腹腔镜直肠癌手术保留左结肠动脉再认识  

Rerecognition of preserving left colonic artery in laparoscopic rectal cancer surgery

作　　者：陈育洪 程黎阳 王长征 Chen Yuhong;Cheng Liyang;Wang Changzheng(Department of General Surgery,the General Hospital of Southern Theater Command,PLA,Guangzhou 510010,China)

机构地区：[1]中国人民解放军南部战区总医院普通外科,510010

出　　处：《中华结直肠疾病电子杂志》2022年第4期319-324,共6页Chinese Journal of Colorectal Diseases(Electronic Edition)

基　　金：广东省自然基金项目(No.8151001002000010)

摘　　要：腹腔镜直肠癌全直肠系膜切除历经30余年的探索,逐步成为直肠癌根治的新标准,虽然微创理念下进行肿瘤根治及功能保护已成为结直肠外科领域的共识,但是肠系膜下动脉(IMA)结扎位置仍有争议,保留左结肠动脉(LCA)在减少吻合口漏、器官功能保护有明显优势,而高位结扎在肿瘤根治度、远期生存疗效具有重要意义,时至今日美国国家综合癌症网络(NCCN)、日本大肠癌研究会(JSCCR)、中国临床肿瘤学会(CSCO)等机构对IMA结扎位置尚无明确规定。本文分析最近证据级别较高文献报道及笔者医院临床数据,通过保留LCA再认识,推荐CT血管重建对IMA进行定位及分型,同时建立临床、影像以及病理多种因素治疗效果评价模式,提倡能保则保原则和精准的个体化治疗理念,术中应用边缘动脉弓压力测定、吲哚菁绿、纳米碳等技术,推荐规范手术操作流程、“六步法”保留LCA操作技巧,对于保留难度大、多因素疗效评价预后较差或淋巴结转移者可以选择高位结扎。与此同时,期待基线资料更趋于均衡的循证医学证据,筛查出腹腔镜下保留LCA的最适用人群并制定更加严谨的共识。After 30 years of exploration, laparoscopic total mesorectal resection (TME) has gradually become a new standard for radical resection of rectal cancer. Although radical resection and functional protection under the concept of minimally invasive has become a consensus in the field of colorectal surgery, the location of ligation of inferior mesenteric artery (IMA) is still controversial. It is generally believed that preserving the left colonic artery (LCA) has obvious advantages in reducing anastomotic leakage and protecting organ function, while high ligation is of great significance in the degree of radical cure and long-term survival. Up to now, National Comprehensive Cancer Network (NCCN), Japanese Society for Cancer of the Colon and Rectum (JSCCR), Chinese Society of Clinical Oncology (CSCO) and other organizations have no clear regulations on the location of inferior mesenteric artery ligation. In this paper we analyze the recent literature reports with high level of evidence and the clinical data of the authors' hospital. We recommend CT revascularization to locate and classify IMA, and establish a multifactor treatment effect evaluation model of clinical, imaging and pathology. We advocate the principle of "preserved if possible " and the concept of accurate individualized treatment. Intraoperative techniques such as marginal arterial stump pressure (MASP) measurement, indocyanine green (ICG) fluorescence angiography and nano carbon are applied. It is recommended to standardize the surgical operation process and "six-step" LCA preserving operation skills. For those with great preservation difficulty, poor prognosis with evaluation model or lymph node metastasis, high ligation can be selected. At the same time, we expect evidence-based medical evidence with more balanced baseline data, screen the most suitable population for laparoscopic preservation of left colonic artery, and develop a more rigorous consensus.

关 键 词：直肠肿瘤 腹腔镜 No.253组淋巴结 左结肠动脉 

分 类 号：R735.37[医药卫生—肿瘤]