保留与不保留左结肠动脉第三站淋巴结清扫术在直肠癌腹腔镜D3根治术中的应用对照
摘要
目的比较保留与不保留左结肠动脉第三站淋巴结清扫术在直肠癌腹腔镜D3根治术中的应用效果。方法 54例直肠癌患者分为保留组29例与非保留组25例,保留组接受保留左结肠动脉并联合第三站淋巴结清扫的直肠癌腹腔镜D3根治术治疗,非保留组接受肠系膜下动脉高位结扎的直肠癌腹腔镜D3根治术治疗,采用结肠边缘动脉弓压力(MASP)水平评估吻合口血流灌注情况。结果两组手术治疗过程中均实现无张力吻合,4例发生吻合口瘘,其中保留组1例,非保留组3例;MASP的检测结果显示,保留组为(48.6±2.5)mmHg,非保留组为(42.2±1.9)mmHg,组间差异有统计学意义(t=10.454 5,P<0.001),年龄、外周血压(SP)及远端结肠长度(DCL)为影响MASP的潜在预测因素,年龄与分组因素为MASP的独立影响因素;MASP与外周血压(SP)呈正相关(r=0.351,P=0.006),与年龄和远端结肠长度(DCL)呈负相关性(r=-0.285,P=0.031和r=-0.324,P=0.023),MASP受手术方式的影响最为显著(P=0.003);两组总淋巴结收获量、D3淋巴结收获量及手术时间差异均无统计学意义(P>0.05),发生吻合口瘘患者的平均MASP较未发生吻合口瘘患者显著更低(P<0.001)。结论保留较不保留左结肠动脉的直肠癌腹腔镜D3根治术更有利于直肠癌根治术患者术后获得更佳的远端结肠及吻合口血供,且对总淋巴结及第三站淋巴结收获数量均未造成影响,也不明显增加手术时间,能在一定程度控制吻合口瘘发生率。
引文
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13 Kobayashi M,Okamoto K,Namikawa T,et al.Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum:is D3 lymph node dissection with preservation of the left colic artery feasible[J].Surg Endosc,2006;20(4):563-9.
14 Fraccalvieri D,Biondo S,Saez J,et al.Management of colorectal anastomotic leakage:differences between salvage and anastomotic takedown[J].Am J Surg,2012;204(5):671-6.
15 Hinoi T,Okajima M,Shimomura M,et al.Effect of left colonic artery preservation on anastomotic leakage in laparoscopic anterior resection for middle and low rectal cancer[J].World J Surg,2013;37(12):2935-43.
2 Stevenson AR,Solomon MJ,Lumley JW,et al.Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer:the ALaCaRT randomized clinical trial[J].JAMA,2015;314(13):1356-63.
3 曾庆敏,王延召,黄文生,等.3D与2D腹腔镜直肠癌根治术近期疗效的观察[J].中国普通外科杂志,2016;25(4):622-6.
4 Lange M,Buunen M,van de Velde C,et al.Level of arterial ligation in rectal cancer surgery:low tie preferred over high tie.A review[J].Dis Colon Rectum,2008;51(7):1139-45.
5 Sekimoto M,Takemasa I,Mizushima T,et al.Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery[J].Surg Endosc,2011;25(3):861-6.
6 Killen D,Reed W,Gorton M,et al.Is routine postaneurysmectomy hemodynamic assessment of the inferior mesenteric artery circulation helpful[J].Ann Vasc Surg,1999;13(5):533-8.
7 Park JS, Gyu-Seog C,Jun SH,et al. Long-term outcomes after laparoscopic surgery versus open surgery for rectal cancer: a propensity score analysis[J]. Ann Surg Oncol,2013;20(8):2633-40.
8 Dworkin MJ,Allen-Mersh TG.Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon[J].Am Coll Surg,1996;183(4):357-60.
9 Seike K,Koda K,Saito N,et al.Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery[J].Colorectal Dis,2007;22(6):689-97.
10 Rouffet F,Hay J,Vacher B,et al.Curative resection for left colonic carcinoma:hemicolectomy vs.segmental colectomy.A prospective,controlled,multicenter trial.French Association for Surgical Research[J].Dis Colon Rectum,1994;37(7):651-9.
11 Alici A,Kement M,Gezen C,et al.Apical lymph nodes at the root of the inferior mesenteric artery in distal colorectal cancer:an analysis of the risk of tumor involvement and the impact of high ligation on anastomotic integrity[J].Tech Coloproctol,2010;14(1):1-8.
12 Elsaleh H,Cserni G,Iacopetta B.Extent of nodal involvement in stage Ⅲ colorectal carcinoma:relationship to clinicopathologic variables and genetic alterations[J].Dis Colon Rectum,2002;45(9):1218-22.
13 Kobayashi M,Okamoto K,Namikawa T,et al.Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum:is D3 lymph node dissection with preservation of the left colic artery feasible[J].Surg Endosc,2006;20(4):563-9.
14 Fraccalvieri D,Biondo S,Saez J,et al.Management of colorectal anastomotic leakage:differences between salvage and anastomotic takedown[J].Am J Surg,2012;204(5):671-6.
15 Hinoi T,Okajima M,Shimomura M,et al.Effect of left colonic artery preservation on anastomotic leakage in laparoscopic anterior resection for middle and low rectal cancer[J].World J Surg,2013;37(12):2935-43.