Department of Surgery, University Hospital Alexandrovska, Sofia, St. Georgi Sofiyski Str. 1, 1431, Sofia, Bulgaria.
Department of Anesthesiology and Intensive Care, University Hospital Alexandrovska, Sofia, Bulgaria.
Surg Endosc. 2022 Mar;36(3):1961-1969. doi: 10.1007/s00464-021-08479-x. Epub 2021 Apr 19.
In addition to ischemia there is also anastomotic ends tension proven to be a risk factor for anastomotic leak. HT vascular ligation is accepted as a rule, in attempt to achieve tension-free anastomosis. LT is a preferred option, based on the more accurate preservation of proximal intestinal segment microperfusion and lower risk of damage to the hypogastric plexus. The aim of this study is evaluation of comparative indicators in high tie (HT) and low tie (LT) laparoscopic rectal resections.
A prospective nonrandomized comparative cohort study of patients in our department with cancer of the rectum in clinical stage I-III, operated on in laparoscopic approach over a 6-years period.
For the period 2015-2020, a number of 208 laparoscopic surgeries have been done for rectal cancer. Patients were divided into three groups-group A with HT vascular ligation 116 pts. (69%), group B-53 pts. (25%), underwent low ligation-LT and group C-39pts. (19%) low tie plus lymph node dissection of the apical LN group (LT-appic LND). The distribution was made without randomization, based on the operators' expertise. Anastomotic leaks were 3.8% in group A, 3.0% in group B and 2.9% in group C (p > 0.05) with no significance difference. There is no significant difference in the number of lymph nodes obtained in group A and group B, while in group C the number of the harvested lymph nodes was higher (p < 0.05). The indicators for intestinal / defecation dysfunction, as well as for urinary/sexual dysfunction, according to our data, are significantly more favorable in patients with LT, in contrast to the other two groups.
HT vascular ligation attempts to achieve tension-free anastomosis and more harvested lymph nodes. However, LT could be a preferred option, based on the lack of significant evidence for a difference in specific oncological survival and due to more accurate preservation of proximal intestinal segment microperfusion to prevent anastomosis dehiscence, also for its lower risk of damage to the hypogastric plexus. Splenic flexure mobilization provides elongation of the proximal intestinal segment, but has no proven effect on anastomotic leakage incidence. It increases surgical duration and is in fact necessary in up to 30% of the cases. At the present moment there is no precise data whether LT has an advantage in terms of prevention of autonomic nervous and urogenital dysfunction. New prospective randomized and highly probative studies are needed to standardize the procedures in specific clinical situations.
除了缺血之外，吻合口张力也是吻合口漏的一个危险因素。HT 血管结扎被认为是实现无张力吻合的一种方法。LT 是一种首选方法，因为它可以更准确地保持近端肠段的微血管灌注，并降低对腹下丛的损伤风险。本研究旨在评估 HT 和 LT 腹腔镜直肠切除术的比较指标。
对我科 6 年内接受腹腔镜治疗的临床 I-III 期直肠癌患者进行前瞻性非随机对照队列研究。
2015 年至 2020 年，我们共完成了 208 例腹腔镜直肠癌手术。患者被分为三组：A 组 HT 血管结扎 116 例（69%），B 组 53 例（25%）行 LT 低位结扎，C 组 39 例（19%）行 LT 加顶 LN 组（LT-appic LND）淋巴结清扫。分组未进行随机化，而是根据术者的专业知识进行。A 组吻合口漏发生率为 3.8%，B 组为 3.0%，C 组为 2.9%（p>0.05），差异无统计学意义。A 组和 B 组获得的淋巴结数量无显著差异，而 C 组获得的淋巴结数量更高（p<0.05）。根据我们的数据，肠道/排便功能障碍以及尿/性功能障碍的指标在 LT 组明显更有利，与其他两组相比差异有统计学意义。
HT 血管结扎试图实现无张力吻合并获得更多的淋巴结。然而，LT 可能是一种更优的选择，因为没有确凿的证据表明 LT 对特定的肿瘤生存有差异，并且因为它可以更准确地保持近端肠段的微血管灌注，从而预防吻合口裂开，同时它对腹下丛的损伤风险也较低。脾曲游离提供了近端肠段的延长，但对吻合口漏的发生率没有明显影响。它增加了手术时间，实际上在 30%的病例中是必要的。目前，LT 是否在预防自主神经和泌尿生殖功能障碍方面具有优势尚没有确切的数据。需要进行新的前瞻性随机对照和高论证研究，以在特定临床情况下规范手术。
