GRP Gastroenterology Research and Practice 1687-630X 1687-6121 Hindawi出版 10.11五五/2020/1958573 1958573 Research Article Clinical Effect of Preservation or Nonpreservation of Left Colic Artery in Total Mesorectal Excision under Laparoscopy: A Meta-analysis Liu Jiefeng 1 Gong 玉井 1 He 苗 1 ženg Xinyu 1 https://orcid.org/0000-0002-9852-9732 Liu Yiping 2 利玛窦 基娅拉 1 Department of General Surgery 该Fourth Hospital of Changsha Hunan Normal University 长沙 410006Hunan Province 中国 hunnu.edu.cn 2 Department of Oncology Xiangya Hospital Central South University 长沙 410078湖南省 中国 csu.edu.cn 2020 21 五 2020 2020 31 12 2019 31 03 2020 21 五 2020 2020 版权所有©2020接风刘等人。 This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Aims。To investigate the clinical effect of preservation or nonpreservation of the left colic artery (LCA) in total mesorectal excision (TME) under laparoscopy. Methods。该words, like “rectal cancer,” “left colonic artery,” and “laparoscopy,” were used as the retrieval terms, and the keyword retrieval method was adopted. The retrieval period was set as from January 1, 2013, to June 1, 2018. We searched databases including PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) to collect randomized and controlled trials which compared the effect of preservation or nonpreservation of the LCA in TME under laparoscopy. Two researchers independently carried out literature screening, data extraction, and literature quality evaluation; Review Manager 5.3 was used for the meta-analysis. 结果。Seven studies including 1467 cases were identified for the meta-analysis. As showed by the meta-analysis, compared with the LCA nonpreservation group, the LCA preservation group had significantly reduced incidence of anastomotic leakage ( OR = 0。44 ， CI = 0。30 ， 0。6五 ， P < 0。0001 ) and postoperative urinary and sexual dysfunction ( OR = 0。26 ， CI = 0.09 ， 0。78 ， P = 0.02 ) and significantly shorter time for intestinal function recovery ( 大规模杀伤性武器 = − 0。26 ， CI = − 0。41 ， − 0.11 ， P = 0。0008 ）。有手术，术中出血量，清扫淋巴结数目，或术后住院期间两组间无显著差异。 Conclusions。From the results, the LCA preservation group seems to achieve comparable success with acceptable safety outcomes. Therefore, this surgical method can be recommended in the clinical practice.

 Natural Science Foundation of Hunan Province 2018jj6125 1。一世ntroduction

Colorectal cancer is the third most common malignancy that causes significant morbidity and mortality in the world. More than 1.3 million people are diagnosed with colorectal cancer each year, and more than 600,000 patients die from colorectal cancer or related complications [ 1， 2]。目前，手术治疗仍然是直肠癌的治疗中的主要方法。1908年，迈尔斯教授首次提出低结扎，也就是直肠癌切除与左结肠动脉（LCA）。同年，莫伊尼汉教授提出高位结扎的概念，这是在肠系膜下动脉远端结扎线结扎肠系膜下动脉[ 3]。近年来,随着TM的发展E concept and the development of laparoscopic surgery, the surgical treatment of rectal cancer has undergone tremendous changes. In laparoscopic rectal cancer TME, the treatment of IMA and its branches mainly includes “high ligation and low ligation.” According to the American Association of Colorectal Surgeons guidelines, high ligation is ligation at the root of the IMA and does not retain LCA. Ligation at the lower site is ligation over the LCA branch of the IMA and retains the LCA [ 4， 五]。该branch of the inferior mesenteric artery (IMA) should be clearly dissected during the surgery, but there is a controversy over whether the LCA should be preserved [ 6]。在这方面，国外的研究主要集中在住院病例。这些案件进行手术，术中出血量，清扫淋巴结数目，术后吻合口瘘发生率，时间，肠功能恢复，术后排尿及性功能障碍，而复发后两年时间进行比较。收集的发病率和总生存率统计。在这些独立的研究，收集病例数相对较少，这导致的结论可靠性降低。因此，根据现有的研究，我们从2013年1月1日进行了公开发表的文献的荟萃分析，到2018年6月1日，调查LCA的保存直肠癌的治疗腹腔镜TME过程中的作用。动脉的临床影响提供的接受直肠癌的治疗腹腔镜TME的患者术后恢复了可靠的科学依据。

 2。Data and Methods 2。1。Literature Retrieval Strategy

We search for laparoscopic rectal cancer surgery (using TME with or without the preservation of the LCA)-related articles published from January 01, 2013, to June 1, 2018, from databases including CNKI, PubMed, and Web of Science. Keywords retrieved were laparoscopic, rectal cancer, left colonic artery, rectal, laparoscopy, and left colic artery.

 2。2。一世nclusion Criteria

入选标准如下：（1）直肠癌和直肠癌症的治疗腹腔镜TME的诊断的文献研究;（2）与文献积分的分析数据和独立的研究，包括带有一致目的至少一个控制组;（3）保存或LCA作为实验组和对照组之间的唯一区别的nonpreservation;（4）类似的文献研究方法;和（5）组合的结果表示由对应的统计指标。

 2。3。Exclusion Criteria

Exclusion criteria are the following: (1) duplicate or multiple articles about the same study, which may lead to content bias; (2) abstracts, research protocols, letters, editorials, comments, guidelines, and case reports; (3) and noncomparative studies.

 2.4。研究筛选

两位研究人员使用统一的检索策略根据入选和排除标准，独立的屏幕和提取数据。如果有差异，决定应通过讨论或咨询第三研究者提出。在这项研究中，获得了37的相关文章，其中最终被纳入符合纳入标准的7篇。

 2。五。Statistical Analysis

被检索到的国内外文献为下进行统计分析：手术，术中出血量，清扫淋巴结，术后吻合口漏，时间为肠功能恢复的数量，术后排尿及性功能障碍，两年复发率的持续时间和总生存。从每篇文章的数据表中的编译和输入计算机。荟萃分析软件审查经理5.3用于计算和分析数据。加权平均差异（WMD）和二进制数据计算对连续变量。胜算比（OR）和组合值在95％置信区间（CI）中表达;的异质性检验 一世 2 was performed on the included literature: a fixed effect model was used in the absence of statistical heterogeneity ( P > 0。1 ， 一世 2 ≤ 五0 ％ );otherwise ( P < 0。1 ， 一世 2 ≥ 五0 ％ ），使用随机效应模型。该 ž -test was used to test the combined effect. A difference was considered of statistical significance at P < 0.05 and of great statistical significance at P < 0.01 。与此同时，漏斗图表构建评估偏压的存在。

 3.结果

该included studies involved a total of 1467 cases, of which 872 had LCA preservation and 595 did not.

3。1。Data Extraction and Quality Evaluation

的文献检索和筛选过程在图中所示 1。All quality evaluations were conducted using the Cochrane risk-of-bias tool for the assessment of the randomization method, allocation concealment, blinding, completeness of outcome data, selective reporting, and other biases. The final literature quality evaluation is shown in Table 1and Figure 2。

流量的确定，包括和排除的研究图。

Characteristics of included studies.

Study 年 国家 Adequate sequence generation Allocation concealment Blinding 一世ncomplete outcome data addressed Free of selective reporting 免费的偏见
Hinoi et al. [ 7] 2013 Japan Yes Yes Yes Yes Yes No
臧et al. [ 8] 2016 中国 不清楚 Yes Yes Yes Yes No
你等。[ 9] 2017 中国 不清楚 不清楚 Yes Yes Yes No
朱等人。[ 10] 2016 中国 Yes 不清楚 Yes Yes Yes No
张和张[ 11] 2017 中国 Yes 不清楚 Yes Yes Yes No
Lv et al. [ 12] 2014 中国 Yes 不清楚 Yes Yes Yes 不清楚
驰et al. [ 13] 2017 中国 Yes Yes Yes Yes Yes No

Characteristics of included studies.

 3。2。Main Meta-analysis Results (Primary Outcomes) 3.2.1。手术时间

该meta-analysis results are shown in Figures 3(a)and 3(b)。手术患者有无LCA的保存期限的结果显著异质性（异质性检验： 一世 2 = 64 ％ ， P = 0.010 );当使用随机效应结合大规模杀伤性武器model, the combined effect of WMD is 3.27 ( 95 ％ CI = − 2。02 ， 8.55 ， ž = 1。21 ，and P = 0.23 ），这是不显著不同。Based on the results of the analysis, it can be concluded that there is no significant difference in the WMD in the duration of surgery between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the duration of surgery. The funnel plot shows a symmetrical shape, indicating that there is no bias.

(a) Forest plot of duration of surgery; (b) funnel plot of duration of surgery.

 3。2。2。一世ntraoperative Blood Loss

该meta-analysis results are shown in Figures 4(a)and 4(b)。该results of blood loss in patients with or without preservation of LCA were not significantly heterogeneous (heterogeneity test: 一世 2 = 0 ％ ， P = 0。81 );when combined with WMD using the fixed effects model, the combined effect of WMD is 0.16 ( 95 ％ CI = − 6.27 ， 12.61 ， ž = 0。30 ，and P = 0。77 ），这是不显著不同。Based on the results of the analysis, it can be concluded that there is no significant difference in the WMD in the intraoperative blood loss between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the amount of blood loss. The funnel plot shows a symmetrical shape, indicating that there is no bias.

(a) Forest plot of intraoperative blood loss; (b) funnel plot of intraoperative blood loss.

 3。2。3。Number of Dissected Lymph Nodes

该meta-analysis results are shown in Figures 五(a)and 五(b)。患者具有或不具有LCA的保存清扫淋巴结的数目，结果为显著异质的（异质性检验： 一世 2 = 90 ％ ， P ≤ 0.00001 );当使用随机效应结合大规模杀伤性武器model, the combined effect of WMD is -1.07 ( 95 ％ CI = − 2。6五 ， 0。五1 ， ž = 1。33 ，and P = 0.18 ），这是不显著不同。根据分析结果，可以得出结论认为，在LCA保存完好的患者和LCA-无防腐剂者之间清扫淋巴结数目的大规模杀伤性武器无显著差异。因此，LCA是否腹腔镜直肠癌切除期间保持不影响清扫淋巴结的数目。漏斗图显示了一个对称的形状，这表明不存在偏差。

(a) Forest plot of number of dissected lymph nodes; (b) funnel plot of number of dissected lymph nodes.

 3。2.4。Anastomotic Leakage

该meta-analysis results are shown in Figures 6(a)and 6(b)。该results of anastomotic leakage in patients with or without preservation of the LCA were not significantly heterogeneous (heterogeneity test: 一世 2 = 0 ％ ， P = 0。五五 );当结合或使用固定效应模型，OR的组合效果是0.44（ 95 ％ CI = 0。30 ， 0。6五 ， ž = 4。09 ，and P < 0。0001 ），这是显著不同。根据分析结果，可以得出结论，在LCA保存完好的患者和LCA-无防腐剂的人之间的吻合口瘘的或显著差异。“钻石”代表共同影响降到无效线的左侧。与LCA保存的患者吻合口瘘比没有LCA保存的发病率较低。因此，LCA的保存可以减少吻合口漏的发生率。与此同时，漏斗图示出了对称的形状，这表明不存在偏差。

（一）吻合口瘘的森林图;（B）吻合口漏漏斗图。

 3.3。次要终点 3.3。1。Time for Intestinal Function Recovery

该meta-analysis results are shown in Figures 7(a)and 7(b)。的时间，从而在患者肠功能恢复与或不与LCA的保存结果并不显著异质的（异质性检验： 一世 2 = 0 ％ ， P = 0。五2 );when combined with WMD using the fixed effects model, the combined effect of WMD is -0.26 ( 95 ％ CI = − 0。41 ， − 0.11 ， ž = 3。3五 ，and P = 0。0008 ），这是显著不同。Based on the results of the analysis, it can be concluded that there is a significant difference in the WMD of time for intestinal function recovery between LCA-preserved patients and LCA-nonpreserved ones. The “diamond” representing the combined effect falls to the left of the ineffective line. The patients with preservation of the LCA had shorter time for intestinal function recovery than those without preservation of the LCA. Therefore, preservation of the LCA can help patients in terms of time for intestinal function recovery. At the same time, the funnel plot shows a symmetrical shape, indicating that there is no bias.

(a) Forest plot of time for intestinal function recovery; (b) funnel plot of time for intestinal function recovery.

 3.3。2。Postoperative Urinary and Sexual Dysfunction

该meta-analysis results are shown in Figures 8(a)and 图8（b）。尿和性功能障碍的患者具有或不具有LCA的保存结果并不显著异质的（异质性检验： 一世 2 = 0 ％ ， P = 0。61 );当结合或使用固定效应模型，OR的组合效果是0.26（ 95 ％ CI = 0.09 ， 0。78 ， ž = 2。41 ，and P = 0.02 ），这是显著不同。Based on the results of the analysis, it can be concluded that there is a significant difference in the OR of postoperative urinary and sexual dysfunction between LCA-preserved patients and LCA-nonpreserved ones. The “diamond” representing the combined effect falls to the left of the invalid line. The patients with preservation of the LCA had a lower incidence of postoperative urinary and sexual dysfunction than those without preservation of the LCA. Therefore, preservation of the LCA can reduce the potential of urinary and sexual dysfunction. At the same time, the funnel plot shows a symmetrical shape, indicating that there is no bias.

(a) Forest plot of postoperative urinary and sexual dysfunction; (b) funnel plot of postoperative urinary and sexual dysfunction.

 3.3。3。Postoperative Hospital Stay

该meta-analysis results are shown in Figures 图9（a）and 图9（b）。该results of postoperative hospital stay in patients with or without preservation of the LCA were significantly heterogeneous (heterogeneity test: 一世 2 = 88 ％ ， P = 0。004 );当使用随机效应结合大规模杀伤性武器model, the combined effect of WMD is -1.69 ( 95 ％ CI = − 6.21 ， 2。73 ， ž = 0。7五 ，and P = 0。4五 ），这是不显著不同。Based on the results of the analysis, it can be concluded that there is no significant difference in the WMD of postoperative hospital stay between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the postoperative hospital stay. The funnel plot shows a symmetrical shape, indicating that there is no bias.

(a) forest plot of postoperative hospital stay; (b) funnel plot of postoperative hospital stay.

 4。Discussion

该re has been a long debate about whether to preserve the left colonic artery in TME under laparoscopy. So far, there is no clear consensus. Anastomotic leakage is one of the most serious complications after rectal cancer surgery. Anastomotic blood supply and tension are two important factors affecting the incidence of anastomotic leakage. Theoretically, preservation of the LCA can improve the blood supply to the colon [ 14， 1五]; there are studies to detect the pressure of the marginal artery by using an instrument during surgery [ 16]。它的结论是，LCA的保护可以提高结肠的血液灌注。在此荟萃分析，全面的临床数据显示，LCA的保存可减少术后吻合口漏。有学者认为，肠系膜下动脉高位结扎术可能会增加盆腔自主神经损伤的几率，从而导致泌尿生殖功能障碍[ 17， 18]，但其他学者提出的间隙精确定位可以减少盆腔自主神经损伤的概率。还有就是动脉盆腔自主神经损伤及结扎水平之间没有显著的关系[ 19]。在本研究中，统计数据显示，患者与LCA的保存有尿和性功能障碍和更短的时间发生率较低，以比没有LCA的保存排气。然而，由于该研究的样本量只有319，但可以推断，维护LCA可以减少盆腔自主神经损伤的风险，同时进一步研究是十分必要证明的结论。

 五。Conclusions

从目前的研究证据表明，在腹腔镜下直肠癌切除术显示了LCA的保存工作减少吻合口瘘，术后排尿及性功能障碍，以及对肠功能恢复时间的发病率有显著影响，但减少的影响手术时间，术中出血量，清扫淋巴结数目，术后住院时间的量是不显著。因此，可以在临床实践中被推荐这种手术方法。然而，我们的结论仍然需要在未来的研究中更多的数据进行测试。

 Data Availability

该retrospective data used to support the findings of this study are included within the article.

 泄露

该manuscript is based on the thesis by the authors.

 Conflicts of Interest

作者宣称，他们没有利益冲突。

 致谢

该authors would like to thank Yujing Gong who is the original author of the Chinese version of this article which has not been published in other magazines now. This work was supported by the Hunan Province Natural Science Foundation (Project No.: 2018jj6125): new model of colorectal cancer screening and prevention based on medical association and multidisciplinary cooperation.

 Ferlay J. Soerjomataram 一世。 Dikshit R. Eser S. 马瑟斯 C。 雷贝洛 M. 帕金 D. M. Forman D. 嘶叫 F。 癌症的发病率和死亡率世界各地：来源，方法和主要模式在2012年GLOBOCAN 一世nternational Journal of Cancer 201五 136 五 E359 E386 10。1002/ijc.29210 2- s2.0-85017330857 2五220842 Siegel R. L. 磨坊主 K. D. Fedewa S. A. Ahnen D. J. Meester R. G. Barzi 一个。 Jemal 一个。 Colorectal cancer statistics, 2017 CA: a Cancer Journal for Clinicians 2017 67 3 177 193 10。3322/caac.21395 2- s2.0-85014032221 Miles W. E. A method of performing abdomino‐perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908) CA: a Cancer Journal for Clinicians 1971年 21 6 361 364 10。3322/canjclin.21.6.361 2 - s2.0 - 0015153724 五0018五3 Monson J. R. T. Weiser M. R. Buie W. D. Chang G. J. 拉弗蒂 J. F. Buie W. D. 拉弗蒂 J. 纪莲 J. Boushey R. Chang G. 法因戈尔德 D. Fleshner P。 Genua J. 哈蒙德 K. Harb W. Hendren S. Herzig的 D. 凯泽 一个。 Larson D. Lee S. McCormick J. Melton-Meaux G. Mills S. Monson J. Moore H. III 佩里 W. B. 攀 P。T. Rivadeneira D. Ross H. 斯蒂尔 S. Strong S. Ternent C。 Varma M. Weiser M. Wilkins K. Practice parameters for the management of rectal cancer (revised) 结肠直肠和疾病 2013 五6 五 五3五 五五0 10.1097 / DCR.0b013e31828cb66c 2-s2.0-84878282334 23575392 Tjandra J. J. 基尔肯尼 J. W. Buie W. D. Hyman N. Simmang C。 Anthony T. Orsay C。 Church J. Otchy D. Cohen J. 地点 R. Practice parameters for the management of rectal cancer (revised) 结肠直肠和疾病 200五 48 3 411 423 10.1007 / s10350-004-0937-9 2- s2.0-20044390067 1五87五292 Cirocchi R. Trastulli S. Farinella E. Desiderio的 J. Vettoretto N. Parisi 一个。 博塞利 C。 诺雅 G. High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed Surgical oncology 2012 21 3 e111 e123 10。1016/j.suronc.2012.04.004 2-s2.0-84864673093 22770982 Hinoi T. Okajima M. 下村 M. Egi H. Ohdan H. Konishi F。 Sugihara K. 渡边 M. Effect of left colonic artery preservation on anastomotic leakage in laparoscopic anterior resection for middle and low rectal cancer World Journal of Surgery 2013 37 12 2935 2943 10。1007/s00268-013-2194-3 2-s2.0-84890372561 24005279 臧 L. Ma J. žheng M. 在吻合口瘘及手术时间直肠癌根治术中的作用左 - 保留结肠动脉 中华未尝外科杂志 2016 19 4 386 387 27112468 You X。 Wang Y. Chen Z. Li W. 许 N. Liu G. žhao X。 Huang C。 Clinical study of preserving left colic artery during laparoscopic total mesorectal excision for the treatment of rectal cancer 中华未尝外科杂志 2017 20 10 1162 1167 29130232 朱 J. M. Han 一个。M. Guo Y.H. Application of left colonic artery preservation in laparoscopic rectal cancer resection Colorectal and Anal Surgery 2016 6 30 32 张 Z.X。 张 g·K。 Clinical significance of left colonic artery preservation in laparoscopic radical resection of rectal cancer 现代医学和健康 2017 22 97 99 Lv R. Huang S. 张 Z.C。 Yang W. J. Guo L. Wang Y. 在submesenteric动脉的腹腔镜低结扎迪克森观察 现代临床医学的 2014 40 1 17 19 驰 L. J. Lin D. J. žheng Y. 左半结肠动脉保存在直肠癌腹腔镜根治术的临床意义 中国现代医生 2017 五五 3五 4五 48 清家 K. Koda K. Saito N. Oda K. 小杉 C。 Shimizu K. Miyazaki M. 在对乙状结肠癌手术吻合口血流肠系膜下动脉根部分工的影响激光多普勒评估 一世nternational Journal of Colorectal Disease 2007 22 6 689 697 10。1007/s00384-006-0221-7 2- s2.0-34547112820 17082922 Komen N. Slieker J. De Kort P。 德威尔特 J. H. W. Van der Harst E. 克纳 P. P. Gosselink M. Tetteroo G. De Graaf E. Van Beek T. Den Toom R. 领带高与低领带直肠手术：吻合口灌注的比较 一世nternational Journal of Colorectal Disease 2011 26 8 107五 1078 10。1007/s00384-011-1188-6 2-s2.0-80051583190 21445553 Guo Y. Wang D. He L. 张 Y. žhao S. 张 L. Sun X。 Suo J. 边际动脉残端压在左结肠动脉保留直肠癌保肛手术的临床试验 ANZ中华外科杂志 2017 87 7-8 五76 五81 10.1111 / ans.13032 2-s2.0-84923600974 25708562 Höer J. Roegels 一个。 Prescher 一个。 Klosterhalfen B. 吨 C。 Schumpelick V. Schonung autonomer Nerven在德Rectumchirurgie Ergebnisse德Präparation的Leichen UND fixiertenBeckenpräparaten 明镜Chirurg;（杂志）毛皮全部Gebiete德operativen Medizen 2000 71 10 1222 1229 10。1007/s001040051206 梁 J. T. Huang K.-C. Lai 火盛 Lee P.-H. Sun C。-T. Oncologic results of laparoscopic D3 lymphadenectomy for male sigmoid and upper rectal cancer with clinically positive lymph nodes 外科肿瘤学年报 2007 14 7 1980年 1990年 10.1245 / s10434-007-9368-X 2-s2.0-34250833306 Kim N. K. Aahn T. W. 公园 J. K. Lee K. Y. Lee W. H. 孙某 S. K. Min J. S. Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer 结肠直肠和疾病 2002 4五 9 1178 118五 10.1007 / s10350-004-6388-5 2- s2.0-0036734181