| Objective(s):Ligation of the inferior mesenteric artery(IMA)is a key step in radical resection of rectal cancer.IMA ligation can be divided into two ways:high ligation(ligation of the initial part of IMA to cut off the blood vessel)and low ligation(ligation of the left colon artery after IMA to cut off the blood vessel).At present,there is a dispute between the two in clinical practice.The essence of the dispute lies in whether the left colonic artery(LCA)should be preserved during the operation.In this study,META analysis was carried out to evaluate the effect of IMA ligation on anastomotic leakage(AL)after rectal cancer surgery from a statistical point of view.Then,we collected our clinical cases and evaluated the reference value of preoperative multi-slice computed angiography(MSCTA)to the ligation site of IMA in radical resection of rectal cancer.Methods:(一)PubMed,EMBASE and Web of Science Databases were searched to determine the relevant literature published from 1984 to 2018.Through inclusion and exclusion criteria,21 articles were finally included,including 5 randomized clinical trials(RCT),1 prospective non randomized study and 15 retrospective cohort studies.The data of patients in the retrospective cohort study were mainly collected after 2006.Therefore,the data of patients in the retrospective study after 2006 were included in the subgroup analysis.Using Revman 5.3 statistical software for meta-analysis of the required literature,or value and 95%confidence interval(95%CI)were calculated to evaluate the effect of high or low ligation of IMA on postoperative AL.(二)The colorectal cancer patients admitted to the Third Affiliated Hospital of Kunming Medical University(Yunnan Cancer Hospital)for colorectal surgery from January 1 to June 30,2019 were collected.MSCTA was performed before the operation,and IMA was ligated at a high level during the operation.The clinical and imaging data of the patients were saved in the file.According to the inclusion criteria and exclusion criteria,the patients were divided into two groups:non display group and display group.The volume rendering(VR)images after reconstruction failed to show the collateral circulation of the mesenteric vessels of the colonic splenic flexure completely as the non display group,while the collateral circulation of the mesenteric vessels of the colonic splenic flexure could be displayed completely as the display group.The statistical differences between the two groups in the operation mode,operation time and the incidence of postoperative anastomotic leakage were compared.Results:(一)In META analysis,6908 patients were evaluated quantitatively.2967 cases were treated with high ligation and 3941 cases were treated with low ligation.The risk of A1 in patients with high ligation(305/2967,10.28%)was significantly higher than that in patients with low ligation(301/3941,7.64%)(or 1.26;95%CI 1.08-1.47;P=0.003).However,according to the retrospective cohort study(or 1.34;95%CI 0.85-2.09;P=0.20);(or 1.12;95%CI 0.90-1.38;P=0.31),there was no significant difference in the risk of AL after ima high ligation and low ligation.(二)In our study,310 patients with rectal cancer underwent MSCTA before operation,230 cases were included in the analysis according to the inclusion criteria and exclusion criteria:210 cases in the non display group;20 cases in the display group.After image reconstruction,only 8.70%(20/230)of the mesenteric vascular collateral circulation could be completely reconstructed on VR images.Results of VR image reconstruction in display group:all of them had Drummond marginal artery arch and Riolan artery arch,30%(6/20)of medial branch of ascending branch of left colonic artery(ABLCA),and 45%(9/20)of middle accessory colonic artery,all of which originated from superior mesenteric artery.The collateral circulation of mesenteric vessels in the splenic flexure of the colon:the medial branch of ABLCA was anastomosed with the left branch of the middle colon artery(8 cases);the medial branch of ABLCA was anastomosed with the right branch of the middle colon artery(1 case);the medial branch of ABLCA was anastomosed with the middle accessory colon artery(5 cases);the left branch of ABLCA was anastomosed with the left branch of the middle colon artery(2 cases);the anastomoses of ABLCA with the middle accessory colon artery(4 cases).There was no significant difference in operation mode,operation time and incidence of anastomotic leakage between the two groups(P>0.05).Conclusion(s):1.According to META analysis,there was no significant difference in the effect of IMA ligation on the postoperative al of rectal cancer,indicating that the location of IMA ligation had no effect on the occurrence of anastomotic leakage.2.By collecting clinical cases,that is,MSCTA examination before operation and IMA ligation at high position during operation,there was no significant statistical difference in AL after operation in the cases with clear or no collateral circulation of splenic flexure of colon after image reconstruction,and no AL after operation in the cases without medial branches at the end of ABLCA,indicating that the marginal artery arch of Drummond is basically continuous at the splenic flexure of colon.It is fully proved that the high ligation of IMA in radical resection of rectal cancer is basically safe and feasible.3.Preoperative MSCTA has certain clinical reference value for the ligation site of the inferior mesenteric artery during the operation,but the proportion of the complete display of the collateral circulation network of the mesenteric vessels on the image reconstruction of the conventional enhanced scanning mode is not high(only 8.70%).The conventional MSCTA is not recommended before the operation... |
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