The Surgical Effect Of Laparoscopic Anterior Resection Of Rectal Carcinoma With Or Without The Left Colic Artery:A Mata-analysis

The surgical modality of rectal cancer has shifted from simpal tumor resection to a comprehensive and individualized era of precise treatment including neo-adjuvant chemoradiation,molecular targeted therapy,and multi-disciplinary treatment(MDT).Not only requires tumor radical treatment and reduce the local recurrence rate,but also minimize trauma and preserve the anus and pelvic autonomic nervous system to retain the autonomic defecation function and genitourinary function to improve the quality of life for patients.The principles of laparoscopic resection of the rectum have reached consensus in many ways after many years of research and discussion such as:(1)Total mesorectal excision(TME)to improve tumor radical;(2)Pelvic autonomic retention to improve patient satisfaction with life;(3)The implementation of no tumor prevention measures for incision and trocar hole to reduce tumor transfer;(4)The lymph node dissection besides the root of inferior mesenteric artery(IMA)and so on.However,there is still controversy about the level of ligation for inferior mesenteric artery in this surgery.Before the 20th century,no one specifically pointed out the exact location of IMA ligation.Until 1908,Miles proposed the low ligation(LL)of the inferior mesenteric artery firstly,which left the left colonic artery(LCA).In the same year,Moynihan proposed the high ligation(HL)of the inferior mesenteric artery,which does not left the left colonic artery.Since then,a hundred years of"high vs low"kick-off of the race kicked off.Objective:The incidence of anastomotic fistula,the number of lymph node dissection were taken as the main endpoints and the operation time,the amount of intraoperative blood loss were taken as the secondary endpoints to systematically evaluate the surgical effect of laparoscopic anterior resection of rectal carcinoma with or without the left colic artery,with a view to further guide clinical treatment.Methods:To develop a strict inclusion and exclusion criteria for the literature.Pubmed,Cochrane Library,Embase,WanFang Date,CNIK were searched using the keyword of???(Rectal neoplasms),?????(Left colic artery),???(Laparoscopic),"rectal neoplasms","rectal cancer","laparoscop*","LCA","IMA"and using the way of the combination of subject terms and free words.The manual search of"gray literature"was paid attention simultaneously and the search period was set from the beginning of construction to March 2017.The randomized controlled trails(RCTs)and clinical controlled trials(CCTs)comparing low ligation with high ligation the inferior mesenteric artery(IMA)in laparoscopic anterior resection of rectal carcinoma were colected.Data were screened,extracted and evaluated by two reviewers independently.In the event of difference through discussion by the third researchers to work out.Meta-analyses were conducted using the sofeware STATE12.0.The mean difference(MD)or standardized mean difference(SMD)are calculated for continuous data and odds ratio(OR)for dichotomous and the point estimates of each effect quantity and95%confidence interval(CI)are calculated.The I~2 test is used to test the heterogeneity of the included literature:If no heterogeneity was detected between included trials,a fixed-effect model was used to the meta-analysis.Conversely,the random-effects model be used.Finally the publication bias analysis was evaluate by the funnel plot.Results:A total of fifteen articles smet the selection criteria.The Meta-analyses showed that:The grope of Low ligation group had lower rate of anastomotic fistula(OR=0.394,95%CI:0.251~0.616,P<0.001)and longer opration time(WMD=7.022,95%CI:3.325~10.718,P<0.001)and more intraoperative blood loss(WMD=4.879,95%CI=3.070~6.687,P<0.001)compared with that in high ligation group.There is no statistical differences in the number of lymph node dissection besides the root of IMA(WMD=-0.014,95%CI:-0.122~0.150,P=0.841).The results of the funnel plot show that the scatter points are roughly symmetrically distributed on both sides of the longitudinal axis and are distributed substantially in the funnel,suggesting that there is low risk of publication bias included in the literature.Conclusions:In spite of had longer operation time and more intraoperative blood loss,reserved the LCA can reduced the rate of anastomotic fistula effectively and there is no statistical differences in the number of lymph node dissection besides the root of IMA.It is possible to promote the use of reserved the LCA in laparoscopic anterior resection of rectal carcinoma.