改良完全腹腔镜胃腔内手术治疗贲门或幽门周围黏膜下肿瘤的临床疗效

Clinical efficacy of modified totally laparoscopic intra-gastric surgery for submucosal tumors adjacent to the gastric cardia or pylorus

目的探讨改良完全腹腔镜胃腔内手术治疗贲门或幽门周围黏膜下肿瘤的临床疗效。方法采用回顾性横断面研究。收集2014年9月至2018年3月吉林大学第二医院收治的48例贲门或幽门周围胃黏膜下肿瘤患者的临床病理资料;男22例,女26例;平均年龄为58岁,年龄范围为38~78岁。根据患者情况选择多孔或单孔改良完全腹腔镜胃腔内手术。观察指标:(1)手术情况。(2)术后恢复情况。(3)术后病理学检查情况。(4)随访情况。采用门诊和电话方式进行随访。了解患者术后并发症及肿瘤转移、复发情况。随访时间截至2018年6月。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示;计数资料以绝对数或百分比表示。结果(1)手术情况:48例患者均顺利完成改良完全腹腔镜胃腔内手术,其中1例联合行近端胃切除术,无中转开放手术患者;其中多孔改良腹腔镜胃腔内手术43例,单孔改良腹腔镜胃腔内手术5例。48例患者手术时间为68 min(45~110 min),术中出血量为20 mL(5~100 mL)。48例患者术中肿瘤学评估:完整切除48例,无肿瘤破裂,肿瘤直径为32 mm(20~40 mm),切缘距肿瘤距离为6mm(5~10mm)。(2)术后恢复情况:48例患者术后首次经口进食时间为2.8d(1.0~5.0 d)。48例患者中手术部位感染4例、胃排空障碍3例、膈下积液1例、消化道漏1例;术后住院时间为5.3d(3.0~11.0d)。(3)术后病理学检查情况:48例患者肿瘤边缘距离贲门或幽门距离为15 mm(0~30 mm),肿瘤直径为24 mm(10~65mm),环周切缘为6 mm(5~10mm)。48例患者肿瘤生长方式:腔内型27例、壁间型12例、混杂型9例。48例患者肿瘤病理学类型:平滑肌瘤26例、胃肠道间质瘤9例、其他少见肿瘤4例、类癌2例、黏膜相关组织淋巴瘤2例、炎性纤维性息肉2例、深在性囊性胃炎2例、异位胰腺1例。(4)随访情况:48例患者中,41例获得术后随访,随访时间为3~48个月,中位随访时间为22个月。41例患者中,37例经术后3次胃镜检查未见肿瘤复发,39例经术后2次上消化道造影检查提示无贲门或幽门狭窄及机能障碍(1例患者可行两种检测);随访期间无手术相关远期并发症发生,无肿瘤特异性死亡。结论改良完全腹腔镜胃腔内手术治疗胃贲门或幽门周围黏膜下肿瘤安全可行。

Objective To explore the clinical efficacy of modified totally laparoscopic intra-gastric surgery for the treatment of submucosal tumors adjacent to the cardia or pylorus. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 48 patients with gastric submucosal tumors adjacent to the cardia or pylorus between September 2014 and March 2018 were collected. There were 22 males and 26 females, aged from 38 to 78 years, with an average age of 58 years. Patients were performed multi-port or single-port modified laparoscopic intra-gastric surgery. Observation indicators:(1) surgical treatments;(2) postoperative recovery;(3) results of postoperative pathological examination;(4) follow-up. Patients were followed up by outpatient examination and telephone interview to detect the postoperative complications and tumor metastasis and recurrence up to June 2018. Measurement data with normal distribution were expressed as Mean±SD and measurement data with skewed distribution were described as M (range). Count data were represented as absolute number or percentage. Results (1) Surgical treatments: 48 patients underwent modified totally laparoscopic intra-gastric surgery successfully, including one patient combined with proximal gastrectomy, without conversion to open surgery. Of the 48 patients, 43 underwent multi-port modified laparoscopic intra-gastric surgery and 5 underwent single-port modified laparoscopic intra-gastric surgery. The operation time and volume of intraoperative blood loss were 68 minutes (range, 45-110 minutes) and 20 mL (range, 5-100 mL). The oncologic evaluation of 48 patients: 48 patients had complete resection of tumors, without tumor rupture. The tumor diameter and distance from margin to tumor were 32 mm (range, 20-40 mm) and 6 mm (range, 5-10 mm).(2) Postoperative recovery: the time for initial oral intake and duration of postoperative stay were 2.8 days (rang, 1.0-5.0 days) and 5.3 days(range, 3.0-11.0 days). There were 4, 3, 1 and 1 patients complicated with surgical infection, delayed gastric emptying, sub-phrenic hydrops and digestive leakage respectively in the 48 patients.(3) Results of postoperative pathological examination: the distance from tumor margin to gastric cardia or pylorus, tumor diameter, circumferential resection margin were 15 mm (range, 0-30 mm), 24 mm (range, 10-65 mm), 6 mm (range, 5-10 mm), respectively. Growth patterns of cancer in the 48 patents included 27 of intraluminal type, 12 of intermural type, 9 of mixed type. Pathological types of 48 patients: there were 26 patients with leiomyoma, 9 with gastrointestinal stromal tumor, 4 with other rare tumors, 2 with carcinoid, 2 with mucosa-associated lymphoma, 2 with inflammatory fibrous polyps, 2 with gastritis cystica profunda, 1 with ectopic pancreas.(4) Follow-up: 41 of the 48 patients were followed up for 3-48 months, with a median follow-up time of 22 months. No tumor recurrence was detected in 37 of 41 patients by 3 times of gastroscopy and no stenosis or dysfunction of cardia or pylorus was detected in 39 patients by 2 times of upper gastrointestinal imaging (one patient undergoing two examinations). During the follow-up, there was no surgery-related complication or tumor-specific death. Conclusion Modified totally laparoscopic intra-gastric surgery is safe and feasible for the treatment of gastric submucosal tumors adjacent to the cardia or pylorus.