Goh N, Fong S S, How K Y, Wong K Y, Loong T H, Tay G T
National University of Singapore, Yong Loo Lin School of Medicine, Singapore, Singapore.
General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
Colorectal Dis. 2016 Jun;18(6):O206-9. doi: 10.1111/codi.13299.
It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique.
We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described (Kobayashi et al., Surg Endosc 2005, 20:563-9; Sekimoto et al. Surg Endosc 2010, 25:861-6) . The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated.
ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 18 min.
ALMA is a safe and feasible technique, allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients none were upstaged due to cancerous involvement of the proximal nodes.
肠系膜下动脉（IMA）高位或低位结扎哪种更具优势存在争议。前者可实现更广泛的淋巴结清扫，而后者可通过左结肠动脉（LCA）保留远端血管供应。IMA根部淋巴结清扫术（ALMA）在低位结扎IMA的同时，清扫LCA近端沿IMA分布的淋巴结组织。这在解剖学上兼具了高位结扎的肿瘤学优势和低位结扎的血管保留优势。本研究评估ALMA的淋巴结收获量及该技术的短期疗效。
我们回顾性研究了19例行ALMA根治性手术切除的乙状结肠癌或直肠癌患者。所有ALMA均采用先前描述的标准技术进行（Kobayashi等人，《外科内镜杂志》2005年，20:563 - 569；Sekimoto等人，《外科内镜杂志》2010年，25:861 - 866）。将清扫所得淋巴结（ALMA标本）的数量与总的淋巴结收获量进行比较。评估LCA解剖结构、实施ALMA所需时间、并发症及术后恢复情况的数据。
18例患者ALMA手术成功。术后中位住院时间为5（2 - 26）天，无与ALMA相关的发病率或死亡率。淋巴结收获量中位数为20（9 - 41）个，其中通过ALMA清扫获得的淋巴结中位数占14.3（0 - 80）%。2例未接受新辅助放化疗的患者，不包括从ALMA清扫获得的淋巴结，其淋巴结数量少于12个。ALMA平均所需时间为18分钟。
ALMA是一种安全可行的技术，可在不牺牲LCA的情况下进行扩大淋巴结清扫。在这一小部分患者中，没有因近端淋巴结癌转移而导致分期上升的情况。
