取LE亦需要充分地权衡利弊。
总结
作者简介
张忠涛 教授
主任医师、教授、博士生导师
首都医科大学普通外科学系主任
北京市普通外科质量控制和改进中心主任
学术任职:
中华医学会外科学分会 副主任委员
中国医师协会外科医师分会 副会长
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