多层螺旋 CT 血管造影辅助精准保留左结肠动脉在腹腔镜直肠前切除术中的应用

Application of multi-slice spiral CT angiography-assisted accurate preservation of the left colic artery in laparoscopic anterior rectal resection

摘要

目的: 探讨腹腔镜直肠前切除术中,根据多层螺旋 CT 血管造影（CTA）判断肠系膜下动脉（IMA）分型辅助行精准化保留左结肠动脉的应用价值。方法 收集2022年1月至2023年12月行腹腔镜直肠前切除术的 203 例直肠癌患者的临床资料。通过术前腹部 CTA 分析 IMA 分型与长度,除无左结肠动脉型外均精准分离并保留左结肠动脉;同时记录围手术期情况（手术时间、术中出血量、术后肛门排气时间、住院时间、预防性造口等）、术后病理资料（TNM 分期、淋巴结清扫总数、阳性淋巴结数量）、术后恢复情况（吻合口漏、尿潴留发生情况）。结果 根据腹部 CTA 重建判断 IMA 分型,其中 I 型 88 例（43.35%）、 II 型 52 例（25.62%）、III 型 48 例（23.64%）、IV 型 15 例（7.39%）;患者均顺利完成手术,无中转开腹,术中证实 IMA 分型与术前腹部 CTA 判断符合率为 100% 。不同 IMA 分型组的手术出血量差异有统计学意义,III型术中出血量较多（P=0.026）;IMA 长度、手术时间、预防性造口率、术后病理分期、淋巴结清扫总数、阳性淋巴结数量、术后首次肛门排气时间、术后住院时间、腹腔引流管留置时间、导尿管留置时间、术后吻合口漏与排尿功能障碍发生率差异均无统计学意义（P>0.05）。结论 术前行腹部 CTA 将 IMA 精准分型,有助于术前评估 IMA 的解剖变异,为腹腔镜直肠癌手术中保留左结肠动脉提供安全的术中导航。

Abstract

Objective: To explore the application value of accurately preserving the left colic artery（LCA）with the assistance of judging the inferior mesenteric artery（IMA）classification by multi-slice spiral CT angiography（CTA）during laparoscopic anterior rectal resection. Methods: The clinical data of 203 rectal cancer patients who underwent laparoscopic anterior rectal resection from Jan. 2022 to Dec. 2023 were collected.Preoperative abdominal CTA was used to analyze the classification and length of IMA, except for the type without LCA, the LCA was accurately separated and preserved.Meanwhile, perioperative conditions（operative time, intraoperative blood loss, time to postoperative first flatus, hospital stay, defunctioning stoma, etc.）, postoperative pathological data（TNM stage, total lymph nodes harvested, and number of positive lymph nodes）, and postoperative recovery（anastomotic leakage and urinary retention） were recorded. Results: The IMA classification was determined by abdominal CTA reconstruction, including 88 cases of type I (43.35%), 52 cases of type II (25.62%), 48 cases of type III (23.64%), and 15 cases of type IV (7.39%) .All procedures were completed successfully without conversion to open surgery, and the intraoperative verification showed that the coincidence rate between IMA classification and preoperative abdominal CTA judgment was 100%.Significant difference in intraoperative blood loss was observed among different IMA types, with more intraoperative blood loss in type III（P=0.026）.No significant differences were found in IMA length, operative time, defunctioning stoma rate, postoperative pathological stage, total number of lymph nodes harvested, number of posi- tive lymph node, time to postoperative first flatus, postoperative hospital stay, abdominal drainage tube indwelling time, urinary catheter indwelling time, and incidence of anastomotic leakage and urinary dysfunction (P>0.05). Conclusions: Preoperative accurate classifica-tion of IMA by abdominal CTA is helpful for preoperative evaluation of anatomical variations of IMA, and provides safe intraoperative navigation for preserving the LCA in laparoscopic rectal cancer surgery.

关键词

直肠前切除术 / 腹腔镜检查 / 肠系膜下动脉分型 / 左结肠动脉 / 腹部 CT 血管造影

Key words

Anterior resection of the rectum / Laparoscopy / Inferior mesenteric artery classification / Left colic artery / Abdominal computed tomography angiography

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基金资助

上海市浦东新区卫生健康委员会卫生计生科研项目（PW2022B-10）