食管残胃间空肠间置术在近端胃癌根治术中的临床应用

Clinical application of modified double tracks anastomosis in proximal gastrectomy

目的 探讨根治性近侧胃大部切除后理想的消化道重建方法，减少反流性食管炎等并发症的发生。方法2004年1月至2006年7月，对71例胃底贲门癌患者行根治性近侧胃大部切除、食管残胃间空肠间置术（在行常规根治性近侧胃大部切除术的基础上，分别行食管空肠端侧吻合、残胃空肠侧侧吻合以及空肠空肠侧侧吻合）。随访9～39个月，根据胃食管反流症状评分标准、胃排空试验（上消化道钡餐造影、ECT）以及食管下段pH电脑测定等方法评价患者食管反流情况。结果重建过程中3个吻合口均应用吻合器，能明显加快手术进程，一般都在3．5h左右（其中消化道重建约为1h），术后平均9d康复出院，均未发生吻合口瘘、狭窄梗阻等并发症。随访除6例出现轻度反流症状外，其余患者均无明显返酸、烧心、胸骨后疼痛等反流性食管炎的表现。胃排空试验（上消化道钡餐造影、ECT）均未见钡剂或食物反流入食管显示，食管下段pH值为（6．9±0．1）。患者多数能维持或超过术前体质量，生活质量尚满意。结论食管残胃间空肠间置术对预防根治性近侧胃大部切除术后反流性食管炎的发生效果显著，较好地解决了食管反流、胃容量缩小、生理途径改变等问题，提高了生活质量。是近端胃癌根治术后理想的消化道重建术式。

Objective To explore the ideal method of digestive tract reconstruction after proximal gastrectomy that decreases the incidence of reflux esophagitis. Methods The modified double tracks anastomosis was used in 71 patients who had undergone proximal gastrectomy for carcinoma of gastric cardia between January 2004 to July 2006. All cases were followed up for 9 to 39 months. The incidence of reflux esophagitis was evaluated by grading standard for reflux esophagitis, gastric emptying test, and 24-hour pH monitoring at inferior segment of esophagus. Results Application of Staplers can speed up operation process obviously. All patients were discharged with average postoperative hospital stay of 9 days. There were no complications such as fistula, stenosis and obstruction around stoma. In follow-up visit, only 6 cases showed slight symptom of contraflow and no patients showed severe symptom of reflux esophagitis such as sour regurgitation, heartburn and retrosternal pain. Contraflow was not seen in gastric emptying test. The value of 24-hour pH monitoring at inferior segment of esophagus was （ 6.9 ± 0. 1 ）. The life quality of all patients was satisfactory. Conclusion The modified double tracks anastomosis is an ideal procedure in digestive tract reconstruction to prevent the incidence of reflux esophagitis after proximal gastrectomy.