【作者】 张伟；

【导师】 王可新；

【作者基本信息】 山东大学 ， 外科学（专业学位）， 2023， 硕士

【摘要】 研究背景直肠癌作为我国常见的消化道恶性肿瘤,其发病率逐年上升,而且随着青年人群发病率的提升,直肠癌已然成为威胁人类生命健康的重要问题。腹腔镜直肠前切除术是目前应用最普遍的直肠癌治疗术式,其优势在于手术创伤相对较小,术后恢复较快。随着技术水平的提高,腹腔镜直肠前切除术的手术指征已包含距肛缘5cm的直肠恶性肿瘤,大大增加了保肛机率,但由于吻合口位置偏低,手术难度增加,术中游离病灶血供是手术的难点之一。复杂的血管解剖变异会对手术整体产生影响,我们关注的问题如下:①肠系膜下动脉根部的位置可能位于十二指肠后方甚至上方,增加手术解剖的难度,甚至会损伤十二指肠引起相关并发症;②肠系膜下动脉分支分型方式较多,尚无统一分型方式;③左结肠动脉走行差异较大,无统一描述方式,左结肠动脉发出的位置及走行,可能与术中是否保留左结肠动脉有关,而是否保留左结肠动脉与吻合口血供及术后吻合口漏可能相关。因此术前对血管解剖进行评估十分重要。术前行血管三维重建,可以清楚直观的显示腹腔血管结构,但该项检查增加患者经济负担,部分地区可能不具备CT三维重建条件。我们发现通过阅读轴位增强CT,也可清楚显示肠系膜下动脉及其分支解剖关系,并指导术中操作。此外术中是否保留左结肠动脉对患者术后恢复的影响也是当前的热点话题,目前尚无明确定论。第一部分基于轴位增强CT肠系膜下血管局部解剖的再探索研究目的基于术前轴位增强CT,探索肠系膜下动脉起始点与十二指肠水平段下缘的关系、肠系膜下动脉分支类型及左结肠动脉与肠系膜下静脉相对位置关系,为腹腔镜直肠前切除术术中血管解剖游离提供指导。研究方法回顾分析山东大学齐鲁医院胃肠及结直肠外科2019年1月至2020年8月收治的316例行腹腔镜直肠前切除术患者的临床数据资料及影像学资料,逐一分析其术前轴位增强CT,测量十二指肠水平段下缘与肠系膜下动脉起始点距离,根据肠系膜下动脉分支结构判定分支类型,在肠系膜下动脉起始水平判断左结肠动脉与肠系膜下静脉位置关系。研究结果对316例临床患者增强CT资料分析并进行测量1.根据肠系膜下动脉起点与十二指肠水平段下缘的关系,将高于十二指肠水平段下缘者定为高位起始,将低于十二指肠水平段下缘者定为低位起始,其中患者肠系膜下动脉高位起始89例(27.93%),低位起始227例(72.07%);研究发现男性患者肠系膜下动脉起始位置距离十二指肠水平段下缘(3.014±0.2)cm,女性为(3.3±0.188)cm二者无显著差异(P>0.05)。2.我们对肠系膜下动脉分支分型为:Ⅰ型:LCA和SA起始点独立于IMA;Ⅱ型:LCA和SA有一个共同的主干,距离起始点长度>5mm;Ⅲ型:LCA和SA起自IMA同一点,或有共同主干,距离起始点≤5mm;Ⅳ型:LCA缺失。其中Ⅰ型 171 例(54.1%)、Ⅱ型 58 例(18.4%)、Ⅲ型 82 例(26.6%)、Ⅳ型 5 例(1.6%),分析显示女性患者Ⅱ型更为少见(P<0.05)。3.在肠系膜下动脉始点水平,判读左结肠动脉与肠系膜下静脉的位置关系,根据左结肠动脉在肠系膜下静脉的方位分成内侧近型(42例,13.3%)、内侧远型(1例,0.3%)、外侧近型(116例,36.7%)、外侧远型(65例,20.6%)、前侧型(75例,23.7%),后侧型(12例,3.8%),LCA缺如(5例,1.6%)。左结肠动脉与肠系膜下静脉位置关系显示男性患者外侧近型为主,女性患者外侧近型与远型相当(P>0.05)。研究结论在腹腔镜直肠前切除术中,术前轴位增强CT可以准确的显示肠系膜下血管局部解剖(肠系膜下动脉起始点与十二指肠水平段下缘的位置关系、肠系膜下动脉分支分型及左结肠动脉与肠系膜下静脉的位置关系),对术中操作有指导意义。第二部分 腹腔镜直肠前切除术中是否保留左结肠动脉对术后短期治疗效果的影响研究目的对比腹腔镜直肠前切除术中是否保留左结肠动脉在患者术后短期内治疗效果,对直肠癌手术是否保留左结肠动脉的选择提供指导。研究方法回顾分析山东大学齐鲁医院胃肠及结直肠外科2019年1月至2020年8月收治的316例行腹腔镜直肠前切除术患者的临床数据资料。随后根据是否保留左结肠动脉将其分为两组:观察组保留左结肠动脉(177例)与对照组不保留左结肠动脉(139例),对比分析两组患者在手术用时、术中出血(以术前术后血红蛋白下降水平表示)、淋巴结清扫数目及术后并发症等方面的差异。研究结果两组患者在性别、年龄、肿瘤分期、肿瘤部位等方面均无显著差异(P>0.05),数据具有可比性。观察组手术用时为(175±42)min,对照组手术用时为(164±42)min(P<0.05);观察组平均淋巴结清扫个数为(17±5)个,对照组平均淋巴结清扫个数为(18±5)个(P>0.05);观察组术后第1天血红蛋白平均降低为(13±8)g/L,对照组术后第1天血红蛋白平均降低为(14±8)/L差异均无统计学意义(P>0.05);在术后吻合口漏、腹腔出血、刀口感染及术后肠梗阻等并发症发生率方面进行对比,无显著差异(P>0.05);术后平均首次排气时间及平均住院天数等术后恢复指标方面进行对比,无统计学差异(P>0.05)。研究结论腹腔镜直肠前切除术中保留左结肠动脉在一定程度上增加手术难度并延长手术用时,对患者术后短期恢复无明显优势。保留左结肠动脉对于患者术后长期的影响尚需进一步研究。更多还原

【Abstract】 BackgroundAs a common malignant tumor of the digestive tract in our country,the incidence of rectal cancer is increasing year by year.With the increase of the incidence of young people,rectal cancer has become an important problem threatensing human life and health.Laparoscopic anterior resection of rectal cancer is currently the most commonly used treatment for rectal cancer,and its advantages are relatively small surgical trauma and fast postoperative recovery.With the improvement of the medical technology,the surgical indications for Laparoscopic anterior resection of rectal cancer include rectal malignant tumors 5 cm from the anal verge,which greatly increases the chance of anal preservation.The blood supply of the lesion is one of the difficulties in the operation.Complex vascular anatomical variations will affect the overall surgical effect.The issues we are concerned about are as follows:①The root of the inferior mesenteric artery may be located behind or even above the duodenum,which increases the difficulty of surgical dissection and may even damage the duodenum and cause related complications;②There are many types of branches of the inferior mesenteric artery,and there is no unified classification method;③The course of the left colic artery is quite different,and there is no unified description method.Whether to preserve the left colic artery may be related to the blood supply of the anastomotic stoma and postoperative anastomotic leakage.Therefore,preoperative assessment of vascular anatomy is very important.Preoperative three-dimensional vascular reconstruction can clearly and intuitively display the peritoneal vascular structure,but this examination increases the financial burden of patients,and some areas may not have the conditions for CT three-dimensional reconstruction.We find that by reading the axial enhanced CT,the anatomical relationship between the inferior mesenteric artery and its branches can also be clearly displayed,and the intraoperative operation can be guided.In addition,whether to preserve the left colic artery during the operation will affect the postoperative recovery of patients is also a current hot topic,and there is no clear conclusion yet.Part Ⅰ:Re-explore the local anatomy of inferior mesenteric vessels based on axial enhanced CTObjectiveBased on preoperative axial enhanced CT,the relationship between the starting point of inferior mesenteric artery and the inferior margin of duodenum,the type of branches of inferior mesenteric artery and the relative position of left colonic artery and inferior mesenteric vein were explored to provide guidance for vascular anatomy during Laparoscopic anterior resection of rectal cancer.MethodsThe clinical data of 316 patients who underwent Laparoscopic anterior resection of rectal cancer in the Department of Gastrointestinal and Colorectal surgery,Qilu Hospital of Shandong University from January 2019 to August 2020 were retrospectively analyzed.The preoperative axial enhanced CT was analyzed one by one,and the distance between the inferior margin of duodenum and the starting point of inferior mesenteric artery was measured.The branch type was determined according to the branch structure of inferior mesenteric artery.The position relationship between the left colonic artery and the inferior mesenteric vein was judged at the initial level of the inferior mesenteric artery.ResultsThe enhanced CT data of 316 clinical patients were analyzed and measured.1.According to the relationship between the origin of inferior mesenteric artery and the lower edge of duodenum,those above the lower edge of duodenum were defined as high-level origin,and those below the lower edge of duodenum were defined as low-level origin,among which 89 patients(27.93%)had high-level origin of inferior mesenteric artery and 227 patients(72.07%)had low-level origin.It was found that the starting position of inferior mesenteric artery in male patients was(3.014±0.2)cm away from the lower edge of duodenum,and that in female patients was(3.3±0.188)cm.There was no significant difference(P>0.05).2.The branching types of inferior mesenteric artery were as follows:type Ⅰ:the starting point of LCA and SA was independent of IMA;type Ⅱ:IMA and SA had a common trunk,which was more than 5mm from the starting point;type Ⅲ:LCA and SA originated from the same point of IMA,or had a common trunk,less than 5mm from the starting point;type Ⅳ:absence of LCA.There were 171 cases of type I(54.1%),58 cases of type Ⅱ(18.4%),82 cases of type Ⅲ(26.6%)and 5 cases of typeⅣ(1.6%).The analysis showed that type Ⅱ was more rare in female patients(P<0.05).3.At the level of the starting point of the inferior mesenteric artery,the positional relationship between the left colic artery and the inferior mesenteric vein was judged,and according to the position of the left colic artery in the inferior mesenteric artery,it was divided into the inner proximal type(42 case,13.3%),the inner distal type(1 case,0.3%),and the lateral proximal type.type(116 cases,36.7%),lateral distal type(65 cases,20.6%),anterior type(75 cases,23.7%),posterior type(12 cases,3.8%),LCA absence(5 cases,1.6%).The positional relationship between the left colic artery and the inferior mesenteric artery showed that the lateral proximal type was dominant in male patients,and the lateral proximal type was similar to the distal type in female patients(P>0.05).ConclusionIn laparoscopic anterior resection of rectal cancer,preoperative axial contrast-enhanced CT can accurately display the local anatomy of the inferior mesenteric vessels(the positional relationship between the starting point of the inferior mesenteric artery and the lower edge of the duodenum,the classification of the branches of the inferior mesenteric artery and the left colon The positional relationship between the artery and the inferior mesenteric vein),which has guiding significance for intraoperative operations.Part Ⅱ:the effect of preservation of left colonic artery on short-term postoperative complications in Laparoscopic anterior resection of rectal cancer.ObjectiveTo compare whether to preserve the left colic artery during operation and the short-term treatment effect after operation,to provide guidance for the choice of whether to preserve the left colic artery in rectal surgery.MethodsThe clinical data of 316 patients who underwent Laparoscopic anterior resection of rectal cancer in the Department of Gastrointestinal and Colorectal surgery,Qilu Hospital of Shandong University from January 2019 to August 2020 were retrospectively analyzed.The patients were then divided into two groups according to whether the left colonic artery was preserved or not.177 cases in the observation group retained the left colonic artery and 139 cases in the control group did not retain the left colonic artery.The differences of operative use,intraoperative bleeding,lymph node dissection and postoperative complications between the two groups were compared and analyzed.ResultsThere were no significant differences in gender,age,tumor stage,and tumor location between the two groups of patients(P>0.05),and the data were comparable.The operation time of the observation group was(175±42)min,and the operation time of the control group was(164±42)min(P<0.05);the average number of lymph nodes dissected in the observation group was(17±5)and that of the control group was The number was(18±5)(P>0.05);the average decrease in hemoglobin in the observation group was(13±8)g/L on the first day after operation,and the average decrease in hemoglobin in the control group was(14±8)on the first day after operation There was no significant difference in/L(P>0.05);there was no significant difference in the incidence of complications such as postoperative anastomotic leakage,abdominal hemorrhage,incision infection and postoperative intestinal obstruction(P>0.05);There was no statistical difference in postoperative recovery indicators such as the average first exhaust time and the average length of hospital stay(P>0.05).ConclusionPreserving the left colic artery in Laparoscopic anterior resection of rectal cancer increases the difficulty of the operation and prolongs the operation time to a certain extent,but has no obvious advantage for the short-term recovery of patients after surgery.The long-term effect of preserving the left colic artery on patients needs further study.更多还原