术前CT血管成像在精准肠系膜下动脉低位结扎并D3淋巴结清扫的腹腔镜直肠前切除术中的应用

Application of preoperative CT angiography in laparoscopic anterior resection of rectal cancer with accurate low ligation of inferior mesenteric artery and D lymphadenectomy

背景与目的:近年来,越来越多的研究发现,腹腔镜直肠癌根治术中保留左结肠动脉(LCA)能够保证近端肠管血供,降低吻合口瘘发生率。但肠系膜下动脉(IMA)分支存在变异,保留LCA的D3淋巴结清扫,会增加操作难度,明显延长手术时间。本研究探讨在术前CT血管成像(CTA)的指导下,行保留LCA的低位结扎并D3淋巴结清扫的可行性和安全性。方法:回顾性分析2018年1月—2019年12月期间安徽医科大学第三附属医院胃肠外科收治的50例行IMA低位结扎并D3淋巴结清扫的腹腔镜直肠前切除术直肠癌患者的临床资料,患者术前均行下腹部血管CTA三维重建,以了解IMA分支分型情况。结果:50例患者中,IMA分支Ⅰ、Ⅱ、Ⅲ、IV型所占比例分别为48.0%(24/50)、16.0%(8/50)、34.0%(17/50)、2.0%(1/50);IMA长度为1.6~4.8 cm,平均(3.7±0.5)cm;Riolan弓缺如率70.0%(35/50)。所有患者手术经过顺利,无中转开腹病例。No.253淋巴结清扫时间12~35 min,平均(18.5±5.8)min,No.253淋巴结清扫数量0~6枚,平均(4.5±1.3)枚,其中淋巴结阳性者2例(4.0%),且2例术后病理分期均为ⅢC期。总手术时间115~190 min,平均(130±26)min;术中出血量30~150 mL,平均(65.8±7.8)mL;淋巴结清扫总数10~39枚,平均(17.6±4.5)枚。50例患者肿瘤组织学分型包括高分化腺癌10例,中分化腺癌25例,低分化腺癌15例;pTNM分期包括Ⅰ期5例,ⅡB期23例,ⅢA期15例,ⅢB期5例,ⅢC期2例。术后住院时间为8~15 d,平均(12.5±2.3)d。患者术后均无吻合口瘘等严重并发症发生,1例术后解暗红色血便,给予止血治疗后好转。患者均痊愈出院。全组患者均获得随访,随访时间为3~26个月,其中1例No.253淋巴结阳性ⅢC期患者,术后14个月出现肝脏转移。全组无死亡病例。结论:直肠癌患者术前均应行常规腹盆腔CTA三维重建。根据IMA分型,精准低位结扎、保留LCA并D3淋巴结清扫的腹腔镜直肠前切除术安全可行。

Background and Aims:In recent years,more and more studies have found that the preservation of left colonic artery(LCA)in laparoscopic radical resection of rectal cancer can ensure the blood supply of the proximal bowel and reduce the incidence of anastomotic leakage.However,there are several variations in the branches of the inferior mesenteric artery(IMA),the D3 lymph node dissection with LCA preservation will increase the operation difficulty and significantly prolong the operative time.This study was conducted to investigate the feasibility and safety of low ligation with LCA-preserving D3 lymph node dissection under the guidance of preoperative CT angiography(CTA).Methods:The clinical data of 50 patients with rectal cancer undergoing laparoscopic anterior resection with low IMA ligation and D3 lymph node dissection from January 2018 to December 2019 in the Department of Gastroenterology of the Third Affiliated Hospital of Anhui Medical University were retrospectively analyzed.All patients underwent preoperative CTA three-dimensional reconstruction of the lower abdominal vessels for identifying the types of branch vessels of the IMA.Results:Of the 50 patients,the proportions of typeⅠ,Ⅱ,Ⅲand IV of IMA branches were 48.0%(24/50),16.0%(8/50),34.0%(17/50),and 2.0%(1/50),respectively.The length of IMA was 1.6-4.8 cm,with an average of(3.7±0.5)cm.the incidence of Riolan artery arcade absence was 70.0%(35/50).The operation was uneventfully completed in all patients,and no open conversion was required.The time for No.253 lymph node dissection was(18.5±5.8)min on average(ranged from 12-35 min),and the number of No.253 lymph node dissection was 4.5±1.3 on average(ranged from 0-6),in which,positive lymph nodes were identified in 2 cases(4.0%),and both of them were classified a pathological stageⅢC.The total operative time was(130±26)min on average(ranged from 115–190 min),the intraoperative blood loss was(65.8±7.8)mL on average(ranged from 30–150 mL),and the total number of lymph node dissection was 17.6±4.5 on average(range from 10–39).The histological classification of the 50 patients included highly differentiated adenocarcinoma in 10 cases,moderately differentiated adenocarcinoma in 25 cases,and poorly differentiated adenocarcinoma in 15 cases,and the pTNM stage included stageⅠin 5 cases,stageⅡB in 23 cases,stageⅢA in 15 cases a,stageⅢB in 5 cases and stageⅢC in 2 cases.The length of postoperative hospital stay was(12.5±2.3)d on average(ranged from 8–15 d).No anastomotic leakage and other serious complications occurred in all patients after surgery,and one patient had dark red blood in stool after surgery,which was improved after hemostatic therapy.All patients were discharged from hospital after recovery.Followed-up was obtained in all patients for a period of 3–26 months.liver metastases occurred in one of the two patients with positive No.253 lymph node and stageⅢC disease at 14 months after surgery,and no death occurred in the entire group.Conclusion:For all rectal cancer patients,routine abdominal and pelvic CTA three-dimensional reconstruction is recommended before operation.Based on the types of branch vessels of the IMA,laparoscopic anterior rectal resection with accurate low ligation,LCA preservation and D3 lymphadenectomy is safe and feasible.