| BackgroundAt present,the incidence and mortality of colorectal cancer is growing,and colorectal cancer has become an of the most common gastrointestinal malignant tumors in our country.Compared with rectal cancer in high position and colon cancer,the prognosis of rectal cancer in middle and low position is worse,and its five years survival rate is approximately 40%.Therefore,rectal cancer has a characteristics of higher incidence and worse prognosis,which exerts dramatically influence on the life health and living quality of Chinese people.The principal therapy for rectal cancer in middle and low position is comprehensive treatments,among which surgery is the most important one.With the development of society,people's demand for higher living standard and the improvement of doctors' skills in operating laparoscopic surgical techniques,anterior resection of rectal cancer in low position under laparoscope has become the most common surgical method in clinical treatment.This surgical techniques results in less wound,faster recovery after surgery and better removal of lymph nodes around inferior mesenteric artery root.Therefore,it has become the first choice for more and more Chinese colorectal surgeon when treating colorectal cancer.The treatment of inferior mesenteric artery under laparoscopic Dixon surgery mainly contains high tie(HT)and low tie(LT).The operation of HT is more simple,and loose intestinal canal and less tension in anastomotic stoma could decrease the injury to autonomic nerve in abdomen.However,it may influence the blood supply of anastomotic stoma and some cases may have to free the splenic flexure.LT has better effect on maintaining the blood supply of anastomotic stoma.Some scholars believe it could reduce the bleeding volume during operation,but it is difficult to clear the node of IMA's root.Combining literature report,there exists disputes about the number of lymph nodes to be removed,the incidence,recurrent rate and survival rate of anastomotic leakage for both methods.Objective1.To explore the risk of anastomotic leakage,the incidence of free splenic flexure and preventive colostomy after high ligation of inferior mesenteric artery in low anterior resection for rectal cancer under laparoscope.2.To explore the influence of HL and LL to the blood supply of anastomotic stoma.3.To explore the incidence of free splenic flexure,preventive colostomy and anastomotic leakage in different anastomotic blood supply.MethodsAccording to the following criteria,collect 101 cases of registered anterior resection for rectal cancer from January 2012 to October 2016 from the department of colorectal surgery,Qilu Hospital,Shandong University.Enter criterion:(1)The mass is testified as rectal cancer based on preoperative endoscopic biopsy and histopathology test.(2)The mass is located in the middle and low position of rectum,which should be testified by preoperative imaging,digital rectal exam and enteroscopy,that is the distance between the inferior margin of the tumor and anal verge is not more than 12 centimeters.(3)There is no tumor distant metastasis and local infiltration to other organs.(4)Operation method is rectal low anterior resection under laparoscope.Exclusion criteria:(1)Patients who got neoadjuvant chemoradiation before surgery.(2)History of lower abdominal surgery.(3)Patients who got emergency surgery because of acute intestinal obstruction,intestinal,bowel perforation complicated with acute peritonitis,acute massive hemorrhage and so on.(4)Extensive abdominal metastasis or infiltration to other nearby organs are found in surgery.According to the ligation methods of inferior mesenteric artery,we divided all the cases into two groups,which are high ligation group,including 39 cases and low ligation group,including 62 cases.Retrospectively analyze the clinical materials of all cases;Chi-square test is used to analyze the differences on the incidence of anastomotic fistula,free splenic flexure and preventive colostomy and anastomotic blood supply between these two groups.According to the anastomotic blood supply,all cases are dived into three groups.In group A,the broken end of intestinal canal exists obvious pulsatile hemorrhage after cut by Endo-GIA stapler.In group B,the broken end of intestinal canal exists obvious errhysis after cut by Endo-GIA stapler.In group C,the broken end of intestinal canal exists no obvious hemorrhage or errhysis after cut by Endo-GIA stapler.Chi-square test is used to analyze the differences on the incidence of anastomotic fistula,free splenic flexure and preventive colostomy between these three groups.Results1.Basic data comparison between groups Compared with high ligation group,there is no difference in the incidence of age,sex,smoking,drinking hypertension,diastases and colorectal cancer family history as well as the amount of blood albumin,hemoglobin(HGB),white blood cells(WBC),glutamic-pyruvic transaminase(ALT),glutamic-oxalacetic transaminase(AST),creatinine(Cr),prothrombin time(PT)(p>0.05).Compared with high ligation group,low ligation group has less carcinoembryonic antigen(CEA)and spend less time in surgery(p<0.05).2.The difference on the incidence of anastomotic fistula,free splenic flexure and preventive colostomy and anastomotic blood supply between high ligation group and low ligation group2.1 The difference on the incidence of anastomotic fistula between groupsCompared with high ligation group,there is no difference on incidence of anastomotic fistula from low ligation group(p>0.05).2.2 The difference on the incidence of free splenic flexure between groupsCompared with high ligation group,low ligation group has lower incidence of free splenic flexure(p<0.05).2.3 The difference on the incidence of preventive colostomy between groupsCompared with high ligation group,there is no difference on incidence of preventive colostomy from low ligation group(p>0.05).2.4 The difference on the anastomotic blood supply between groupsCompared with high ligation group,low ligation group has better blood supply(p<0.01).3.The difference on the incidence of anastomotic fistula,free splenic flexure and preventive colostomy and anastomotic blood supply between anastomotic blood supply groups3.1 The difference on the incidence of anastomotic fistula between groupsCompared with group A,the incidence of anastomotic fistula in group B is higher(p<0.01),and there is no difference from group C(p>0.05);compared with group B,there is no difference on the incidence of anastomotic fistula from group C(p>0.05).3.2 The difference on the incidence of free splenic flexure between groupsCompared with group A,there is no difference on the incidence of free splenic flexure from group B and C(p>0.05);compared with group B,there is no difference on the incidence of free splenic flexure from group C(p>0.05)3.3 The difference on the incidence of preventive colostomy between groupsCompared with group A,group B and C have lower incidence of preventive colostomy(p<0.05);compared with group B,group C has lower incidence of preventive colostomy(p<0.05).Conclusion1.High ligation of inferior mesenteric artery in rectal low anterior resection is not an independent risk factor for the occurrence of anastomotic fistula.2.Compared with high ligation,cases with low ligation of inferior mesenteric artery have lower incidence of free splenic flexure and better blood supply in anastomotic stoma.3.In different groups defined as the blood supply of anastomotic stoma,the group with better blood supply in anastomotic stoma has lower incidence of anastomotic fistula and preventive colostomy. |
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