腹腔镜全直肠系膜切除术中保留左结肠动脉治疗直肠癌的临床效果观察

Effectiveness of preserving left colic artery in laparoscopic radical resection of rec⁃tal cancer

目的探讨腹腔镜全直肠系膜切除术中保留左结肠动脉(LCA)治疗直肠癌的临床疗效。方法回顾性分析2017年6月至2019年2月东南大学医学院附属徐州医院胃肠外科收治的151例直肠癌行腹腔镜全直肠系膜切除术患者的临床资料,根据术中是否保留LCA分为保留LCA组(n=78)和不保留LCA组(n=73),对比分析两组患者的手术时间、术中出血量、总淋巴结清扫数目、IMA根部淋巴结清扫数目、游离脾曲率、预防性造口数量、吻合口漏发生率、吻合口出血发生率、术后首次肛门排气时间和平均住院时间等指标,并随访患者生存情况。结果151例患者均顺利完成腹腔镜下TME操作,无中转开腹及死亡病例。两组手术时间、术中出血量、总清扫淋巴结数目、IMA根部淋巴结清扫数目、游离脾曲率、术后吻合口出血发生率、吻合口漏发生率、术后首次肛门排气时间和平均住院时间比较,差异均无统计学意义(均P>0.05);不保留LCA组和保留LCA组预防性造口数量分别为9例和2例,两组预防性造口率比较差异有统计学意义(P<0.05)。不保留LCA组和保留LCA组未行预防性造口术后吻合口漏发生率分别为14.1%(9/64)和3.95%(3/76),差异有统计学意义(P<0.05)。所有患者随访时间为12~30个月,中位随访时间为19个月,无远期并发症发生,不保留LCA组局部复发5例(6.8%),远处转移10例(13.7%),保留LCA组局部复发6例(7.7%),远处转移11例(14.1%),两组比较差异均无统计学意义(均P>0.05)。结论腹腔镜全直肠系膜切除术中保留LCA,可以保证IMA根部淋巴结的清扫,降低患者造口率及未行预防性造口患者的吻合口漏发生率,在腹腔镜直肠癌手术技术成熟的单位具有一定推广价值。

Objectives To investigate the effect of preserving left colic artery(LCA)in laparoscopic radical resection of rectal cancer.Methods This was a retrospective analysis of 151 patients who received laparoscopic radical resection of rectal cancer at the Department of Gastrointestinal Surgery,Xuzhou Affiliated Hospital of Medical College of Southeast University,between June 2017 and February 2019.Patients were divided into preservation group(n=78)and no-preservation group(n=73)depending on whether the LCA was preserved during the surgery.Operation time,intraoperative blood loss,total lymph node yield,inferior mesenteric arterial(IMA)root lymph node yield,incidence of free splenic flexure,quantity of prophylactic stoma,incidence of anastomotic leakage and anastomotic bleeding,time to postoperative flatulence,hospitalization time were compared between the two groups.Patients were followed-up to record their survival status.Results Total mesorectal excision was uneventful in all 151 patients with no conversion to open surgery or death.Operation time,intraoperative blood loss,total lymph node yield,IMA root lymph node yield,incidence of free splenic flexure,incidence of anastomotic leakage and anastomotic bleeding,time to post⁃operative flatulence,hospitalization time were comparable between the two groups(P>0.05).Nine patients in the no-preservation group and two in the preservation group received prophylactic stoma,the difference in the incidence of prophylactic stoma be⁃tween the two groups was statistically significant(P<0.05).For patients who did not receive prophylactic stoma,the incidence of anastomotic leakage was significantly higher in the no-preservation group(14.1%,9/64)than in the preservation group(3.95%,3/76,P<0.05).Patients were followed up for 12 to 30 months with a median follow-up of 19 months.There were no long-term complications.In the no-preservation group,five(6.8%)patients had recurrence and ten(13.7%)distant metastasis.The corre⁃sponding figures in the preservation group were 6(7.7%)and 11(14.1%),respectively.The incidence of recurrence and distant metastasis was similar between the two groups(P>0.05).Conclusion Preserving the LCA in laparoscopic radical resection for rectal cancer can ensure IMA root lymph node yield,reduce the likelihood of a stoma,and lower the risk of anastomotic leak⁃age in patients who did not undergo prophylactic stoma.In clinics that are experienced in laparoscopic surgery for rectal cancer,this procedure could be widely applied.