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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2021, Vol. 10 ›› Issue (02) : 137 -143. doi: 10.3877/cma.j.issn.2095-3224.2021.02.005

所属专题： 文献；

论著

血管三维重建技术在腹腔镜保留左结肠动脉的直肠癌低位前切除术的临床应用研究
沈海玉1, 刘正1, 陈佳楠1, 梅世文1, 李娟1, 王治杰1, 赵富强1, 魏方泽1, 刘骞1,†(), 王锡山1   
  1. 1. 100021　北京，国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院结直肠外科
  • 收稿日期:2021-03-18 出版日期:2021-04-25
  • 通信作者: 刘骞
  • 基金资助:
    国家重点研发计划(2019YFC1315705); 中国医学科学院医学与健康科技创新工程(2017-12M-1-006); 中国癌症基金会北京希望马拉松专项基金(LC2017L03)

Clinical study of vascular three-dimensional reconstruction in the laparoscopic surgery for rectal cancer with preservation of the left colic artery

Haiyu Shen1, Zheng Liu1, Jia'nan Chen1, Shiwen Mei1, Juan Li1, Zhijie Wang1, Fuqiang Zhao1, Fangze Wei1, Qian Liu1,†(), Xishan Wang1   

  1. 1. Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
  • Received:2021-03-18 Published:2021-04-25
  • Corresponding author: Qian Liu
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引用本文：

沈海玉, 刘正, 陈佳楠, 梅世文, 李娟, 王治杰, 赵富强, 魏方泽, 刘骞, 王锡山. 血管三维重建技术在腹腔镜保留左结肠动脉的直肠癌低位前切除术的临床应用研究[J]. 中华结直肠疾病电子杂志, 2021, 10(02): 137-143.

Haiyu Shen, Zheng Liu, Jia'nan Chen, Shiwen Mei, Juan Li, Zhijie Wang, Fuqiang Zhao, Fangze Wei, Qian Liu, Xishan Wang. Clinical study of vascular three-dimensional reconstruction in the laparoscopic surgery for rectal cancer with preservation of the left colic artery[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2021, 10(02): 137-143.

目的

探讨术前血管三维重建技术在保留左结肠动脉（LCA）的腹腔镜直肠癌低位前切除术中的临床应用价值。

方法

采用回顾性队列研究的方法，分析中国医学科学院肿瘤医院结直肠外科2019年1月至8月行保留LCA的腹腔镜直肠癌低位前切除术的146例患者临床资料。所有病例均行保留LCA的腹腔镜直肠癌低位前切除术，术中及术后数据资料完整。根据术前是否行血管三维重建，分为重建组（72例）和非重建组（74例）。收集并比较分析两组患者临床特征、手术情况、并发症、病理结果以及术后恢复情况等。

结果

研究共纳入符合入组条件的直肠癌患者146例，其中重建组72例，非重建组74例。重建组男性47例，女性25例，年龄（59.75±6.2）岁，体质指数（24.1±2.2）kg/m2，非重建组男性51例，女性23例，年龄（58.77±6.1）岁，体质指数（23.6±2.7）kg/m2，两组患者基线资料的比较，差异均无统计学意义（P＞0.05）。肠系膜下动脉分型重建组I型35例，Ⅱ型25例，Ⅲ型11例，Ⅳ型1例；非重建组I型37例，Ⅱ型24例，Ⅲ型12例，Ⅳ型1例，两组动脉分型比较，差异无统计学意义（P＞0.05）。手术时间重建组（162.2±10.8）min，非重建组（197.9±19.1）min，两组比较重建组手术时间缩短，差异有统计学意义（t=-13.840，P＜0.05）。术中出血量重建组（30.4±20.0）mL，非重建组（61.2±26.4）mL，重建组出血量较少，差异有统计学意义（t=-7.930，P＜0.05）。重建组和非重建组在吻合口漏（1.4% vs. 1.4%，P=0.984）、吻合口出血（2.8% vs. 4.1%，P=0.672）、术后住院时间（6.8±0.7 d vs. 7.0±0.7 d，P=0.141）和术后病理方面差异均无统计学意义（P＞0.05）。

结论

术前血管三维重建技术可以缩短手术时间，减少术中出血量，建议行术前血管三维重建，为腹腔镜保留LCA的低位前切除术提供术中参考。

关键词: 直肠肿瘤, 手术时间, 左结肠动脉, 三维重建, 出血量
Objective

To investigate the clinical application of vascular three-dimensional reconstruction in laparoscopic low anterior resection for rectal cancer with preservation of left colic artery (LCA).

Methods

A retrospective cohort study was carried out. Clinical data of 146 patients undergoing laparoscopic rectal cancer surgery with preservation of the LCA in the Cancer Hospital Chinese Academy of Medical Sciences from January 2019 to August 2019 were retrospectively analyzed. All the patients were treated with laparoscopic rectal cancer surgery with preservation of the LCA and had complete operative and postoperative data. Based on the vascular reconstruction or not, seventy-two patients received vascular three-dimensional reconstruction (reconstruction group) and 74 patients did not receive reconstruction (non-reconstruction group). Patient demographics, operative data, postoperative complications, pathological data and postoperative recovery data were compared between the two groups.

Results

A total of 146 patients with rectal cancer eligible for enrollment were included in the study, of which 72 were in the reconstruction group and 74 were in the non-reconstruction group. In the reconstruction group, there were 47 males and 25 females, mean age was (59.75±6.2) years old, mean body mass index was (24.1±2.2) kg/m2. In the non-reconstruction group, there were 51 males and 23 females, mean age was (58.77±6.1) years old, mean body mass index was (23.6±2.7) kg/m2. There was no statistically significant difference in the baseline data between the two groups (P＞0.05). In terms of vascular type of IMA, there were 35 cases for type I, 25 cases for type Ⅱ, 11cases for type Ⅲ and 1 case for type Ⅳ in the reconstruction group and 37 cases for type I, 24 cases for type Ⅱ, 12 cases for type Ⅲ and 1 case for type Ⅳ in the non-reconstruction group. There was no statistically significant difference in the vascular type between the two groups (P＞0.05). The operation time was (162.2±10.8) min in the reconstruction group and (197.9±19.1) min in the non-reconstruction group. Compared with the non-reconstruction group, the operation time was shortened in the reconstruction group, and the difference was statistically significant (t=-13.840, P＜0.05). Intraoperative blood loss was (30.4±20.0) mL in the reconstruction group and (61.2±26.4) mL in the non-reconstruction group. The blood loss in the reconstruction group was less, and the difference was statistically significant (t=-7.930, P<0.05). There were no statistically significant differences between the reconstruction group and non-reconstruction group, with regard to anastomotic leakage (1 case, 1.4% vs. 1 case, 1.4%, P=0.984), anastomotic bleeding (2 cases, 2.8% vs. 3 cases, 4.1%, P=0.672), postoperative hospitalization (6.8±0.7 d vs.7.0±0.7 d, P=0.141) and postoperative pathological outcomes (P＞0.05).

Conclusions

Our study suggested that preoperative vascular three-dimensional reconstruction can reduce the operative time and blood loss in laparoscopic rectal cancer surgery with preservation of the LCA. Preoperative vascular three-dimensional reconstruction, which can provide reference for the operation, is therefore recommended for laparoscopic rectal cancer surgery with LCA preservation in rectal cancer surgery.

Key words: Rectal neoplasms, Operation time, Left colic artery, Three-dimensional reconstruction, Blood loss
图1 保留左结肠动脉的手术操作流程。1A：分离裸化肠系膜下动脉主干；1B：分离裸化左结肠动脉；1C：廓清第253组淋巴结；1D：结扎离断乙状结肠动脉；1E：结扎离断直肠上动脉；1F：操作完成术野
表1 患者基线资料[
xˉ
±s，例（%）]
临床特征 重建组（n=72） 非重建组（n=74） 检验值 P值
性别 0.219 0.640

男性

 47（65.3） 51（68.9）

女性

 25（34.7） 23（31.1）
年龄（岁） 59.75±6.2 58.77±6.1 0.961 0.338
BMI（kg/m2） 24.1±2.2 23.6±2.7 1.123 0.263
新辅助治疗 12（16.7） 13（17.6） 0.021 0.885
ASA评分 0.174 0.917

ASA I

 24（33.3.0） 23（31.3）

ASA II

 37（51.4） 38（51.4）

ASA III

 11（15.3） 13（17.6）
图2 肠系膜下动脉分型模式图。2A：I型；2B：II型；2C：III型；2D：Ⅳ型（IMA：肠系膜下动脉，LCA：左结肠动脉，SA：乙状结肠动脉，SRA：直肠上动脉）
图3 三维重建肠系膜下动脉分型。3A：I型；3B：II型；3C：III型；3D：Ⅳ型（IMA：肠系膜下动脉，LCA：左结肠动脉，SA：乙状结肠动脉；SRA：直肠上动脉）
表2 肠系膜下动脉分支类型[例（%）]
动脉分型 重建组（n=72） 非重建组（n=74） χ2值 P值
分支类型 0.092 0.993

I型

 35（48.6） 37（50.0）

II型

 25（34.7） 24（32.4）

Ⅲ型

 11（15.3） 12（16.2）

Ⅳ型

 1（1.4） 1（1.4）
表3 手术和并发症数据（
xˉ
±s）
术中术后指标 重建组（n=72） 非重建组（n=74） 检验值 P值
手术时间（min） 162.2±10.8 197.9±19.1 -13.840 0.000
中转开腹（例） 0 0
术中出血量（mL） 30.4±20.0 61.2±26.4 -7.930 0.000
吻合口漏 1（1.4%） 1（1.4%） 0.000 0.984
吻合口出血 2（2.8%） 3（4.1%） 0.180 0.672
术后住院时间 6.8±0.7 7.0±0.7 1.480 0.141
表4 术后病理结果资料[
xˉ
±s，例（%）]
病理指标 重建组（n=72） 非重建组（n=74） 检验值 P值
肿瘤大小（cm） 3.1±0.8 2.9±0.9 1.309 0.193
淋巴结数目 18.3±2.7 17.6±2.1 1.720 0.088
分化程度 0.085 0.958

低

 20（27.8） 19（25.7）

中

 39（54.2） 41（55.4）

高

 13（18.1） 14（18.9）
病理分期 0.248 0.883

Ⅰ

 14（19.4） 13（17.6）

Ⅱ

 35（48.6） 39（52.7）

Ⅲ

 23（31.9） 22（29.7）
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