利用3D-CTA揭示高位结扎的直肠癌术后吻合口瘘的高危血管变异的研究

Blood supply is the most important factor in the healing process of anastomosis after rectal cancer surgery. It has been found that, splenic marginal artery formed by the anastomosis of the branches of left colic artery (LCA) could be sometimes weakly structured. This type of patients would be at greater risk for anastomosis leakage, if LCA branches was hurt during rectal cancer surgery with IMA high ligation. Till now, there is no ideal method to identify the high risk LCA type and to assess the integrity of splenic marginal artery before surgery. Thus, we utilize high definition 3D-CTA, to characterize the track and branching pattern of LCA, and to reveal the high risk LCA type by retrospective case-control study and prospective cohort study. Then we set prospective randomized controlled study to find the better method of IMA ligation for rectal cancer patients with high risk LCA type. This study would help build the model of personalized vessel management in rectal cancer surgery.

血供障碍是直肠癌术后吻合口瘘的最重要原因之一。肠系膜下动脉（IMA）高位结扎是直肠癌术中最常用的血管处理方法，部分病人的左结肠动脉（LCA）及其分支常与肠系膜下静脉（IMV）紧密伴行，此类病人在IMA高位结扎后常将IMV与LCA一同离断。考虑到脾曲边缘血管弓在部分病人结构薄弱，此时扮演脾曲二级弓的LCA分支若被离，吻合口血供将受限于薄弱的脾曲边缘弓，进而造成吻合口血供下降。目前尚缺乏术前评价高危LCA变异和脾曲边缘弓薄弱程度的方法，因此无法针对变异制定个体化的直肠癌手术策略。本研究利用高分辨三维血管成像（3D-CTA），对LCA走形和分支变异进行分类，再经回顾性病例对照和前瞻性队列研究，揭示影响IMA高危结扎的直肠癌术后吻合口瘘高危LCA变异，最后建立前瞻性随机对照研究，提出针对高危变异患者能降低吻合口瘘发生的最优血管处理策略。

肠系膜血管变异是造成胃肠道手术腹腔出血或缺血性并发症的关键环节。针对直肠癌术后吻合口瘘中吻合口血供的问题，研究团队利用高分辨三维血管成像（3D-CTA）技术，对吻合口近端血供来源的左结肠动脉（Left colic artery，LCA）走形和分支变异进行了分类，并且描述了LCA、IMA、IMV之间的相互关系；同时，并用回顾性临床队列进一步证实了直肠癌术中肠系膜下动脉（Inferior mesenteric artery, IMA）高位结扎时高危LCA变异的分型，并提出了应对该高危分型的外科处理办法；同时，提出了右结肠动脉和中结肠动脉变异规律。研究团队开发了稳定清晰显示门静脉变异的检查方法，利用门静脉增强CT静脉成像（CTV）分析了右半结肠血管，特别是胃结肠静脉干（Henle干）的解剖变异情况。本项目研究成果为制订结直肠手术个体化手术方案提供了术前解剖学参考。