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.     

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。     

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.     

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...     

直肠癌术中从根部结扎肠系膜下动脉临床意义探讨

目的探讨直肠癌术中从根部结扎肠系膜下动脉的临床意义。方法回顾性分析华中科技大学同济医学院附属同济医院2000年1月至2005年12月499例肠系膜下动脉根部结扎的直肠癌临床病理资料。结果肠系膜下动脉根部淋巴结转移率为14．4％。肿瘤分化程度为低分化腺癌、黏液腺癌或印戒细胞癌，肿瘤浸润深度达到pT3和pT4的直肠癌病人，其肠系膜下动脉根部淋巴结转移率较高。结论低分化腺癌、黏液腺癌或印戒细胞癌，浸润深度达到pT3和pT4时，直肠癌肠系膜下动脉根部淋巴结转移率较高，在行直肠癌根治手术时应行肠系膜下动脉根部结扎以提高5年存活率。     

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。     

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。     

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??Laparoscopic radical resection of rectal cancer with and without preservation of the left colonic artery??A comparative study LUO Yang, QIN Jun, CHEN Jian-jun, et al??Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
Corresponding author??ZHONG Ming, E-mail: drzhongming1966@163.com
Abstract Objective To evaluate the clinical significance and value of preserving left colic artery ??LCA?? when treating the inferior mesenteric artery ??IMA?? in laparoscopic resection for rectal cancer. Methods The clinical data of 523 cases of rectal cancer performed laparoscopic resection of rectal cancer in Renji Hospital, Shanghai Jiaotong University School of Medicine from January 2015 to December 2016 were analyzed retrospectively. All the cases include 203 cases with preservation of LCA ??low ligation group?? and 320 cases without preservation of LCA ??high ligation group??. The clinical conditions during operation and after operation were compared between two groups. Results The difference was not significant statistically in age?? sex?? tumor size?? depth of tumor invasion?? histopathologic type??tumor differentiation?? blood loss and urinary retention rate between two groups??P??0.05??. The postoperative exhaust time, anastomotic leakage rate and defecation frequency 3 months after operation in low ligation group were lower than those in high ligation group??P??0.05??. What’s more?? the number of lymph node and operative time in low ligation group was more in high ligation group??P??0.05??. Conclusion Preservation of left colic artery in laparoscopic resection of rectal cancer can achieve radical clearance of lymph nodes?? increase the number of lymph node detection?? reduce the incidence of anastomotic leakage rate and postoperative exhaust time?? which is worth clinical promotion.     

Outcomes of high versus low ligation of the inferior mesenteric artery with lymph node dissection for distal sigmoid colon or rectal cancer

We compared the complication rates and oncologic and functional outcomes of high versus low ligation of the inferior mesenteric artery (IMA). We reviewed data retrospectively from 776 patients, divided into high and low IMA ligation groups. Low ligation was performed with lymph node dissection around the IMA root. Postoperative complications and oncologic and functional outcomes were analyzed. There were 613 patients in the high ligation group and 163 patients in the low ligation group. Most clinicopathological variables were similar. There were no significant differences in complication rates (25.1% vs. 28.8%; p = 0.336), anastomotic leakage (2.8% vs. 2.5%; p = 1.000), colonic ischemia (2.8% vs. 1.2%; p = 0.393), 5-year overall survival (79.6% vs. 81.3%; p = 0.137) or 5-year relapse-free survival (77.4% vs. 73.3%; p = 0.973) between the groups. In terms of functional outcomes, both techniques were equivalent. The International Prostate Symptom Score and Fecal Incontinence Severity Index were significantly better in the low ligation group 12 months postoperatively than 3 months postoperatively. The oncologic and functional outcomes, as well as postoperative complications, after low ligation of the IMA with lymph node dissection are not significantly different from those after high ligation of the IMA.     

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。     

High versus low ligation of the inferior mesenteric artery in rectal cancer

The argument for and against high ligation of the inferior mesenteric artery in rectal cancer has yet to be resolved. Between 1948 and 1983, 4250 patients underwent surgery for rectal carcinoma at St. Mark's Hospital, London. From these, 250 patients were selected who had undergone curative anterior resection of a Dukes' C adenocarcinoma and their records were examined. In 150 (60 per cent) the inferior mesenteric artery was ligated above the origin of the left colic artery. The outcome was analysed using the Dukes', Gastrointestinal Tumour Study Group and Astler-Coller classifications, either alone or in combination. Tumour differentiation and extent of local invasion were also considered. Despite this detailed analysis, no improved survival was seen in patients when the inferior mesenteric artery was ligated above the origin of the left colic artery.     

肠系膜下动脉低位结扎和高位结扎对腹腔镜直肠癌根治术的疗效影响

目的分析肠系膜下动脉(IMA)低位结扎和高位结扎对腹腔镜直肠癌根治术的疗效影响。 方法以2013年3月至2017年3月收治的215例接受腹腔镜直肠癌根治术的患者为研究对象,进行回顾性分析。按照患者治疗术式,将接受IMA低位结扎者纳入低位结扎组127例,将接受IMA高位结扎者纳入高危结扎组88例。采用SPSS18.0进行分析,术后短期并发症发生情况采用χ²检验;手术情况、恢复情况等计量资料以( ±s)表示,独立t检验,以P<0.05为差异有统计学意义。 结果低位结扎组术中残端缺血性改变发生率和术后首次排气时间均低于高位结扎组,其术后性功能障碍或尿失禁发生率高于后者,差异有统计学意义(P<0.05)。 结论腹腔镜直肠癌根治术中,两种结扎方式疗效相当,IMA低位结扎对于患者术后早期恢复具有积极意义,但较高危结扎有着更高的盆腔自主神经损伤风险,需根据患者实际情况做出决策。     

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。     

Optimal lymph node dissection for colorectal cancer]

Previous studies on the distribution of positive lymph nodes have revealed that the colon should be resected 10 cm from the tumor on both sides and that the intermediate nodes along the main vessel should be dissected in patients with colon cancer. In rectal cancer, superior lymphatic spread along the inferior mesenteric artery (IMA) is the main metastatic route. The IMA should be dissected immediately after the bifurcation of the left colic artery, and the intermediate lymph nodes should be removed. The positive rate of the lateral lymph nodes is about 10%. The rate of local failure is high and the prognosis is poor in patients with positive lateral lymph nodes, even if the lateral lymph nodes have been dissected. However, it has been reported that lateral lymph node dissection combined with excision of the internal iliac vessels results in good disease-free survival in patients with positive lateral nodes. Therefore the indications for lateral node dissection remain controversial. Lymphatic spread into the mesorectum on the anal side has been shown to be an important factor in local failure. The mesorectum should be resected for up to 4 or 5 cm from the inferior tumor margin in middle rectal cancer, and the entire mesorectum should be removed in lower rectal cancer. Nerve tissue preserved in pelvic autonomic nerve-preserving surgery contains a small amount of lymphoid tissue and lymph nodes. Therefore the extent of lymph node dissection and the area of autonomic nerves to be preserved based on tumor site or tumor penetration remain controversial.     

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.     

Impact of upward lymph node dissection on survival rates in advanced lower rectal carcinoma

BACKGROUND/AIMS: This study investigated appropriate level of upward lymph node (LN) dissection in advanced lower rectal carcinoma. METHODS: A total of 285 consecutive patients with stage II/III lower rectal carcinoma were analyzed. LN dissection was classified as follows: division of the root of the superior rectal artery (UD2), division of the root of the inferior mesenteric artery (UD3) and UD3 with para-aortic LN dissection (UD4). RESULTS: LN metastases at the root of the inferior mesenteric artery were found in 4 patients. Their prognoses were worse than those of the other stage III patients (p = 0.011). On the other hand, LN metastases along the superior rectal artery were discovered in 14 patients, whose 5-year overall survival rate was 61.2%. By removing the LNs either UD2 or UD3/4, a similar survival rate was achieved in stage III patients with LN metastases along the superior rectal artery. CONCLUSION: Survival of a minority with metastatic LNs at the root of the inferior mesenteric artery was poor. Additionally, survival is no worse in patients with positive LN along the superior rectal artery as long as these positive nodes are resected by either UD2 or UD3/4. Low ligation is adequate for advanced lower rectal carcinoma.     

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。     

Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection

OBJECTIVE: To identify the parameters related to the effective selection of patients who could receive prognostic benefit from lateral pelvic node dissection. BACKGROUND: Accurate preoperative diagnosis of lateral nodal involvement (LNI) remains difficult, and the indications for lateral lymph node dissection have been controversial. PATIENTS AND METHODS: A total of 244 consecutive patients who underwent potentially curative surgery with lateral dissection for advanced lower rectal cancer (1985-2000) were reviewed. Patients were stratified into groups based on various parameters, and the therapeutic value index for survival benefit was compared among groups. The therapeutic index of lateral dissection was calculated by multiplying the frequency of metastasis to the lateral area and the cancer-related 5-year survival rate of patients with metastasis to the lateral area, irrespective of metastasis to other areas (mesorectal, superior rectal artery [SRA], and inferior mesenteric artery [IMA] areas). RESULTS: LNI was observed in 41 patients (17%); and 88% of them had nodal involvement in the region along the internal iliac/pudendal artery or in the obturator region ("vulnerable field"). The cancer-related 5-year survival rate among the patients with LNI was 42%; the therapeutic index for lateral dissection was calculated as 7.0 patients, which was much higher than that of lymphadenectomy of the SRA area (1.6 patients) and the IMA area (0.4 patients), and almost comparable to that of lymphadenectomy of the upward mesorectal area (6.9 patients). Although it was possible to select groups at high and low risk for LNI based on several parameters related to tumor aggressiveness, such as tumor differentiation in biopsy specimens, the therapeutic value index was not significantly different between these groups. Unlike these parameters, the diameter of the largest lymph node in the "vulnerable field," which was positively correlated with the rate of LNI but irrelevant to the prognosis, was able to successfully stratify patients by therapeutic index. CONCLUSIONS: Advanced lower rectal cancer patients having LNI in the lateral pelvic area are likely to receive prognostic benefit from lymphadenectomy. The most efficient means of determining the effectiveness of lateral dissection preoperatively is to estimate the nodal diameter in the "vulnerable" lateral regions by diagnostic imaging.     

Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer.

In an attempt to determine whether "high ligation" of the inferior mesenteric artery during surgery for cancer of the rectum and rectosigmoid confers any significant 5-year survival advantage over "low ligation," the outcome of 1370 patients was reviewed. There were 784 patients in whom the inferior mesenteric artery was ligated below the origin of the left colic artery (low ligation) and 586 in whom it was ligated above this level (high ligation). The distribution of histologic grades of the tumors and incidence of venous invasion were similar in both groups. Five-year follow-up was complete in 98.5%. No difference in the crude or age-corrected 5-year survival was found for patients with Dukes A, B, C overall, or C1 tumors, whether having had a low or high ligation. In hopes of identifying a population that benefited from high ligation, C1 patients were further subgrouped according to tumor location and number of involved lymph nodes. However, in no such subgroup was any significant high ligation advantage seen. In conclusion, high ligation of the inferior mesenteric artery has not been found to improve 5-year survival in patients with cancer of the rectum or rectosigmoid.