ISSN 1009-3079 CN 14-1260/R World Journal of Chinese Gastroenterology 2003 Jan 15 Vol. 11 No. 1
World Journal of Chinese Gastroenterology 2003;1(11 ):117-119
http://www.wjgnet.com/1009-3079/11/117.htm
Chen Yuanguang, Chen Daojin, Jin Qinwen, Wu Junhui, Qian Liyuan, Department of General Surgery, Xiangya Third Hospital, Central South University, Guangzhou, China Chen Yuanguang, Department of General Surgery, The First Hospital of Guangzhou Medical University
Changsha City, Hunan Province 410013, China
Project leader:Yuanguang Chen, Tongzipo Road, Yuelu District, Changsha City, Hunan Province, 410013, China
Department of General Surgery, Third Hospital, Changsha, Hunan Province, China. [email protected]
Received:2002-08-24 Accepted:2002-10-03
Abstract
Objective:To investigate the guiding significance of transrectal superior rectal artery infusion of melanoma on total rectal mesenteric resection.
Methods:Twenty-five cases of rectal cancer were resected by total rectal mesenteric resection after transrectal superior rectal artery infusion of melanoma, and intraoperative and postoperative anatomic pathology, bleeding, operation time and lymph node examination were observed.
Results:After instillation of Meridian blue through the superior rectal artery, the rectum and its mesentery wrapped in the pelvic fascial visceral layer stained significantly, which was easily distinguished from the non-stained tissue outside the pelvic fascial visceral layer, and the rectal fascial capsule could be maintained intact. were 250.24 ± 80.64 mL, 5.07 ± 1.25 h, and 12.75 ± 5.93, respectively, with significant differences between the two groups (P < 0 . 0 1 ).
Conclusion:The infusion of melphalan into the superior rectal artery reduces the surgical difficulty of total rectal mesenteric resection and has guiding significance.
0 Introduction
Surgical resection is the most definite method with therapeutic effect on rectal cancer, and the treatment of rectal cancer is a comprehensive treatment mainly based on surgery [1, 2], but traditional radical surgery has a high local recurrence rate, and total mesorectal excision (TME) was proposed by Heald et al in 1982, and a large number of studies have proved that this procedure can In 1982, Heald et al proposed total mesorectal excision (TME), which has become the gold standard for radical rectal cancer surgery because it has been shown in numerous studies to significantly reduce the recurrence rate, but it has problems such as difficult anatomy, bleeding and time consuming [1, 3-11]. We recently adopted intraoperative transrectal superior rectal artery perfusion with US blue staining followed by TME to solve the above problems, and the results are reported as follows.
1 Materials and methods
1.1 Materials There were 45 rectal cancer patients in both groups, 25 cases in the perfusion merocyanine group and 20 cases in the control group, all of whom had no distant metastasis, and the general information of both groups is shown in Table 1.
1.2 Methods
1.2.1 Method of melanoma infusion Before performing TME in the melanoma infusion group, melanoma was infused transarterially according to the method we reported [12, 13], firstly, the superior rectal artery was isolated, and 8 ml of melanoma was injected slowly after successful scalp needle puncture, and then the superior rectal artery and vein were ligated.
The supra-rectal artery and vein were then ligated. In the control group, no transrectal artery puncture and infusion of melanoma was performed before the TME.
1.2.1 TME operation Both groups were performed according to the method described by Heald et al [3, 4], with sharp separation between the anterior sacral space, pelvic fascial layer and wall layer under direct vision, keeping the pelvic fascial layer wrapped with posterior rectal fat and lymphatic vessels intact.
The distal rectal mesentery of the tumor should be resected at least 5 cm, and the intestinal segment should be resected more than 2 cm.
1.2.3 Lymph node detection of postoperative specimens The specimens were laid flat, and the mesentery was cut along the vessels in the order of inferior mesenteric artery→superior rectal artery→superior rectal artery branches, and the lymph nodes distributed next to the vessels were picked out one by one and sent for routine histological examination [13, 14].
Statistical treatment The data were processed using SPSS10.0 software. The mean±standard deviation ( ) was used for measurement data, and the t-test was used for comparison of differences. The χ2 test was used for the comparison of logarithmic data.
2 Results
2.1 Intraoperative findings After perfusion of Meridian blue through the superior rectal artery, the rectum and its mesentery stained blue, but the surrounding tissues did not stain, and the demarcation between them was obvious. When separating the anterior sacral space, the anterior sacral fascia was seen to be unstained (Figure 2), and the white nerve plexus was seen in the lower fashion on both sides of the rectum after careful separation. When separating the lateral ligaments, it is also visible that the rectal fascia capsule is stained blue, which is clearly distinguishable from the non-stained tissue outside the fascia capsule, and when the lateral ligaments are cut at the root, it is only necessary to compress or ligate the inferior rectal artery once to stop bleeding. Examining the resected specimen, it was seen that the rectal fascial sac was intact, and the lymph nodes within the tethered membrane were stained blue with merocyanine, which were clearly distinguished from the surrounding fatty tissues, facilitating the examination ( Figure 3 ).
2.2 The operative time and blood loss were significantly reduced in the perfusion group compared with the non-perfusion group, and the number of lymph nodes detected in the postoperative specimens increased (Table 2).
2.3 The distal cut ends and tethered margins of the specimens in both groups were free of cancer, and there was no anastomotic fistula in either group.
3 Discussion
Studies have confirmed that TME can reduce the recurrence rate of rectal cancer and improve the survival rate, and it has become the gold standard for radical rectal cancer surgery. However, TME still has disadvantages such as difficult anatomy, bleeding, time consuming, and prone to anastomotic fistula [1,3-11], so TME is not widely used in clinical practice, especially in primary hospitals. We believe that the root cause is the lack of a clear intraoperative landmark to distinguish between the rectal mesentery wrapped in the pelvic fascia visceral layer and the surrounding tissues wrapped outside the pelvic fascia visceral layer. Anatomically, there is a posterior gap between the perirectal fat and the pelvic wall, which is covered by the pelvic fascial visceral layer and the wall layer, respectively, and the perirectal fat, blood vessels, and lymphatic vessels wrapped in the pelvic fascial visceral layer constitute the rectal mesentery [15,16]. The main trunk of the superior rectal artery enters the pelvic cavity through the two layers of the sigmoid mesentery, reaches the middle of the posterior rectal wall and divides into the left and right branches, and then divides into branches that penetrate the rectal wall to reach the submucosa, and its terminal branches anastomose with each other and with the branches of the inferior rectal artery and the anal artery above and below the dentate line. The superior rectal artery and its branches are the main supply vessels to the rectal mesentery [16].
Therefore, the rectal mesentery within the pelvic fascial visceral layer is stained blue by instillation of US blue from the superior rectal artery, while the surrounding tissues outside the pelvic fascial visceral layer, such as the pelvic fascial wall layer and the autonomic nerves under it, cannot be stained due to the separation of the pelvic fascia. In the TME procedure, instillation of US blue via the superior rectal artery can provide a clear marker to distinguish the extent of the procedure and reduce the difficulty of the procedure. This was confirmed in the present study, where both operative time and blood loss were significantly reduced in the perfused group compared with the non-perfused group (P<0.
0 1 , Table 2 ).
The number of lymph nodes detected in postoperative specimens meanwhile increased after transrectal superior rectal artery infusion of melanoma (P < 0.01), and the number of positive lymph nodes and metastasis rate in metastatic cases also increased (see Table 2), which is consistent with our previous studies [13,14,17]. This result also suggests that intraoperative lymphatic clearance may be more beneficial to improve the radicality of the procedure by instilling melanoma through the superior rectal artery.
The TME technique was introduced in China since the early 1990s, but nowadays TME has not been widely used in clinical practice, especially in primary hospitals. This is related to the failure to standardize the TME procedure in general. Recently, Bernard Nordlinger, chairman of the European Organization for Research and Treatment of Cancer Digestive Group, pointed out that TME is difficult and standardized surgery is necessary to improve the efficacy [18]. In this study, it was suggested that the infusion of melanoma blue from the superior rectal artery to guide the TME procedure, because there is always a clear color marker to distinguish the rectal mesentery wrapped in the pelvic fascial viscera from the surrounding tissues wrapped outside the pelvic fascial viscera, makes TME simpler and easier to standardize without compromising the radicality, which makes it easy to be widely used in clinical practice, especially in primary hospitals. In conclusion, transrectal superior rectal artery instillation of US blue guides TME, because there is a clear color mark, the operation is more
In conclusion, transrectal superior rectal artery instillation of TME, due to the obvious color markings, is simpler and easier to standardize, and is worth further study.
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