直肠癌手术保留左结肠动脉共识与争议

Consensus and controversy on the preservation of left colonic artery in rectal cancer surgery

吻合口漏是直肠癌手术中较为严重的并发症,其发生除与吻合技术、术前治疗等因素有关外,还与吻合两端结肠(直肠)张力及血运有关。保留左结肠动脉(LCA)与否而引发的高位抑或低位结扎争议无非是在不影响肿瘤学结局的同时,能否降低吻合口并发症发生率和(或)术后功能损害。从现有证据看,保留LCA可改善吻合口近端动脉血液供应,由有经验的医生实施可以达到与高位结扎等同的淋巴结清扫程度。但是否影响病人存活率、能否降低吻合口漏发生率、会否改善病人术后生活质量?上述3个指标均受多个因素影响,LCA保留与否作为其中一个因素,应引起关注,但权重较低。对外科具体步骤的评价宜放在综合治疗的系统中为妥。筛选LCA保留的获益人群尚须进行细致的、针对亚组人群的研究。作为外科医生,应熟悉血管变异、细化解剖及清扫路径的技术要点,明确No.253淋巴结的界限及其手术标准化,改进和优化手术方案,并积极探索个体化的淋巴结清扫。

Anastomotic leakage is a serious complication of rectal cancer surgery,which relates to anastomotic technique,preoperative treatment and other factors,the conditions at both ends of the colon(rectum),proximal intestinal and tension blood supply,are also important.High or low ligation with or without the preservation of the left colonic artery is a proposition that whether it can reduce anastomotic complications and/or postoperative functional impairment without affecting the oncologic outcome.Existing evidences suggest that retention of the left colonic artery improves the blood supply to the proximal colon at the anastomotic site,and that experienced physicians can achieve the extent of lymph node dissection as by high ligation.But does it affect the survival of patients,reduce the incidence of anastomotic leakage,and improve the postoperative quality of life of patients?There are multiple factors influencing the three parameters.The author believes that whether the left colic artery is retained or not as one of the factors should be paid attention to,but the weight is relatively low.The evaluation of specific surgical procedures should be integrated into the comprehensive treatment for a specific patient.Detailed research on subgroup population are needed.As a surgeon,one should be familiar with the technical issues such as vascular variation,refinement of anatomy and dissection approach.And clear definition of No.253 lymph node and standardization of surgical dissection,optimization of the surgical plan,and active exploration on individualized lymph node dissection should be investigated further.