切换至 "中华医学电子期刊资源库"

中华结直肠疾病电子杂志 ›› 2020, Vol. 09 ›› Issue (05) : 502 -506. doi: 10.3877/cma.j.issn.2095-3224.2020.05.012

所属专题: 文献

综述

肠系膜下动脉分型在腹腔镜直肠癌手术中保留左结肠动脉的应用价值
骆洋1, 钟鸣2,()   
  1. 1. 200127 上海交通大学医学院附属仁济医院胃肠外科
    2. 200127 上海交通大学医学院附属仁济医院胃肠外科;315336 宁波市杭州湾医院普外科
  • 收稿日期:2020-03-20 出版日期:2020-10-25
  • 通信作者: 钟鸣
  • 基金资助:
    国家自然科学基金项目(No. 81802308,81672347); 上海市科学技术委员会(No.19411966200)

The clinical value of inferior mesenteric arterial classification for preserving left colon artery in laparoscopic radical resection of rectal cancer

Yang Luo1, Ming Zhong2,()   

  1. 1. Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
    2. Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; Department of General Surgery, Ningbo Hangzhou Bay Hospital, Ningbo 315336, China
  • Received:2020-03-20 Published:2020-10-25
  • Corresponding author: Ming Zhong
  • About author:
    Corresponding author: Zhong Ming, Email:
引用本文:

骆洋, 钟鸣. 肠系膜下动脉分型在腹腔镜直肠癌手术中保留左结肠动脉的应用价值[J]. 中华结直肠疾病电子杂志, 2020, 09(05): 502-506.

Yang Luo, Ming Zhong. The clinical value of inferior mesenteric arterial classification for preserving left colon artery in laparoscopic radical resection of rectal cancer[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2020, 09(05): 502-506.

吻合口漏是腹腔镜直肠癌围手术期的主要并发症之一。为降低其发生率,外科医师在手术过程中选择保留左结肠动脉来增加吻合口血供。但由于肠系膜下动脉(IMA)的分支变异较大,术前对IMA分型以及周围结构判断不足,在手术过程中处理IMA根部时导致各种意外出血,而被迫选择结扎IMA根部。利用CT血管重建技术对IMA进行影像学分型,一方面有利于精准保留左结肠动脉,减少不必要的手术时间;另一方面有助于判断左结肠动脉和肠系膜下静脉之间的关系,达到规范化清扫D3站淋巴结的目的。因此,笔者认为,应将"通过CT血管重建技术对IMA进行精准化分型"纳入诊疗规范中,使直肠癌的外科治疗更加个体化,精准化;但这尚需要多中心大样本的前瞻性研究来提供循证医学证据。

Anastomotic leakage is one of the severe complications of laparoscopic assisted-resection of rectal cancer. In order to increase the blood pressure of anastomosis, many surgeons choose to be preserved the left colon artery during operation. However, due to the large branch variation of the inferior mesenteric artery (IMA), the artery bleeding was frequently by various accidents during the operation. The vascular reconstruction for the classification of the IMA could accurately preserve the left colon artery (LCA), and completely dissected D3 lymph nodes. Therefore, we think that the "accurate classification of the inferior mesenteric artery by abdominal CT vascular reconstruction" should be routine examination before rectal cancer surgery. However, in the further, this requires a multi-center large sample clinical studies to provide medical evidence.

图1 肠系膜下动脉两种结扎方式。1A:高位结扎:肠系膜下动脉根部结扎;1B:低位结扎:保留LCA
图2 肠系膜下血管各种意外性出血。2A~2C:肠系膜下动脉根部出血;2D~2E:肠系膜下静脉出血;2F~2H:左结肠动脉根部出血。IMA:肠系膜下动脉,IMV:肠系膜下静脉,LCA:左结肠动脉
图3 保留左结肠动脉的两种方式。3A:保留左结肠动脉,253组淋巴结未清扫;3B:保留左结肠动脉,253组淋巴结规范化清扫。LCA:左结肠动脉
图4 肠系膜下动脉四种分型。4A:IMA四种分型手绘模式图以及保留LCA四种方式;4B:三维血管成像显示的IMA四种分型
图5 253组淋巴结清扫范围。5A:253组淋巴结清扫范围模式图;5B:腹腔镜直肠癌手术中253组淋巴结清扫范围。LCA:左结肠动脉,IMV:肠系膜下静脉,SRA:直肠上动脉,IMA:肠系膜下动脉
[1]
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence?[J]. Br J Surg, 1982, 69(10): 613-616.
[2]
Wibe A, Syse A, Andersen E, et al. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection [J]. Dis Colon Rectum, 2004, 47(1): 48-58.
[3]
Portale G, Popesc GO, Parotto M, et al. Delayed colo-anal anastomosis for rectal cancer: pelvic morbidity, functional results and oncological outcomes: a systematic review[J]. World J Surg, 2019, 43(5): 1360-1369.
[4]
骆洋,秦骏,陈建军,等. 腹腔镜直肠癌手术中保留左结肠动脉与否临床对比研究[J]. 中国实用外科杂志, 2017, 37(6): 660-664.
[5]
Cirocchi R, Trastulli S, Farinella E, et al. High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed [J]. Surg Oncol, 2012, 21(3): e111-123.
[6]
Ke J, Cai J, Wen X, et al. Anatomic variations of inferior mesenteric artery and left colic artery evaluated by 3-dimensional CT angiography: Insights into rectal cancer surgery - A retrospective observational study[J]. Int J Surg, 2017, 41: 106-111.
[7]
Palumbo P, Usai S, Pansa A, et al. Anastomotic leakage in rectal surgery: role of the ghost ileostomy [J]. Anticancer Res, 2019, 39(6): 2975-2983.
[8]
Abe T, Ujiie A, Taguchi Y, et al. Anomalous inferior mesenteric artery supplying the ascending, transverse, descending, and sigmoid colons [J]. Anat Sci Int, 2018, 93(1): 144-148.
[9]
Shrivastava P, Tuli A, Kaur S, et al. Right sided descending and sigmoid colon: its embryological basis and clinical implications[J]. Anat Cell Biol, 2013, 46(4): 299-302.
[10]
Dobrowolski S, Wojciechowski J, Dobosz M, et al. Prospective evaluation of the defecatory functional results in patients following aorto-aortic reconstruction surgery for an abdominal aortic aneurysm [J]. Surg Today, 2007, 37(10): 831-836.
[11]
Kudo T. Surgical complications after open abdominal aortic aneurysm repair: intestinal ischemia, buttock claudication and sexual dysfunction [J]. Ann Vasc Dis, 2019, 12(2): 157-162.
[12]
张善家,朱志强,梁伟,等. 保留盆腔自主神经的腹腔镜直肠癌根治术对男性性功能的影响[J]. 中国微创外科杂志, 2011, 11(12): 1075-1078.
[13]
Liang JT, Lai HS, Lee PH, et al. Laparoscopic pelvic autonomic nerve-preserving surgery for sigmoid colon cancer [J]. Ann Surg Oncol, 2008, 15(6): 1609-1616.
[14]
Si MB, Yan PJ, Du ZY, et al. Lymph node yield, survival benefit, and safety of high and low ligation of the inferior mesenteric artery in colorectal cancer surgery: a systematic review and meta-analysis [J]. Int J Colorectal Dis, 2019, 34(6): 947-962.
[15]
Crocetti D, Cavallaro G, Tarallo MR, et al. Preservation of left colic artery with lymph node dissection of IMA root during laparoscopic surgery for rectosigmoid cancer. Results of a retrospective analysis [J]. Clin Ter, 2019, 170(2): e124-e128.
[16]
Yang XF, Li GX, Luo GH, et al. New insights into autonomic nerve preservation in high ligation of the inferior mesenteric artery in laparoscopic surgery for colorectal cancer [J]. Asian Pac J Cancer Prev, 2014, 15(6): 2533-2539.
[17]
Girard E, Trilling B, Rabattu PY, et al. Level of inferior mesenteric artery ligation in low rectal cancer surgery: high tie preferred over low tie [J]. Tech Coloproctol, 2019, 23(3): 267-271.
[18]
Yada H, Sawai K, Taniguchi H, et al. Analysis of vascular anatomy and lymph node metastases warrants radical segmental bowel resection for colon cancer [J]. World J Surg, 1997, 21(1): 109-115.
[19]
Murono K, Kawai K, Kazama S, et al. Anatomy of the inferior mesenteric artery evaluated using 3-dimensional CT angiography [J]. Dis Colon Rectum, 2015, 58(2): 214-219.
[20]
周家铭,谭淑云,黄俊,等. 根据肠系膜下动脉各分支分型行精准低位结扎并根部淋巴结清扫的腹腔镜直肠癌根治术[J]. 中华胃肠外科杂志, 2018, 21(1): 46-52.
[21]
黄俊,周家铭,万英杰,等. 肠系膜下动脉血管分型及Riolan动脉弓缺如对腹腔镜直肠癌根治术后吻合口瘘发生率的影响[J]. 中华胃肠外科杂志, 2016, 19(10): 1113-1118.
[22]
Al-Asari SF, Lim D, Min BS, et al. The relation between inferior mesenteric vein ligation and collateral vessels to splenic flexure: anatomical landmarks, technical precautions and clinical significance[J]. Yonsei Med J, 2013, 54(6):1484-1490.
[23]
张琪,孙枢文,吴晓清,等. 直肠癌根治术中肠系膜下动脉处理方式研究进展[J]. 中国实用外科杂志, 2018, 38(10): 1193-1196.
[24]
Katsura M, Mototake H, Takara H, et al. Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review[J]. World J Emerg Surg, 2011, 6: 16.
[25]
骆洋,陈建军,秦骏,等. 腹腔镜直肠癌根治术中肠系膜下动脉低位结扎对第3站淋巴结清扫的影响及第3站淋巴结转移危险因素分析[J]. 中华消化外科杂志, 2018, 17(2): 1-7.
[1] 赖全友, 高远, 汪建林, 屈士斌, 魏丹, 彭伟. 三维重建技术结合腹腔镜精准肝切除术对肝癌患者术后CD4+、CD8+及免疫球蛋白水平的影响[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 651-654.
[2] 唐梅, 周丽, 牛岑月, 周小童, 王倩. ICG荧光导航的腹腔镜肝切除术临床意义[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 655-658.
[3] 王兴, 文阳辉, 姚戈冰, 郭平学, 杨自华. ICG荧光腹腔镜下胆囊切除术的临床应用[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 663-666.
[4] 康婵娟, 张海涛, 翟静洁. 胰管支架置入术治疗急性胆源性胰腺炎的效果及对患者肝功能、炎症因子水平的影响[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 667-670.
[5] 白浪, 张雪玉, 白铁成, 贺爱军. 腹腔镜近端胃切除术中圆锥形重叠吻合成形术对Siewert Ⅱ型AEG患者胃食管反流、营养状态的影响研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 679-682.
[6] 庄宝雄, 邓海军. 单孔+1腹腔镜直肠癌侧方淋巴结清扫术[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 601-601.
[7] 张朝军, 袁新普. 腹腔镜辅助低位直肠癌根治术[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 602-602.
[8] 郑民华, 蒋天宇, 赵轩, 马君俊. 中国腹腔镜直肠癌根治术30年发展历程与未来[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 591-595.
[9] 池畔, 黄胜辉. 中国腹腔镜直肠癌根治术30年来的巨大进步[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 596-600.
[10] 李明, 屠松, 闫鹏, 钱军, 高鹏程, 许文山, 杨发英, 胡振涛, 单永玮. 应用前列腺电切镜引导置管治疗直肠低位吻合口漏研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 603-606.
[11] 李玲, 刘亚, 李培玲, 张秀敏, 李萍. 直肠癌患者术后肠道菌群的变化与抑郁症相关性研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 607-610.
[12] 赵梓竣, 兰运升. 改良一针法末端回肠造口术对低位直肠癌保肛术后应激反应及安全性的影响[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 611-614.
[13] 吴胜伟, 王志伟, 陈贵进, 刘序, 吴晓翔. 系膜肥厚低位直肠癌患者改良NOSES Ⅰ式手术的临床效果评价[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 615-618.
[14] 刘海旺, 施海, 尚利峰. 不同吻合器在腹腔镜远端胃癌根治术Roux-en-Y式吻合中的应用对比[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 643-646.
[15] 许杰, 李亚俊, 冯义文. SOX新辅助化疗后腹腔镜胃癌D2根治术与常规根治术治疗进展期胃癌的近期随访比较[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 647-650.
阅读次数
全文


摘要