中国实用外科杂志

中国实用外科杂志

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腹腔镜低位直肠癌手术中肠系膜下动脉高位结扎和低位结扎对低位前切除综合征影响研究

骆    洋1，何承祥2，敬    然1，杨智岗2，俞旻皓1，盛春晓2，秦绍岚1，方洪生1，贡婷月1，谢    荟1，钟    鸣1   

  • 出版日期:2022-03-01

  1. 1上海交通大学医学院附属仁济医院胃肠外科，上海200127；2上海市普陀区利群医院，上海200060
  • Online:2022-03-01

摘要： 目的    分析腹腔镜低位直肠癌前切除术肠系膜下动脉高位结扎和低位结扎对低位前切除综合征（LARS）的影响。方法    采用回顾性队列研究方法，收集2019年1月至2020年8月期间在上海交通大学医学院附属仁济医院胃肠外科腹腔镜低位直肠癌前切除术的282例病人的临床资料。根据术中是否保留左结肠动脉（LCA），分为低位结扎组（n=126）和高位结扎组（n=156），比较两组术后LARS发生率和严重程度，并通过单因素和多因素分析LARS的危险因素。结果    对126例低位结扎病人术后3个月，6个月和12个月的影像学随访发现，117例（92.86%）病人术后左结肠动脉通畅，仅9例（7.14%）病人术后左结肠动脉闭塞。282例病人术后3个月，6个月，12个月LARS总发生率为：57.44%（162/282），42.91%（121/282），34.04%（96/282）；术后3个月后无新发LARS病例。低位结扎组的术后3个月、6个月 LARS的发生率明显低于高位结扎组（46.83% vs. 66.03%，P=0.00；35.71% vs. 48.72%，P=0.03）。而术后12个月低位结扎组和高位结扎组LARS发生率差异无统计学意义（25.40% vs. 34.62%，P=0.09）。通过单因素分析，发现肿瘤大小＞3.5 cm（P=0.01）、非专业化水平（P=0.01）、高位结扎（P=0.03）、吻合口距齿状线距离≤2 cm（P=0.01）是LARS的危险因素；进一步通过多因素分析，发现高位结扎（P=0.02）、非专业化水平（P=0.01）、吻合口距齿状线距离≤2 cm（P=0.01）是LARS的独立危险因素。结论    腹腔镜低位直肠癌前切除术中保留左结肠动脉可以降低术后LARS的发生率，尤其是轻度LARS病人，其近期疗效较满意，有临床推广价值。

关键词: 腹腔镜低位直肠癌前切除术, 肠系膜下动脉低位结扎, 肠系膜下动脉高位结扎, 低位前切除综合征

Abstract: Analysis on influencing factors of postoperative low anterior resection syndrome for rectal cancer patients in low-tie vs high-tie of IMA with laparoscopic lower anterior resection        LUO Yang*, HE Cheng-xiang, JING Ran, et al. *Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
Corresponding author：ZHONG Ming, E-mail:drzhongming1966@163.com
Abstract    Objective    To analyze the influencing factors of postoperative low anterior resection syndrome（LARS）in low-tie and high-tie of the inferior mesenteric artery after laparoscopic low anterior resection. Methods    A retrospective case⁃control study was used in this study.Two hundred eighty-two consecutive patients scheduled for laparoscopic surgery for low rectal cancer between January 2019 and August 2020 were classified into two groups，according to whether preservation of Left colic artery（LCA）：the low-tie of IMA group（n=126）and the high-tie of IMA group（n=156）.The rate of LARS was observed and compared between the groups.And the risk factors of LARS were tested by univariate and multivariate Cox regression analyses. Results    The imaging CT showed 117 patients（92.86%）had LCA and only 9 patients（7.14%）without LCA，following up 126 low-tie patients at 3，6 and 12 months.The incidence of LARS was 57.44%（162/282），42.91%（121/282），34.04%（96/282）at 3，6，and 12 months postoperatively , respectively，and no new case of LARS was found after 3 months postoperatively.The rate of LARS in the low-tie group was lower in the high-tie group at 3 and 6 months（6.83% vs. 66.03%，P=0.00；35.71% vs. 48.72%，P=0.03）.While，There was no significant between the low-tie and high-tie about the 12 months LARS rates（25.40% vs.34.62%，P=0.09）.Univariate analysis showed that tumor size＞3.5 cm（P=0.03），non-professional surgeon（P=0.00）, high-tie of IMA（P=0.00）and anastomotic level from anal verge ≤2 cm（P=0.00）were associated with unsatisfied LARS outcomes. Logistic regression analysis showed that high-tie of IMA（P=0.01）, on-professional surgeon（P=0.03）and anastomotic level from anal verge ≤2 cm（P=0.00）were independent risk factors for LARS outcome. Conclusion    The low-tie of IMA could reduce LARS rate after laparoscopic lower anterior resection of rectal cancer，especially in patients with mild LARS，which is beneficial to improve the quality of postoperative life of patients.

Key words: laparoscopic lower anterior resection of rectal cancer, low-tie of IMA, high-tie of IMA, low anterior resection syndrome