腹腔镜下保留左结肠动脉直肠癌根治术的临床研究

王永森; 谢贻祥; 王传思; 黄宏武; 葛思堂

doi:10.16766/j.cnki.issn.1674-4152.002354

腹腔镜下保留左结肠动脉直肠癌根治术的临床研究

doi: 10.16766/j.cnki.issn.1674-4152.002354

1.
安徽医科大学附属六安医院(安徽省六安市人民医院)结直肠外科，安徽六安 237005
2.
蚌埠医学院第一附属医院胃肠外科，安徽蚌埠 233004

基金项目:

安徽高校自然科学研究项目 KJ2020A0550

详细信息

通讯作者:
葛思堂，E-mail：gesitang@163.com

中图分类号: R735.37 R730.56
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出版历程
- 收稿日期: 2021-03-09
- 网络出版日期: 2022-08-13

Clinical study of laparoscopic radical resection of rectal cancer with preservation of left colonic artery dissection

1.
Department of Colorectal Surgery, Lu'an Hospital Affiliated to Anhui Medical University, Lu'an, Anhui 237005, China

摘要

摘要: 目的探讨保留左结肠动脉(LCA)并行第253组淋巴结清扫对腹腔镜直肠癌根治术手术安全性和疗效的影响。方法选取2017年4月—2021年2月六安市人民医院结直肠外科80例腹腔镜直肠癌根治术患者，按随机数字表法分为观察组和对照组各40例。观察组给予保留LCA, 并清扫第253组淋巴结。对照组不保留LCA，于肠系膜下动脉根部离断。比较2组术中、术后情况。结果术中情况：观察组和对照组吻合口上端结肠边缘动脉弓压力分别为(47.00±9.02) mm Hg(1 mm Hg=0.133 kPa)、(37.40±7.52)mm Hg, 组间差异有统计学意义(P＜0.05)；观察组术中暂时夹闭LCA，结肠边缘动脉弓压力为(36.00±8.37) mm Hg，与夹闭前差异有统计学意义(P＜0.05)，与对照组比较差异无统计学意义(P＞0.05)；2组手术时间、术中出血量、253组淋巴结清扫数、肠系膜淋巴结清扫数比较差异均无统计学意义(均P>0.05)；2组游离脾曲率、预防性造口率比较差异有统计学意义(均P＜0.05)。术后情况：2组术后吻合口漏发生率、首次肛门排气时间比较差异有统计学意义(均P＜0.05)。结论保留LCA并行第253组淋巴结清扫可保证清扫彻底，并发症发生率未增加；明显提高吻合口近端结肠边缘动脉弓压力，降低预防回肠造口率、脾曲游离率，降低术后吻合口漏发生率，是一种安全可靠的术式。
- 直肠癌 /
- 左结肠动脉 /
- 第253组淋巴结 /
- 边缘弓动脉压 /
- 腹腔镜下直肠癌根治术 /
- 吻合口瘘 /
- 游离脾曲
Abstract: Objective To evaluate the safety and efficacy of laparoscopic radical resection of rectal cancer with left colonic artery (LCA) preservation and group 253 (253rd group) lymph node dissection. Methods From April 2017 to February 2021, 80 patients who underwent laparoscopic radical resection of rectal cancer in the Colorectal Surgery Department of Lu'an People's Hospital were selected and randomly divided into the observation group and control group (40 cases in each group). The observation group was given LCA preservation, and the 253rd group lymph nodes were cleaned. In the control group, LCA was not retained, but the inferior mesenteric artery was severed. The intraoperative and postoperative conditions of both groups were compared. Results Intraoperative conditions: the pressures of colonic marginal artery arch in the observation group and the control group were (47.00±9.02) mm Hg (1 mm Hg=0.133 kPa) and (37.40±7.52) mm Hg, respectively. The difference between the two groups was statistically significant (P < 0.05). In the observation group, LCA was temporarily clamped during operation, and the pressure of colonic marginal artery arch was (36.00±8.37) mm Hg. The difference before and after clipping was statistically significant (P < 0.05), but there was no significant difference between the two groups (P>0.05). There was no significant difference in operation time, intraoperative blood loss, number of lymph nodes removed in 253rd group lymph node dissection and mesenteric lymph node dissection between the two groups (all P>0.05). There was significant difference in free spleen curvature and preventive stoma rate between the two groups (all P < 0.05). Postoperative situation: there were significant differences in the incidence of anastomotic leakage and the first anal exhaust time between the two groups (all P < 0.05). Conclusion Preserving LCA and 253rd group lymph node dissection can ensure thorough dissection without increasing complications, significantly increase the pressure of proximal colonic artery arch, reduce the rate of ileostomy prevention and splenic flexure dissociation, and reduce the incidence of postoperative anastomotic leakage. It is a safe and reliable operation.
- Rectal cancer /
- Left hemicolonic artery /
- Group 253 lymph nodes /
- Arterial pressure of marginal arch /
- Laparoscopic radical resection of rectal cancer /
- Anastomotic leakage /
- Free splenic flexure

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图 1 保留LCA直肠癌根治术术中

注：在LCA出口处的远端离断血管，保留LCA。

Figure 1. Radical resection of rectal cancer with LCA reservation

下载: 全尺寸图片幻灯片

图 2 不保留LCA直肠癌根治术术中

注：于肠系膜下动脉(IMA)根部离断血管。

Figure 2. Radical resection of rectal cancerwithout LCA reservation

下载: 全尺寸图片幻灯片

图 3 保留LCA直肠癌根治术标本

注：在LCA水平以下离断血管同时清扫253区域淋巴结。

Figure 3. The specimen of radical resection of rectal cancerwith LCA reservation

下载: 全尺寸图片幻灯片

图 4 保留LCA直肠癌根治术系膜处理

注：清扫淋巴结后从系膜中游离出IMA根部和全部或部分LCA后系膜不会牵拉血管产生张力。

Figure 4. Surgical treatment of mesentery in the radical resectionof rectal cancer with LCA reservation

下载: 全尺寸图片幻灯片

表 1 2组腹腔镜直肠癌根治术患者临床资料比较

Table 1. Comparison of clinical data between two groups of patients undergoing laparoscopic radical resection of rectal cancer

组别	例数	性别(例)		年龄 (x±s，岁)	BMI (x±s)	糖尿病 (例)	肿瘤直径 (x±s，cm)	肿瘤距肛缘距离 (x±s，cm)	TNM分期(例)
组别	例数	男性	女性	年龄 (x±s，岁)	BMI (x±s)	糖尿病 (例)	肿瘤直径 (x±s，cm)	肿瘤距肛缘距离 (x±s，cm)	Ⅰ期	Ⅱ期	Ⅲ期
观察组	40	21	19	66.03±9.36	23.14±3.28	3	3.45±1.02	6.94±2.49	10	14	16
对照组	40	22	18	67.00±10.71	23.62±3.07	2	3.35±0.95	7.10±2.22	9	16	15
统计量		0.050^a		-0.456^b	-0.679^b	＜0.001^a	0.455^b	-0.308^b	-0.722^c
P值		0.823		0.650	0.499	0.999	0.651	0.759	0.470
注：^a为χ²值，^b为t值，^c为Z值。

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表 2 2组腹腔镜直肠癌根治术患者术中术后观察指标比较

Table 2. Comparison of intraoperative and postoperative observation indexes between2 groups of patients undergoing laparoscopic radical resection of rectal cancer

组别	例数	边缘弓动脉压 (x±s，mm Hg)	夹闭LCA边缘弓动脉压(x±s，mm Hg)	术中出血量 (x±s，mL)	手术时间 (x±s，min)	游离脾曲例数(例)	第253组淋巴结获得数(x±s，个)	清扫淋巴结总数 (x±s，个)	吻合口瘘发生例数(例)	回肠造口例数(例)	肛门首次排气时间(x±s，h)
观察组	40	47.00±9.02	36.00±8.37^bc	45.75±34.71	127.50±27.97	2	3.03±1.27	13.53±2.98	0	3	32.25±9.26
对照组	40	37.40±7.52		47.75±30.76	129.75±38.50	8	3.18±1.17	13.68±3.92	6	10	36.65±9.46
统计量		5.172^a		-0.273^a	-0.299^a	4.114^d	-0.548^a	-0.193^a	4.505^d	4.501^d	-2.102^a
P值		＜0.001		0.786	0.766	0.043	0.585	0.848	0.034	0.034	0.039
注：^a为t值，^d为χ²值。与观察组边缘弓动脉压比较，^bP＜0.001；与对照组边缘弓动脉压比较，^cP=0.434。

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