腹腔镜根治性全胃或近端胃切除后食管抵钉座置入新技术

Insertion of anvil into esophagus for anastomosis during laparoscopic radical proximal gastrectomy or radical total gastrectomy for gastric cancer

目的 探讨腹腔镜根治性全胃切除或根治性近端胃大部切除后,牵引法放置食管抵钉座行食管残胃或食管空肠吻合新技术的临床价值.方法 回顾性分析2010年3月至2011年2月我中心应用牵引法将吻合器抵钉座置入食管完成腹腔镜根治性全胃切除食管空肠吻合或根治性近端胃大部食管残胃吻合的21例胃癌患者的临床资料.手术采用五孔法,在完成胃周淋巴结清扫和食管游离后,先在超过肿瘤上方3 cm处切开食管,将带牵引线抵钉座完全置入食管近端,保留牵引线在食管切口外,然后切割缝合器横断食管,借助牵引线将抵钉座定位杆拉出,最后在腹腔镜下完成吻合.结果 21例患者均在腹腔镜下顺利完成手术,无中转开腹.15例行腹腔镜根治性全胃切除,6例行根治性近端胃大部切除.平均手术时间为（257±38） min,术中平均出血量为（119±32） ml,术后平均下床活动时间为92.5±0.5）d,术后肛门平均排气时间为（3.7±0.8）d,术后平均住院时间为（7.5±2.6）d.本组患者术后无围手术期死亡,无吻合口出血、吻合口瘘等；但3例患者术后出现并发症,其中1例为肺部感染合并胸腔积液,经积极保守治疗后痊愈；1例为吻合口狭窄,经胃镜气囊扩张治疗后症状缓解；另有1例为切口感染,经积极切开引流换药后痊愈.术后病理检查：所有患者吻合圈和标本切缘未见癌细胞.组织学类型：高分化腺癌4例,中分化腺癌8例,低分化或黏液腺癌9例.UICC分期：Ⅰ期5例,Ⅱ期10例,Ⅲ期6例.21例患者平均随访时间为（11±4）个月96～17个月）,无肿瘤复发、转移.结论 牵引法放置食管抵钉座行食管残胃或食管空肠吻合安全可靠,操作简单容易掌握,为腹腔镜下消化道重建提供了一种新的技术选择.

Objective To investigate the clinical value of a new anvil inserting method for esophagogastrostomy or esophagojejunostomy during laparoscopic radical proximal gastrectomy or radical total gastrectomy for gastric cancer.Methods The clinical data of 21 patients with gastric cancer who received laparoscopic radical proximal gastrectomy or radical total gastrectomy at the Southwest Hospital from March 2010 to February 2011 were retrospectively analyzed.Five trocars were inserted through the abdominal wall of the patients.After perigastric lymphadenectomy and mobilization of esophagus,an incision was made on the esophagus above the tumor,and then the anvil with drawn wire attached was inserted into the esophagus.An endo-cutter was applied to cut the esophagus adjacent to the incision left the drawn wire untouched,and then the stem of the anvil was pulled out by the drawn wire for laparoscopic anastomosis. Results The operations were successfully accomplished under the laparoscope with no conversion to open surgery.Fifteen patients received laparoscopic radical total gastrectomy and 6 received laparoscopic radical proximal gastrectomy. The mean operation time,volume of blood loss,time to off-bed activity,passage of flatus and postoperative duration of hospital stay were （257 ± 38） minutes,（ 119 ± 32） ml,（2.5 ± 0.5 ） days,（ 3.7 ± 0.8 ） days and （7.5 ± 2.6） days,respectively.No perioperative mortality,anastomotic bleeding or anastomotic fistula was detected.One patient was complicated with pulmonary infection ＋ pleural effusion and was cured by conservative treatment; 1 was complicated with anastomotic stenosis which was alleviated by gastroscopic balloon dilation; 1 was complicated by incisional infection and was cured by medical treatment after drainage.No cancer cells were detected at the anastomotic ring or resection margin of the specimen.There were 4 patients with well-differentiated adenoma,8 with moderate-differentiated adenoma and 9 with poor-differentiated mucinous adenoma.There were 5 patients in stage Ⅰ,10 in stage Ⅱ and 6 in stage Ⅲ （UICC staging）.Twenty-one patients were followed up for a mean period of （11 ±4） months （range,6-17 months ）,no tumor recurrence or metastasis was detected. Conclusions The new technique for anvil insertion is safe,effective and easy for manipulation and learn.It offers a new approach for laparoscopic digestive tract reconstruction.