腹腔镜胃中上部癌切除术后胃肠道重建方式的选择

Reconstruction of gastrointestinal tract after laparoscopic gastrectomy for upper and middle gastric cancer-preliminary experience from a single institute

目的:总结腹腔镜胃中上部癌切除术后食管与胃或空肠吻合的各种方式,探讨其优缺点及适用范围。方法:2004年5月～2006年11月共行腹腔镜下根治性胃中、上部癌手术95例,4例中转开腹,6例行远端胃大部切除。其余病人中有49例行小切口辅助的食管胃或食管空肠吻合,12例行腹腔镜食管空肠侧侧吻合,25例行腹腔镜食管胃/空肠端侧吻合(含1例因残端癌阳性而中转开腹者)。结果:3组中除腹腔镜食管胃或食管空肠端侧吻合组中有1例因抵钉座放置后残端癌残留而中转开腹外,其余均顺利完成吻合。小切口吻合组术后发生吻合口漏、吻合口出血各1例,均经内科保守治疗痊愈;发生吻合口狭窄1例,经胃镜下扩张后治愈。两个腹腔镜吻合组均无吻合相关并发症。3组吻合平均耗时分别为(50.2±13.6)min、(43.5±10.4)min、(55.4±14.5)min。结论:尽管对于多数病人,在小切口辅助下能安全地完成食管胃/空肠吻合,但对于肥胖、左肝肥大等特殊体型病人,或因进展期贲门癌要求食管切断平面较高者,以采用腹腔镜下吻合为宜。合理地选择吻合方式,是安全、省时及切除充分的手术保证。

Objective To explore the merits and disadvantages of 3 different reconstruction methods after laparoscopic total or proximal gastrectomy for patients with upper or middle gastric cancer. Methods A total of 95 laparoscopic gastrectomy for upper or middle gastric cancers were performed from May 2004 to Nov 2006. Four cases were converted to open surgery. Except for 6 patients with middle gastric cancer undergoing laparoscopic distal gastrectomy, the other 86 patients underwent laparoscopic total or proximal gastrectomy （including one patient who had a conversion to open surgery performing the reanastomosis due to a positive resective margin after laparoscopic end-to-side esophagojejunostomy. Esophagogastrostomy or esophagojejunostomy was performed through a small incision in 49 cases. Laparoscopic side-to-side esophagojejunostomy was performed with endo-linear cutter in 12 cases. Laparoscopic end-to-side esophagogastrostomy or esophagojejunostomy was performed with circular stapler in 25 cases. Results Only one patient was converted to open surgery in the laparoscopic end-to-side group, due to the positive esophageal resective margin. There were one case of fistula, one case of anastomotic bleeding and one case of anastomotic stenosis, they were all managed successfully with medical means. No anastomosis-related complication was observed in the laparoscopic groups. Conclusions Although laparoscopy-assisted anastomosis through a small incision is preferable and safe for most patients, it is still advisable that total laproscopic esophagogastrostomy or esophagojejunostomy is to be considered in the following situation： obesity, enlargement of left lobe of liver, advanced cardia cancer with lower esophagus invasion.