摘要
目的评价腹腔镜直肠癌全直肠系膜切除（TME）术中保留左结肠动脉（LCA）的可行性、安全性以及肿瘤根治性和近期临床疗效。方法回顾性分析2013年1月至2016年12月期间在江苏省泰州市人民医院接受腹腔镜TME手术的136例患者的临床资料，病例纳入标准为肿瘤距肛缘10cm以内、术后病理数据及随访资料完整的中低位原发性直肠癌患者：排除（1）术前接受新辅助放化疗、多灶性直肠癌、肿瘤固定、侵犯周围组织器官不可切除或姑息性手术及复发性肿瘤者；（2）合并急性肠梗阻、出血或穿孔等急诊手术者；（3）有严重基础疾病或发生远处转移者。按术中肠系膜下动脉（IMA）不同处理方式分为两组：不保留左结肠动脉（高位结扎组，72例）和保留左结肠动脉（低位结扎组，64例），对两组患者的手术学指标、肿瘤安全性指标和近期疗效进行比较。结果两组患者基线资料（包括性别、年龄、体质指数、肿瘤分期、肿瘤距肛缘距离）的比较差异无统计学意义（均P〉0．05）。高位结扎组和低位结扎组手术时间分别为（164．0±12．6）min和（167．3±9．4）min，术中出血量分别为（30．0±3．6）ml和（30．1±3．0）ml，差异均无统计学意义（均P〉0．05）。两组患者手术均为R0切除，无围手术期死亡病例，高位结扎组和低位结扎组淋巴结清扫数目分别为（13．7±2．6）枚和（13．3±2．1）枚；近端切缘长度分别为（16．4±1．9）cm和（16．7±2．1）cm；远端切缘长度分别为（3．9±0．6）cm和（4．1±0．9）cm；两组比较，差异均无统计学意义（均P〉0．05）。与高位结扎组相比，低位结扎组保肛率更高[92．2％（59／64）比79．2％（57／72），x^2=4．580，P=0．032]、术后吻合口瘘发生率低[1．6％（1／64）比9．7％（7／72），x^2=4．075，P=0．044]、术后吻合口狭窄发生率低[3．1％（2／64）比12．5％（9／72），x^2=4．006，P=0．045]以及术后排尿及性功能障碍发生率低[6．3％（4／64）比18．1％（13／72），x^2=4．317，P=0．038]，两组差异均有统计学意义。平均随访19个月，高位结扎组局部发率为5．6％（4／72），远处转移率13．9％（10／72），总体生存率90．3％，无瘤生存率80．6％；低位结扎组局部发率为4．7％（3／64），远处转移率12．5％（8／64），总体生存率90．6％，无瘤生存率82．8％：两组差异均无统计学意义（均P〉0．05）。结论腹腔镜直肠癌TME术中保留左结肠血管安全可行，并可降低术后吻合口瘘、吻合口狭窄、排尿及性功能障碍等并发症的发生率。
Objective To evaluate the feasibility, safety, radicality and short-terra outcome of preserving left colic artery （LCA） during laparoscopic total mesorectal excision （TME） for the treatment of rectal cancer. Methods From January 2013 to December 2016,136 patients with mid-lower rectal cancer received laparoscopic TME in the Gastrointestinal Surgery Department of Taizhou People＇s Hospital of Jiangsu Province. Patients with rectal tumor within 10 cm to the anal verge were enrolled into the study. All the enrolled patients had complete data of pathology and follow-up. Those receiving neoadjuvant chemoradiotherapy, with severe base diseases, multifocal tumor, tumor invasion of surrounding tissues, fixation of tumor, recurrent tumor, complications such as acute ileus, bleeding, perforation were excluded. In this study, 72 patients did not undergo preservation of LCA （high ligation group） and 64 patients underwent preservation of LCA （low ligation group）. Operative parameters, clinicopathological data and short-term outcome were collected and compared between two groups. Results The baseline data including gender, age, body mass index, tumor stage, and distance of tumor from anal verge of two groups were comparable （P 〉 0.05）. The differences between two groups about the mean time of operation and the operative blood loss were not significant [ （164.0 ± 12.6） rain vs. （167.3 ± 9.4） rain, （30.0 ± 3.6） ml vs. （30.1±3.0） ml, all P 〉 0.05]. There was no operative death in both groups. Differences in the lymph node dissection （13.7 ± 2.6 vs. 13.3 ± 2.1） and the specimen length of proximal resection margin [ （16.4 ±1.9） crn vs. （16.7 ± 2.1 ） cm] or distal resection margins [ （3.9 ± 0.6） cm vs. （4.1 ± 0.9） cm] between high and low ligation groups were not significant （all P 〉 0.05）. Compared with high ligation group, the low ligation group had higher rate of sphincter preservation [92.2% （59/64） vs. 79.2% （57/72）, x^2 = 4.580, P = 0.0321, lower rate of anastomotic leakage [ 1.6% （1/64） vs. 9.7% （7/72）, x^2 = 4.075, P= 0.0441, anastomotic stenosis [3.1% （2/64） vs. 12.5% （9/72）, x^2 = 4.006, P= 0.045], and voiding and sexual dysfunction [6.3% （4/64） vs. 18.1%（13/72）, x^2=4.317, P=0.038]. Mean time of follow-up was 19 months. In high ligation group, the local recurrent rate was 5.56%, distant metastasis rate was 13.89%, overall survival rate was 90.28%, disease-free survival rate was 80.56%, while in low ligation group, the local recurrence rate was 4.69%, distant metastasis rate was 12.50%, overall survival rate was 90.63%, disease-free survival rate was 82.81%, whose differences between two groups were not significant （allP 〉 0.05）. Conclusion Preservation of LCA during laparoscopic TME for the treatment of rectal cancer is safe and feasible, which can reduce the incidence of anastomotic leakage and stenosis, and voiding and sexual dysfunction.
作者
尤小兰
王元杰
程之逸
李文琦
徐宁
刘贵远
赵小军
黄传江
You Xiaolan Wang Yuanjie Chen Zhiyi Li Wenqi Xu Ning Liu Guiyuan Zhao Xiaojun Huang Chuanjiang(Department of Gastrointestinal Surgery, Taizhou People＇s Hospital, Jiangsu Taizhou 225300, China （You XL, Wang Y J, Cheng ZY, Xu N, Liu GY, Zhang X J, Huang C J Department of Medical Quality and Safety, Taizhou People＇s Hospital, Jiangsu Taizhou 225300, China （Li WQ)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2017年第10期1162-1167,共6页
Chinese Journal of Gastrointestinal Surgery
关键词
直肠肿瘤
腹腔镜
全直肠系膜切除术
肠系膜下动脉
Rectal neoplasms
Laparoscopy
Total mesorectal excision
Inferior mesenteric artery
