保留左结肠动脉及253淋巴结清扫在腹腔镜下乙状结肠癌根治术中的安全性及可行性分析

目的 探讨保留左结肠动脉及253淋巴结清扫在腹腔镜下乙状结肠癌根治术中的安全性及可行性.方法 回顾性分析2018年10月至2019年11月在华中科技大学同济医学院附属协和医院胃肠外科接受腹腔镜乙状结肠癌根治术的病人,共计74例.将病人分为低位结扎组(33例)和高位结扎组(41例).低位结扎组行保留左结肠动脉乙状结肠癌根...     

腹腔镜直肠癌根治保留左结肠血管的技巧及意义

腹腔镜直肠癌根治有高位结扎和低位结扎处理肠系膜下动脉两种方式,高位结扎肠系膜下动脉可能会影响吻合口的血运,从而导致吻合口漏的发生。低位结扎保留了左结肠动脉(LCA),能够改善吻合口的血供。按照全直肠系膜切除原则,腹腔镜下保留LCA进行直肠癌术还需对肠系膜下动脉根部淋巴结进行D3清扫。本文结合国内外文献,对腹腔镜保留LCA直肠癌根治的意义及相关手术技巧进行综述。     

老年中低位直肠癌患者腹腔镜直肠前切除术中保留左结肠动脉的疗效分析

目的:探讨老年中低位直肠癌患者行腹腔镜直肠前切除术中保留左结肠动脉(LCA)的可行性及临床疗效。方法:回顾分析2016年1月至2019年12月66例行腹腔镜直肠前切除术的老年中低位直肠癌患者的临床资料,其中33例术中保留LCA(保留LCA组);33例术中行肠系膜下动脉根部结扎不保留LCA(不保留LCA组)。对比分析两组患者基本资料及术中、术后、随访、标本等相关指标。结果:保留LCA组术后排气时间[(56.45±22.06)h vs.(70.61±26.39)h]、术后住院时间[(11.03±3.56)d vs.(13.36±4.94)d]短于不保留LCA组(P0.05);两组手术时间、术中出血量、进食流质时间、253组淋巴结清扫数量、淋巴结清扫总数、术后总并发症发生率、吻合口漏发生率及短期随访指标差异均无统计学意义(P0.05)。结论:老年中低位直肠癌患者行腹腔镜直肠前切除术中保留LCA是安全、可行的,不影响肠系膜下动脉根部淋巴结的清扫、短期复发、转移、死亡率,且可缩短术后排气时间、术后住院时间,具有较好的临床应用价值。     

腹腔镜扩大左半结肠切除术

采用5孔法,经典中间入路。在右侧输尿管内侧2 cm切开,进入左侧Toldt间隙,自尾侧向头侧锐性分离,清扫肠系膜下动脉根部的淋巴脂肪组织。解剖降结肠及乙状结肠动脉,根部离断。十二指肠空肠曲左侧离断肠系膜下静脉根部,向外侧拓展降结肠后间隙、乙状结肠后间隙和直肠上段后间隙,确认左输尿管及生殖血管以防止损伤。切开并游离横结肠系膜,在胰颈下缘显露中结肠动静脉,于根部离断。沿降结肠沟剪开左侧腹膜,上至脾曲,下至直肠上段,与之前已拓展完成的左结肠后间隙汇合。自胃大弯侧血管弓内离断血管分支,直至根部切断胃网膜左血管,并切断脾结肠韧带,完全游离脾曲。于左侧经腹直肌切口切开腹壁,长约5 cm,将左半结肠拖出体外。在肿瘤近远端10～15 cm横断结肠,行端端吻合术。     

左半结肠癌行No.223、No.253淋巴结清扫意义及争议

淋巴结转移是结直肠癌的主要转移方式,NCCN、日本大肠癌研究会（JSCCR）和我国结直肠癌诊疗相关规范都规定了结肠癌根治术需要行区域淋巴结清扫,No.223、No.253淋巴结属于左半结肠癌的区域淋巴结。结肠脾曲癌由结肠中动脉左支和左结肠动脉双重供血,推荐行No.223、No.253淋巴结清扫,降结肠癌和乙状结肠癌主要由肠系膜下动脉供血,只须行No.253淋巴结清扫。目前,部分研究认为血管低位结扎（血管根部淋巴结清扫）与血管高位结扎对于淋巴结清扫数量及肿瘤学效果一致,部分研究提示血管高位结扎可能影响肠管血供,增加吻合口漏的发生。因此,推荐清扫No.223、No.253淋巴结时可以保留结肠中动脉和肠系膜下动脉。由于左半结肠癌发病率较低,目前缺乏有说服力的证据,期待临床进行高级别循证医学研究进一步明确淋巴结清扫范围。     

保留左结肠动脉及直肠上动脉的腹腔镜乙状结肠癌根治术的临床应用及近期疗效分析

目的:探讨保留左结肠动脉及直肠上动脉的乙状结肠癌手术的具体操作技术及临床可行性,并与传统术式进行对比。方法:回顾分析2015年1月至2016年11月为82例患者行腹腔镜乙状结肠癌根治术的临床资料,将患者分为保留血管组(n=24)与传统术式组(n=58)。保留血管组行保留左结肠动脉及直肠上动脉的乙状结肠癌根治术,传统术式组行不保留上述血管的根治术。比较两组手术时间、淋巴结清扫数量、术中出血量、吻合口愈合情况等指标。结果:两组淋巴结清扫数量差异无统计学意义(P0.05);保留血管组手术时间长于传统术式组,差异有统计学意义(P0.05);保留血管组患者未发生吻合口瘘,传统组发生2例,差异无统计学意义(P0.05)。结论:保留左结肠动脉及直肠上动脉的腹腔镜乙状结肠癌根治术安全、可行,具有良好的临床应用前景。     

腹腔镜直肠癌根治术保留左结肠动脉关键技术与意义

腹腔镜直肠癌根治术保留左结肠动脉是近年临床上争议的热点,也有其发展的过程。前腹腔镜时代直肠癌手术更多的是低位结扎肠系膜下动脉(IMA),保留或不保留左结肠动脉(LCA),一般不清扫系膜根部淋巴结(253组),近年随着手术越来越规范,更多的强调行253组淋巴结清扫,为了手术方便多行IMA根部离断,不保留LCA,同时带来一系列临床问题的探讨,又提出保留左结肠动脉直肠癌根治术。本文列举腹腔镜直肠癌根治术中保留左结肠动脉的要求、关键技术、以及临床意义,更多的是结合自己的体会,认为保留左结肠动脉一定要在根治的前提下,在腹腔镜下更易做好,该术式改进有很多优点和重要的临床意义。     

腹腔镜下保留直肠上动脉的D3淋巴结廓清术在乙状结肠癌根治术中的临床应用

目的探讨腹腔镜下保留直肠上动脉(SRA)的D3淋巴结廓清术在乙状结肠癌根治术中应用的临床可行性、安全性及有效性。方法 2016年1月～2018年12月间收治的乙状结肠癌病人45例,根据治疗方法不同分为两组,保留SRA组25例,采用腹腔镜下保留SRA的D3淋巴结廓清术,不保留SRA组20例,行直接离断肠系膜下动脉根部不保留直肠上动脉手术。比较两组术中出血量、手术时间、肠道功能恢复以及术后并发症等指标。结果保留SRA组和不保留SRA手术组手术时间分别为(202.2±46.5)分钟和(147.5±37.3)分钟,术后肠道功能恢复时间分别为(2.1±1.1)天和(3.1±1.3)天,住院时间分别(8.1±0.9)天和(11.5±1.1)天,两组比较差异均有统计学意义(P0.05);保留SRA组和不保留SRA手术组术中出血量分别为(65.3±10.2)ml和(59.2±9.9)ml,淋巴结清扫数量分别为(14.4±3.5)枚和(15.3±4.2)枚,术后并发症发生率分别为8%(2/25)和15%(3/20),两组比较差异均无统计学意义(P0.05)。结论腹腔镜下乙状结肠癌根治术保留直肠上动脉的D3淋巴结廓清术安全可行,未增加并发症发生率,有助于术后肠功能恢复。     

保留左结肠动脉的乙状结肠癌根治术的疗效分析

【摘要】 目的 探讨保留左结肠动脉(LCA)的乙状结肠癌根治术的术式安全性和可行性。方法 回顾性分析2010年4月至2013年5月开腹下行保LCA的乙状结肠癌根治术手术(n=32,LCA保留组),采用历史对照的方法,评估保LCA组和肠系膜下动脉根部结扎的传统乙状结肠癌根治术(n=43,传统组)两组患者的手术效果、临床病理资料以及术后并发症。结果 保LCA组和传统手术组的平均手术时间和出血量亦未见明显差异。但LCA组与传统手术组相比,切除的近端肠管(11.5 cm vs 16.7 cm)和远端肠管(5.8 cm vs 8.7 cm)长度更短,差异具有显著的统计学差异(P<0.05)。LCA组并不减少术后活检淋巴结的个数,亦未见主淋巴结群活检的淋巴结个数(2.3枚 vs 2.1枚)及阳性淋巴结个数(0.2枚 vs 0.3枚)减少。两组患者术后并发症的比较并无明显的差别。结论 保LCA的乙状结肠癌根治术治疗乙状结肠癌是可行、安全、有效的,可保证肠系膜下动脉根部淋巴结的根治性,并不增加手术的风险。     

保留左结肠动脉的腹腔镜直肠前切除术的可行性研究

目的探讨根部结扎与腹腔镜直肠前切除术的可行性。 方法回顾性分析2015年9月至2019年9月直肠癌患者74例资料,根据手术方法不同将其分为两组,对照组进行肠系膜下动脉的根部结扎不保留左结肠动脉,研究组进行保留左结肠动脉高清腹腔镜直肠前切除术,每组37例。应用SPSS20.0软件处理数据,术中术后指标、肠管远、近切缘长度、淋巴结清扫数目以( ±s)表示,独立t检验;术后并发症采用χ²检验,P<0.05差异有统计学意义。 结果研究组术中出血量和手术时间多于对照组(P<0.05),但术后排气时间少于对照组(P<0.05);两组肠管远切缘长度、肠管近切缘长度、第3站淋巴结清扫数目、淋巴结清扫总数目、术后并发症发生率等差异无统计学意义(P>0.05)。 结论直肠癌的治疗中,保留左结肠动脉将会更多应用于临床,治疗效果较好,应进一步推广。     

Laparoscopic D3 lymph node dissection with preservation of the superior rectal artery for the treatment of proximal sigmoid and descending colon cancer

In this paper we report a technique for laparoscopic lymph node (LN) dissection for descending and proximal sigmoid colon cancer with the preservation of the superior rectal artery (SRA) to maintain the blood supply to the distal sigmoid colon. Five (5) cases were included from November 2004 to March 2005. For D3 LN dissection, the root of inferior mesenteric artery was exposed with ultrasonic cutting and coagulating surgical device to avoid bleeding. The arterial wall was then exposed with a spatula-type electric cautery down to the left colic artery (LCA). The LCA was then clipped and cut while preserving the SRA. The inferior mesenteric vein was divided at the caudal side of the LCA and prior to joining to the splenic vein. All cases underwent a LN dissection laparoscopically. There were no cases of complications originating from the LN dissection. Although long-term outcomes should be investigated, our results indicate that this is a safe, applicable method.     

腹腔镜保留左半结肠血管的直肠癌第3站淋巴结清扫术

直肠癌手术中清扫位于肠系膜下动脉根部的第3站淋巴结,可以降低直肠癌的复发率和转移率.如何既能保证规范的第3站淋巴结清扫又能充分保障左侧剩余肠段的血供值得临床医师进一步探讨.2012年1月至2013年3月吉林大学第一医院对133例直肠癌患者施行了腹腔镜保留左半结肠血管的第3站淋巴结清扫术.133例患者均顺利施行该手术,无一例中转开腹,无术中并发症发生,术后总体并发症发生率为6.77％（9/133）.118例患者随访2～16个月,中位随访时间为7个月,2例患者出现肝转移,6例肿瘤标志物水平升高,但腹腔内未见明确肿瘤复发及转移征象,其余患者无异常表现.腹腔镜保留左半结肠血管的直肠癌第3站淋巴结清扫术安全可行.     

Laparoscopic colectomy for persistent descending mesocolon in sigmoid colon cancer: A case report

A 55-year-old-man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Preoperative barium enema showed a slightly medial displacement of the descending colon, and the sigmoid colon was quite long. The operative findings showed that the descending colon was not fused with the retroperitoneum and shifted to the midline and the left colon adhered to the small mesentery and right pelvic wall. Thus, a diagnosis of persistent descending mesocolon (PDM) was made. The left colon, sigmoid colon, and superior rectal arteries often branch radially from the inferior mesenteric artery. The sigmoid mesentery shortens, and the inferior mesenteric vein is often close to the marginal vessels. By understanding the anatomical feature of PDM and devising surgical techniques, laparoscopic sigmoidectomy for sigmoid colon cancer with PDM could be performed without compromising its curative effect and safety.     

Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum

BACKGROUND: When we perform laparoscopic lymph node dissection around the inferior mesenteric artery (IMA), we preserve the left colic artery (LCA) to maintain the blood supply to the proximal sigmoid colon. In this study, we present our laparoscopic D2 and D3 lymph node (LN) dissection technique and evaluate its applicability and safety. METHODS: We performed LN dissection on 23 rectal and lower sigmoid colon cancer cases from April 2002 to December 2004. For D3 LN dissection, the incision to the mesosigmoid extends to just before the root of the IMA, which is exposed with an ultrasonic cutting and coagulating surgical device to avoid bleeding. Then, the arterial wall is exposed with a dissecting electrocautery spatula down to the LCA, at least 2 cm of which is exposed. Adipose tissue surrounding the IMA and inferior mesenteric vein is dissected. For D2 LN dissection, we partially expose the IMA to confirm the location of the LCA. RESULTS: The mean times taken for D2 and D3 LN dissections were 36.2 and 68.2 min, respectively. Both procedures took longer in male patients. There was a trend for the procedure overall to take less time in female patients. However, D2 dissection took significantly longer in male than female patients (p < 0.05). In women, D3 dissection took significantly longer than D2 (p < 0.05), but this trend was not seen in men. Increased experience among surgeons with this procedure was associated with significantly faster LN dissections in men (p < 0.05), but not in women (p = 0.493). Pearson product moment analysis identified a relationship between body mass index (BMI) and the time taken for D2 LN dissection (r = 0.765), but not D3 LN dissection (r = 0.158). There was no treatment-related morbidity with this technique. CONCLUSIONS: This method was safe and feasible for all patients in this series, but takes longer to perform in male patients.     

直肠癌手术保留左结肠动脉共识与争议

吻合口漏是直肠癌手术中较为严重的并发症，其发生除与吻合技术、术前治疗等因素有关外，还与吻合两端结肠（直肠）张力及血运有关。保留左结肠动脉（LCA）与否而引发的高位抑或低位结扎争议无非是在不影响肿瘤学结局的同时，能否降低吻合口并发症发生率和（或）术后功能损害。从现有证据看，保留LCA可改善吻合口近端动脉血液供应，由有经验的医生实施可以达到与高位结扎等同的淋巴结清扫程度。但是否影响病人存活率、能否降低吻合口漏发生率、会否改善病人术后生活质量？上述3个指标均受多个因素影响，LCA保留与否作为其中一个因素，应引起关注，但权重较低。对外科具体步骤的评价宜放在综合治疗的系统中为妥。筛选LCA保留的获益人群尚须进行细致的、针对亚组人群的研究。作为外科医生，应熟悉血管变异、细化解剖及清扫路径的技术要点，明确No.253淋巴结的界限及其手术标准化，改进和优化手术方案，并积极探索个体化的淋巴结清扫。     

Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery

Aim  

Curative resection of sigmoid and rectal cancer includes “high tie” of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate. Accordingly, some surgeons employ a technique of lymph node (LN) dissection around the IMA, preserving the IMA and left colic artery (LCA). The same technique was reported to need longer time in laparoscopic surgery due to technical difficulties. We present herein a simple and secure method of laparoscopic LN dissection around the IMA that allows preservation of the IMA and LCA, and report the operative results.     

精准保留左结肠动脉并根部淋巴结清扫的腹腔镜直肠癌根治术的疗效分析

目的:探讨腹腔镜下直肠癌根治术中根据肠系膜下动脉(IMA)不同分型精准保留左结肠动脉(LCA)及根部淋巴结清扫的临床意义。方法:采用回顾性对比性的方法纳入2016年6月至2018年6月施行的72例腹腔镜下直肠癌根治术,其中38例根据IMA分型行精准保留LCA并廓清IMA根部淋巴结(保留LCA组),34例不保留LCA,行传统高位结扎术(高位结扎组);对比分析两组临床资料、围手术期疗效指标及术后恢复情况。结果:两组手术均顺利完成,无一例中转开腹,两组手术时间、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),两组淋巴结清扫总数、阳性淋巴结数量差异无统计学意义(P>0.05)。保留LCA组术后1例发生吻合口出血,高位结扎组术后2例发生排尿功能障碍、2例吻合口漏,两组术后并发症总发生率分别为2.6%与11.8%,差异有统计学意义(P<0.05)。结论:腹腔镜直肠癌根治术中保留LCA并清扫根部淋巴结可达到肿瘤根治效果,并能降低术后总并发症发生率,是安全、有效的。     

Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery

BACKGROUND: The aim of this study was to assess the impact of inferior mesenteric artery (IMA) root nodal dissection before high ligation of the artery on survival in patients with sigmoid colon or rectal cancer. METHODS: Data on 1188 consecutive patients who underwent resection for sigmoid colon or rectal cancer, with high ligation of the IMA, were identified from a prospective database (April 1965 to December 1999). Survival of patients with involvement of nodes along the IMA proximal to the origin of the left colic artery (root nodes, station 253) through the bifurcation of the superior rectal artery (trunk nodes, station 252) was determined. RESULTS: Twenty patients (1.7 per cent) had metastatic involvement of station 253 lymph nodes and 99 (8.3 per cent) had metastases to station 252. The 5- and 10-year survival rates of patients with metastases to station 253 were 40 and 21 per cent, and those for patients with metastases to station 252 were 50 and 35 per cent, respectively. CONCLUSION: High ligation of the IMA allows curative resection and long-term survival in patients with cancer of the sigmoid colon or rectum and nodal metastases at the origin of the IMA.