根据肠系膜下动脉各分支分型行精准低位结扎并根部淋巴结清扫的腹腔镜直肠癌根治术  

Accurate low ligation of inferior mesenteric artery and root lymph node dissection according to different vascular typing in laparoscopic radical resection of rectal cancer

作　　者：周家铭[1] 谭淑云[1] 黄俊[1] 黄品助[1] 彭绍勇 林金鑫[1] 李拓阳 汪建平[1] 黄美近[1] 

机构地区：[1]中山大学附属第六医院结直肠外科,广州510655

出　　处：《中华胃肠外科杂志》2018年第1期46-52,共7页Chinese Journal of Gastrointestinal Surgery

摘　　要：目的探讨腹腔镜直肠癌手术中根据肠系膜下动脉（IMA）分支分型的不同进行精准低位结扎、保留左结肠动脉（LCA）及清扫根部淋巴结的应用价值。方法2015年10月至2016年6月．中山大学附属第六医院结直肠外科采用前瞻性对比研究的方法，纳入104例经术前检查证实为肿瘤距肛2～15cm、原发灶可完整切除且无远处转移、可接受腹腔镜手术的18—75岁直肠癌患者实施腹腔镜直肠癌根治手术，其中男性67例，女性37例，年龄22～83岁，中位体质指数25．3kg／m2：I期6例，Ⅱ期51例。Ⅲ期47例。按照完全随机的原则，52例应用低位结扎IMA合并根部淋巴结清扫（LAND，低位结扎组），通过术前CT分析IMA的分支分型及长度，精准分离并保留LCA，清扫根部淋巴结（No．253）并将其单独送检；另52例予以传统高位结扎（高位结扎组）；对两组患者的临床资料进行回顾性分析并比较其围手术期疗效指标及术后恢复情况。结果两组患者的IMA分支分型、长度及术前肿瘤临床分期差异均无统计学意义（P〉0．05）。两组患者手术均顺利完成，无一例中转开腹，但低位结扎组有2例患者因术中需要行LCA结扎（1例在分离IMV时损伤LCA导致出血，1例因吻合张力较大）。两组患者的手术时间、术中出血量、预防性造口率及术后病理分期差异无统计学意义（P〉0．05）。低位结扎组的淋巴结清扫总数目及No．253组淋巴结清扫数目[（24．9±5．7）枚及（2．4±1．1）枚]显著多于高位结扎组[（16．9±4．2）枚（1，5±0．8）枚]（均P=0．001），但两组总体淋巴结阳性率及No．253淋巴结阳性率比较．差异无统计学意义（P〉0．05）。两组患者术后首次肛门排气时间、住院时间、腹腔引流总量、腹腔引流管和肛门引流管及尿管停留时间差异均无统计学意义（P〉0．05）。低位结扎组术后有2例排尿功能障Objective To explore the feasibility and clinical significance of precision low inferior mesenteric artery （IMA） ligation with the left colonic artery （LCA） preservation and root lymph node dissection in laparoscopic radical resection for rectal cancer, according to the inferior mesenteric artery （IMA） types. Methods One Hundred and fore cases of rectal cancer patients who underwent laparoscopic resection in The Sixth Affiliated Hospital of Sun Yat-sen University from October 2015 to June 2016 were selected and divided into study group and control group according to different surgical methods. The study group （52 cases） accepted precision low IMA ligation with the LCA preservation and root lymph node （No.253） dissection, according to the IMA types and length examined by preoperative computed tomography angiography （CTA） reconstruction. The control group （52 cases） accepted the traditional high IMA ligation. The perioperative efficacy indexes and postoperative recovery situation of the two groups were compared. Results The IMA types, IMA length and preoperative clinical stages were not significantly different between the two groups （all P 〉 0.05）. The surgery was completed smoothly for patients in both groups, with no conversion to open surgery. But two patients in the study group underwent left colonic artery ligation for intra-operative need. There were no significant differences in the operative time, intra-operative blood lose, the rate of protective ileostomy and post- operative pathological stages between the two groups （all P 〉 0.05）. More total lymph nodes [（24.9 ＋ 5.7） vs. （16.9 ~ 4.2）, P= 0.0011 and No.253 lymph nodes [（2.4 ＋1.1） vs. （1.5 ~0.8）, P= 0.001] were harvested in study group as compared to control group. However, the positive rate of total harvested lymph nodes and No.253 lymph nodes between the two groups were not significantly different （P 〉 0.05）. There were no significant differences between the two groups in postoperative fi

关 键 词：直肠肿瘤 腹腔镜 肠系膜下动脉分支分型 根部淋巴结 左结肠动脉 

分 类 号：R735.37[医药卫生—肿瘤]