进展期直肠癌肠系膜下动脉根部结扎及淋巴廓清的临床评价

目的　研究进展期直肠癌肠系膜下动脉（ＩＭＡ）根部结扎和区域性淋巴廓清对患者生存率的影响。方法　分析行肠系膜下动脉根部结扎的Ｄ３ 式淋巴廓清术６９ 例和同期行非根部结扎根治术直肠癌５６ 例。结果　肠系膜下动脉根部及腹主动脉周围淋巴结转移率为１１－６％ ,肿瘤浸润深度ｐＴ３ 和ｐＴ４ 期发生转移明显增多。有肠系膜下动脉根部淋巴结转移者５ 年生存率为３７－５％ ,明显低于无根部淋巴转移者（７０－５ ％） ;同时,行肠系膜下动脉根部结扎的Ｄ３ 式淋巴廓清术总的５ 年生存率为６６－７％ ,明显高于非根部结扎的根治术者（４８－２％ ）。结论　对直肠癌根治术,强调行肠系膜下动脉根部结扎和近腹主动脉周围淋巴结清扫,对下部直肠癌加行侧方及全直肠系膜切除术,尤其对ｐＴ３ 和ｐＴ４ 期患者,能提高患者５ 年生存率。     

肠系膜下动脉不同处理方式对直肠癌根治术影响的对比研究

目的探讨肠系膜下动脉（IMA）低位结扎与高位结扎并根部淋巴结廓清对直肠癌根治术的意义。方法对2007年5月—2008年5月收治的156例直肠癌患者进行回顾性分析,低位结扎组80例,高位结扎组76例。低位结扎组采用肠系膜下动脉低化结扎并根部淋巴结廓清,高位结扎组采用肠系膜下动脉高位结扎斤根部淋巴结廓清。比较两组IMA根部淋巴结转移率、淋巴结清扫数量、复发率、5年生存牢及并发症发病率,并进行统计学分析。结果低位结扎组IMA根部淋巴结转移率为15．0％,高位结扎组IMA根部淋巴结转移率为14．5％,两组比较差异无统计学意义（P〉0．05）;对比两组术后复发率、5年生存率、吻合口瘘、性功能障碍和尿潴留的发病率,差异均无统计学意义（P〉0．05）;低位结扎组肠道功能恢复时间、低位直肠前切除综合征的发病率低于高位结扎组,两组比较差异有统计学意义（P〈0．05）。结论肠系膜下动脉低位结扎并根部淋巴结廓清可达到直肠癌根治。与传统IMA高位结扎相比,对患苦的复发率、5年生存率及并发症发病率无影响。     

High ligation of the inferior mesenteric artery in rectal cancer surgery

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.     

Prognostic Impact of Inferior Mesenteric Artery Lymph Node Metastasis in Colorectal Cancer

Aim

The aims of this study are to identify the natural course of inferior mesenteric artery (IMA) lymph node metastasis, and to evaluate the prognostic impact of IMA lymph node metastasis in the sigmoid colon and rectal cancer.

Patients and Methods

From our prospectively collected database, a total of 625 patients who underwent resection with curative intent for stage III adenocarcinoma of the sigmoid colon and rectal cancer between June 1995 and June 2007 were selected. Patients were divided into the IMA-positive group (n = 33) and the IMA-negative group (n = 592) according to IMA lymph node metastasis status. Clinicopathological features, recurrence patterns, and 5-year disease-free survival rates were compared between the two groups.

Results

Following curative resection, 5-year disease-free survival rate was 31.9% in the IMA-positive group and 69.4% in the IMA-negative group (p < 0.001). Cox regression analysis revealed that rectal cancer, pathologic stage, and presence of IMA lymph node metastasis were independently associated with disease-free survival. Systemic recurrence rate was significantly higher in the IMA-positive group than in the IMA-negative group (48.5 vs. 20.8%, respectively, p = 0.001). Para-aortic nodal recurrence showed significant association with presence of IMA lymph node metastasis on multivariate analysis (hazard ratio 11.8; 95% confidence interval 2.7–52.2, p = 0.001).

Conclusion

Presence of IMA lymph node metastasis should be considered as a predictive factor for high systemic recurrence, and should be treated and followed up with caution for para-aortic nodal recurrence.     

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。     

Non-operative management of the primary tumour in patients with incurable stage IV colorectal cancer

BACKGROUND: Excision of primary colorectal cancer associated with irresectable synchronous metastases confers high morbidity and mortality with uncertain benefit. METHODS: For patients with incurable stage IV colorectal cancer, minimally symptomatic primary tumours were left in situ and 5-fluorouracil-based chemotherapy was administered systemically. Primary tumour-specific complications and survival were monitored. RESULTS: There were 13 men and 11 women with primary tumours in the right colon (eight), transverse colon (one), sigmoid colon (eight) or rectum (seven). Eleven patients had metastases limited to the liver (liver replacement less than 25 per cent in one, 25-50 per cent in four and more than 50 per cent in six) and 13 patients had extrahepatic disease (lung or peritoneum). Four patients with sigmoid colon tumours developed bowel obstruction, which required an uncomplicated operation in two and deployment of colonic stents in two patients, at 1, 3, 12 and 20 months from diagnosis. Three further patients underwent right hemicolectomy for abdominal pain of uncertain aetiology, with poor symptomatic relief, and another had a potentially curative operation following disease downstaging. The overall median survival was 10.3 months with a 1-year actuarial survival rate of 44 per cent. CONCLUSION: A policy to defer resection of minimally symptomatic primary colorectal cancer is associated with a low risk of complications before death from progressive systemic disease.     

肠系膜下动脉低、高位结扎在腹腔镜直肠癌根治术中的效果比较

目的:探讨低、高位结扎肠系膜下动脉(IMA)在腹腔镜直肠癌根治术中的临床疗效、应用价值及患者术后生存情况.方法:回顾分析2014年1月至2017年1月收治的215例直肠癌患者的临床资料,根据IMA结扎方式分为低位结扎组(n=98)与高位结扎组(n=117).对比分析两组患者一般情况、围手术期相关指标(手术时间、术中出血...     

Colorectal cancer patterns of care in the Western Sydney and Wentworth Area Health Services

INTRODUCTION: Colorectal cancer is a leading cause of morbidity and mortality in Australia. Recent clinical trials show that the recurrence of colorectal cancer decreases with chemotherapy and/or radiotherapy in advanced disease. The present study aimed to document the patterns of care by the type of treatment, document the preoperative investigations and provide results to the Area Health Services. METHODS: A prospective data collection was initiated in May 1994 and ended in May 1996 in the Western Sydney and Wentworth Area Health Services of New South Wales. Deaths and recurrences were followed up until July 2002. RESULTS: There were 253 colon cancers, 107 rectal cancers and 10 patients with tumours in both the colon and rectum. Forty-one surgeons performed 299 curative procedures with 78% of them performing one to four procedures annually. One hundred and twenty-two patients had non-fatal complications and six (2%) died postoperatively. Twenty-eight per cent of rectal cancer patients underwent abdomino-perineal resection and 56% underwent low anterior resection. Forty-five per cent of rectal cancer patients and 51% of colon cancer patients who were potentially eligible received appropriate adjuvant therapy. Ninety-one per cent of patients who received chemotherapy had no or mild toxicity. By the end of follow-up period, 30% of rectal cancer patients and 24% of colon cancer patients had developed recurrence. At last follow up, 197 patients had died. Median overall survival from time of diagnosis was 73 months. Overall 5-year survival for colonic and rectal cancers was 50% and 57%, respectively. For the 299 patients who had curative procedures, the 5-year survival was 63% and 62% for colonic and rectal cancers, respectively. CONCLUSION: Colorectal cancer patients who were eligible for and received adjuvant therapy had significantly better survival. Rectal cancer patients whose tumours only required low anterior resection had a better survival than those who needed an abdomino-perineal resection. High-volume surgeons have less postoperative complications than low-volume surgeons. The high proportion of late presentations seen in colon cancer patients supports the need for screening to improve early detection.     

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。     

Effects of high and low ligation on survival in patients operated for colorectal cancer

In spite of numerous studies on the subject, it is still unclear whether or not high ligation of the inferior mesenteric artery (at about 1 cm from its origin) improves the 5-year survival rate in patients operated on for colorectal cancer in comparison to low ligation (ligation below the origin of the left colic artery). From February 2000 to November 2001 40 patients with cancer of the colic segment between the descending sigmoid junction and the low rectum underwent surgical colorectal resection and low ligation of the inferior mesenteric artery. At the end of 5 years of observation we report a survival rate of 70% which is not very far from the value reported in the literature. In our study, the incidence of lymph-node metastases, inexistent in patients with T1 grading increases with the increase in the TNM T grading but does not depend on the location of the cancer. In our patients age below 65 years was a negative prognostic indicator because colorectal tumours in patients of that age are associated with a higher incidence of lymph-node metastases. On the basis of the data we obtained, it is also evident that the 5-year survival rate decreases in proportion to the increase in the distance of the lymph-node metastases from the mesenteric margin of the colon. In conclusion, in the treatment of cancers located between the descending sigmoid junction and the low rectum, we prefer to execute a low ligation of the inferior mesenteric artery because it exposes the patient to a lower risk of intra- and postoperative complications and also because several authors have demonstrated that high ligation with removal of lymph nodes at the origin of the artery for colorectal cancer does not improve the 5-year survival rate.     

Krukenberg tumours of colorectal origin: Experience of a tertiary referral centre and review of the literature

Aim: Krukenberg tumours are tumours of the gastrointestinal tract that metastasize to the ovary. The condition is uncommon and accounts for 5 per cent of ovarian tumours. It is our objective to describe the outcome of patients after resection of Krukenberg tumours of colorectal origin. Patients and Methods: The present study is a retrospective review of 20 patients with resection performed for Krukenberg tumours of colorectal origin from November 1996 to April 2010 at Queen Elizabeth Hospital, Hong Kong, China. Results: The most common colonic primary site was sigmoid colon (40 per cent). Thirteen patients (65 per cent) had T4 tumours. Ten patients (50 per cent) had synchronous tumours. Seven patients (35 per cent) had bilateral ovarian involvement. Nine patients (45 per cent) had elevated serum carcinoembryonic antigen levels. The median carbohydrate antigen 125 (was 57 U/mL (range: 12–850 U/mL). Seven patients (35 per cent) developed metastases after ovarian resection. The most common sites were intra‐abdominal lymph nodes (15 per cent), bone (15 per cent) and liver (10 per cent). The overall 3‐ and 5‐year survival rates after ovarian resection were 40 per cent and 25 per cent, respectively. Right colon cancer (30 per cent right colon vs 60 per cent left colon vs 10 per cent rectum, P = 0.021) and T4 staging of the colonic primary (30 per cent T3 vs 65 per cent T4, P = 0.033) were found to be poor prognostic factors for survival. Conclusion: Although recurrence after resection of Krukenberg tumours is common, bilateral salpingo‐oophorectomy should still be considered. A more aggressive approach, such as debulking surgery or metastasectomy, is also recommended to improve the outcome of these patients.     

肠系膜下动脉高位结扎后顽固性便秘21例临床分析

目的分析进展期乙状结肠癌或直肠上段癌行根治性切除术后顽固性便秘的致病因素,并总结其治疗经验。方法对江汉大学附属医院胃肠外科2004年1月至2014年12月收治的共21例顽固性便秘病人临床资料进行回顾性分析。结果所有病例既往均为进展期乙状结肠癌或直肠上段癌于外院行根治性手术,原手术均明确记录为肠系膜下动脉高位结扎。术后2~4年(平均3.4年)逐渐出现顽固性便秘,以腹痛、腹胀、大便次数减少及排便困难为主要临床表现。所有病例术前行X线钡剂灌肠造影均显示一共同特征,即结肠脾曲未游离,降结肠未切除,降结肠结肠袋消失,犹如小肠;结肠传输试验均提示为慢传输型,排粪造影均未见出口梗阻。12例再次接受手术,余9例因个人因素放弃手术,仍选择保守治疗(灌肠或口服泻药通便)。所有病人均随访至今,随访时间24~168个月,平均87.8个月,手术组术后效果显著,1年内均恢复正常排便(1~2次/d);而保守治疗组便秘症状无改善。结论乙状结肠癌或直肠上段癌根治术中行肠系膜下动脉高位结扎,而未游离结肠脾曲行包括降结肠、乙状结肠和直肠腹膜返折以上部分肠切除。其后果是部分病人降结肠慢性缺血,结肠形态及生理功能退化,导致顽固性便秘发生(慢传输型便秘)。其有效治疗为再手术行降结肠切除,横结肠-直肠吻合。     

腹腔镜直肠癌前切除术肠系膜下动脉不同结扎平面对患者预后的影响

目的分析腹腔镜直肠癌前切除术中肠系膜下动脉不同结扎平面对患者预后的影响。 方法选取2007年6月至2014年6月间青岛市市立医院收治的行腹腔镜直肠癌前切除术136例患者为研究对象，根据肠系膜下动脉不同的结扎平面，分为保留左结肠动脉的低位结扎组（LL组）76例和不保留左结肠动脉的高位结扎组（HL组）60例。比较两组患者围手术期指标，随访并评价两组的预后。 结果两组手术时间、术中出血量、术后肛门排气时间、淋巴结清扫总数和第253组淋巴结清扫个数差异无统计学意义（t=6.109、4.339、8.386、0.233、0.198，P=0.318、0.416、0.512、0.821、0.669）；LL组术后吻合口瘘的发生率明显低于HL组（χ²=5.186，P=0.029）。HL组术后3、5年总体生存率分别为80.00%和73.33%，LL组分别为77.63%和72.37%，两组比较差异无统计学意义（χ²=1.536、2.156，P=0.863、0.698）。 结论腹腔镜直肠癌前切除术中肠系膜下动脉不同结扎平面可获得相近的淋巴结清扫效果，保留左结肠动脉的低位结扎平面术后吻合口瘘的发生率更低，其他围手术期指标没有差异，联合第三站中央淋巴结清扫值得应用推广。     

MSCTA肠系膜下动脉成像的临床应用

目的探讨多层螺旋CT血管造影（MSCTA）在肠系膜下动脉（IMA）成像中的临床应用价值。方法选择因直肠或左半结肠癌和血管性病变行MSCTA检查的患者75例，采用容积再现（VR）血管生长技术（AV）进行血管重建，观察肿瘤供血动脉及IMA狭窄或闭塞后的侧支循环情况。结果35例直肠癌患者中，显示肿瘤供血动脉：直肠上动脉35、直肠下动脉29例、骶正中动脉6例、乙状结肠动脉4例；7例乙状结肠癌由乙状结肠动脉供血；3例直肠乙状结肠交界区癌中，1例乙状结肠动脉供血，2例乙状结肠动脉和直肠上动脉供血；2例降结肠癌由左结肠动脉供血；5例脾曲癌由左结肠动脉升支和中结肠动脉左支供血。23例IMA狭窄或闭塞患者均有Riolan动脉弓侧支循环形成。结论MSCTA能清楚显示IMA参与肿瘤供血及准确评价其狭窄或闭塞后侧支循环形成情况。     

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。     

Outcome of colorectal cancer

The outcome of 454 patients who presented with colorectal carcinoma during a 16 year period is reviewed: 54 per cent were males, 58 per cent were aged more than 60 and 10 per cent had an emergency admission, 42 per cent of tumours occurred in the rectum. A curative resection was possible in 68 per cent. Postoperative mortality was 7 per cent. The overall crude 5-year survival was 41 per cent. The mortality from local recurrence was significantly higher in rectal (11.7 per cent) than in colonic cancer (8.8 per cent; P less than 0.01). The rate of recurrence and metastases was higher in patients with low rectal cancer than in patients with cancer of the middle and the upper rectum (P less than 0.01). Distant metastases were the cause of death in 94 per cent of the patients who had a Miles' operation for cancer of the middle rectum, whereas local recurrence was responsible for late mortality in 80 per cent of patients who underwent an anterior resection. No difference in 5-year survival was found in the restorative and in the excisional group.     

肠系膜下动脉低位结扎及根部淋巴结廓清在腹腔镜低位前切除手术中的临床意义

目的:探讨腹腔镜低位前切除(low anterior resection,LAR)术中行肠系膜下动脉(inferior mesenteric artery,IMA)低位结扎及根部淋巴结廓清的临床意义。方法:2011年10月至2013年10月为114例直肠癌患者行腹腔镜LAR,随机分为对照组(n=55)与观察组(n=59)。观察组采用IMA低位结扎及根部淋巴结廓清;对照组采用IMA高位结扎术及根部淋巴结廓清。对比分析手术时间、淋巴结清扫数量、吻合口漏发生率及术后首次通气时间。结果:手术时间、淋巴结清扫数量、吻合口漏发生率两组差异无统计学意义(P>0.05);术后首次通气时间观察组少于对照组,差异有统计学意义(P<0.05)。结论:LAR术中行IMA低位结扎及根部淋巴结廓清优于IMA高位结扎术及根部淋巴结廓清,具有推广应用的价值。     

Preliminary study on radioguided sentinel node identification in colon cancer

The purpose of this study was to prove the prognostic value of the sentinel node (SN) in colon tumors, and to validate radioguided surgery in identifying the SN. Nodal metastases are a strong prognostic factor in patients operated on for colon or rectal cancer, decreasing the 5-year survival rate by approximately 20 per cent and dropping it to 30 per cent. Unfortunately, of 50 per cent of patients judged to be nodal disease-free at surgery, about 20 to 30 per cent will die from a local tumor relapse or distant metastases within 5 years of diagnosis. These data suggest that other steps are needed for more precise staging of patients, and specifically, to accurately harvest and study the nodes on which to base the prognosis. Mapping lymph nodes predictive of the whole basin status, referred to as SN, may help focus the pathologist's attention on a small but representative target, and achieve correct nodal harvesting, which includes atypical drainage pathways, when present. Twenty selected patients with colon tumor were administered a subserosal, peritumoral, intraoperative injection of blue dye and 99mTc-marked colloidal particles. The SN was identified visually and with a handheld gamma probe and was subsequently stitch-labeled. The operation was then conducted after standard surgical procedures, and the required lymphadenectomy was performed. Later, the probe was used to confirm radioactivity in the excised specimen and the absence of radioactivity in the operative field after resection; the purpose of the latter was to exclude the presence of aberrant routes of lymphatic drainage. The labeled SN were stained with hematoxylin and eosin and, in case of negative findings, cytokeratin immunostaining was performed. The remaining resected nodes were stained with hematoxylin and eosin. The probe identification of SN was 95 per cent overall (19/20); in 13 patients, a single SN was labeled, and two were labeled in six patients, harvesting 25 SN. In the 19 patients in whom a radioemitting SN was labeled, we recorded only one false-negative; in one case, a micrometastasis in the SN was the only extracolonic site. The blue dye identified the SN in 14 cases; in some of them, the number of nodes was overestimated (five single, seven double, and two triple SN) in comparison with the radioisotope, but at least one of the dyed nodes was also radioemitting. SN identification in colon cancers is a safe, fast, and easy procedure for ultrastaging the nodal basin. The technique involves a relatively flat learning curve and could become standard care for identifying the presence of nodal micrometastases at a low cost, thereby also making it affordable at small health centers.     

Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial

BACKGROUND: Extended lymphadenectomy (D2) provides accurate nodal staging of gastric cancer. The aim of this study was to clarify the degree of stage migration seen with D2 combined with para-aortic lymph node dissection for gastric cancer invading the subserosa, the serosa and adjacent structures (T2ss-4) in patients considered not to have distant metastases (M0). METHODS: Between July 1995 and April 2001, 523 patients were recruited and randomized in a prospective phase III trial comparing D2 with D2 and para-aortic nodal dissection for T2ss-4 gastric cancer without macroscopic para-aortic nodal metastases. Stage migration was evaluated by Japanese Gastric Cancer Association staging in 260 patients who underwent D2 with para-aortic dissection by analysing pathological information from the dissected lymph nodes. RESULTS: Node (N)-stage migration was observed in 1 per cent (1 of 82) of patients with N1 disease, 20 per cent (12 of 59) with N2, 43 per cent (10 of 23) with N3 and 8.8 per cent (23 of 260) of all patients. Final stage migration occurred in 9 per cent (5 of 58) of patients with stage IIIa, 19 per cent (8 of 42) with stage IIIb, 56 per cent (9 of 16) with stage IVa and 8.5 per cent (22 of 260) of all patients. Metastasis to N4 nodes was found in 4 per cent (four of 95) of tumours invading the subserosa and 17.4 per cent (19 of 109) of tumours penetrating the serosa. The overall incidence of N4 involvement was 8.8 per cent (23 of 260). CONCLUSION: Extended para-aortic lymphadenectomy for gastric cancer provides accurate nodal staging and results in stage migration, which may improve stage-specific survival regardless of overall survival benefit.     

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。