直肠癌根治术近端切缘的研究进展：从“10 cm规则”到个体化决策

Research progress on proximal resection margins in radical rectal cancer surgery: from the "10-cm rule" to individualized decision-making

摘要:

中低位直肠癌的根治性切除不仅要求达到肿瘤学安全，还关系到器官保留与术后肠功能恢复。远端切缘已基本形成1~2 cm的共识，而近端切缘的最佳长度仍存在较大争议。临床通常参考结肠癌“10 cm规则”，但其在直肠癌中的适用性尚未得到统一证据支持。既往研究表明，近端过长可能增加吻合口张力导致吻合口漏；切除不足则提升切缘阳性及局部复发风险。此外，淋巴结转移范围、近端肠管血供情况、新辅助放化疗所致的放射性损伤以及术后肠功能（尤其是低位前切除综合征）均是影响近端切缘选择的重要因素。近年来，吲哚菁绿荧光成像技术的应用为术中血供评估提供了新的依据；而对于接受新辅助放化疗的患者，放射性损伤呈梯度分布，切除肿瘤近端约≥20 cm可能降低吻合口相关并发症的发生率。本综述基于现有研究，对直肠癌手术近端切缘的历史演变、影响因素及临床证据进行系统梳理，以期为个体化切缘制定和手术策略优化提供参考。

Abstract:

Radical resection of mid- and low-rectal cancer requires not only oncologic safety but also preservation of organs and postoperative bowel function. While a 1-2 cm distal resection margin has been largely accepted, the optimal length of the proximal margin remains highly controversial. Clinically, the "10-cm rule" derived from colon cancer is often referenced, yet its applicability to rectal cancer lacks consistent supporting evidence. Previous studies have shown that an excessively long proximal margin may increase anastomotic tension and lead to anastomotic leakage, whereas insufficient resection heightens the risk of positive margins and local recurrence. In addition, the extent of lymph node metastasis, vascular perfusion of the proximal bowel, radiation-induced injury after neoadjuvant chemoradiotherapy, and postoperative bowel function-particularly low anterior resection syndrome-are all important factors influencing the selection of the proximal margin. In recent years, the application of indocyanine green fluorescence imaging has provided new evidence for intraoperative assessment of bowel perfusion; for patients receiving neoadjuvant chemoradiotherapy, radiation injury presents a gradient pattern, and resecting approximately ≥20 cm proximal to the tumor may reduce the incidence of anastomosis-related complications. Based on current literature, this review provides a systematic overview of the historical evolution, influencing factors, and clinical evidence regarding proximal resection margins in rectal cancer surgery, with the aim of informing individualized margin selection and optimizing surgical strategies.