腹腔镜肠系膜下动脉低位结扎对直肠癌术后吻合口漏和预后的影响研究

Effect of laparoscopic low ligation of inferior mesenteric artery on postoperative anastomotic leakage and prognosis of rectal cancer

目的探讨腹腔镜肠系膜下动脉(IMA)低位结扎对直肠癌术后吻合口漏和预后的影响。方法回顾性分析本院120例腹腔镜直肠癌根治术患者临床病历资料,根据术中IMA结扎位置不同分为两组,观察组60例行IMA低位结扎,对照组60例行IMA高位结扎。比较两组患者手术相关指标、术后并发症发生率及第3站淋巴结转移情况,并分析患者术后发生吻合口漏的影响因素,术后随访3年记录两组生存情况。结果两组患者手术时间、术中出血量、术后住院时间、淋巴结清扫数目、肿瘤直径、第3站淋巴结清扫数目及第3站淋巴结转移率差异均无统计学意义(均P> 0.05)。观察组术后首次肛门排气时间短于对照组,术后吻合口漏发生率低于对照组,差异均有统计学意义(均P<0.05)。两组患者术后3年总生存率和无进展生存率差异均无统计学意义(Log-rank X^2=0.349、0.576,P=0.555、0.448)。多因素分析结果显示高位结扎和术前辅助治疗是术后发生吻合口漏的独立危险因素,预防性造瘘是独立保护因素(P<0.05)。结论腹腔镜IMA低位结扎术与高位结扎对患者第3站淋巴结转移率和术后3年生存率的影响均无明显差异,但低位结扎有助于降低术后吻合口漏发生率,对于术前行辅助治疗和高位结扎患者,术后要注意防治吻合口漏发生。

Objective To investigate the effect of laparoscopic low ligation of inferior mesenteric artery （IMA） on postoperative anastomotic leakage and prognosis of rectal cancer. Methods Clinical data of 120 patients who received laparoscopic radical surgery for rectal cancer in our hospital were retrospectively analyzed. Patients were divided into two groups according to the position of ligation of IMA. The treatment group （60 patients） received low ligation and the control group （60 patients） high ligation of IMA. Indices related to surgery, incidence of postoperative complications, and metastasis at D3 lymph nodes were compared between the two groups. We analyzed factors that influenced occurrence of postoperative anastomotic leakage. Patients were followed-up for three years to evaluate survival status. Results There was no significant difference in duration of surgery, amount of intraoperative blood loss, duration of postoperative hospitalization, total number of lymph node dissection, tumor size, number of D3 lymph node dissection and metastasis at D3 lymph node between the two groups （P 〉 0.05）. Time to first anal exhaust was shorter and incidence of postoperative anastomotic leakage significantly lower in the treatment group than in the control group （P 〈 0.05）. There was no significant difference in three-year overall survival and progression-free survival between the two groups （Log-rank χ^2 = 0.349 and 0.576, respectively, P = 0.555 and 0.448, respectively）. Multivariate analysis showed that high ligation and preoperative adjuvant therapy were independent risk factor and prophylactic colostomy was the protective factor for the occurrence of anastomotic leakage. Conclusion Effect of laparoscopic low or high ligation of IMA were comparable in terms of D3 lymph node metastasis and postoperative three-year survival, but low ligation could reduce risk of postoperative anastomotic leakage. Cautions should be given to patients who received preoperative adjuvant therapy and ligation patients.