胃癌手术消化道重建方式的选择及评价

Selection and assessment of digestive tract reconstruction patterns for gastric cancer

随着现代外科治疗效果的提高，患者术后生命质量越来越受到重视。其中消化道重建方式是患者术后生命质量最相关的因素。目前的证据表明：食管空肠储袋Roux-en-Y吻合在全胃切除术中应用较合适；Roux-en-Y吻合在远端胃大部切除术的消化道重建中可能具有一定优势；保留幽门的胃大部切除术和近端胃大部切除术只考虑在早期胃癌（cT1cN0）中采用，保留幽门的胃大部切除术并不完全优于远端胃大部切除术；对于预期寿命相对较短、全身状况差、高龄、不可切除肿瘤、伴幽门梗阻的患者考虑内镜下支架置入；而预期寿命可相对延长的患者仍推荐Devine胃癌旷置＋胃空肠短路术。然而，由于目前获得的证据级别还不高，对于现有各种胃癌消化道重建方式尚不能得出明确的评价，还需要高质量的研究结果来进一步论证。

With the improvement of survival outcome by modern surgical treatment, more and more attention has been paid to the postoperative quality of life. As known, the most related factor of postoperative quality of life is the pattern of digestive tract reconstruction. Current evidences indicate that Roux-en-Y esophagojejunostomy＋jejunal pouch has some advantages in total gastrectomy and Roux-en-Y gastrojejunostomy might be most suitable reconstruction in distal gastrectomy. Pylorus-preserving gastrectomy and proximal gastrectomy are only considered in early gastric cancer, i.e. predictive cT1cN0. Pylorus-preserving gastrectomy does not exactly superior to distal gastrectomy. Total gastrectomy with RouxenY esophagojejunostomy is superior to proximal gastrectomy with esophagogastrostomy. For unresectable lower tumor with gastric outlet obstruction, gastric cancer Devine exclusion＋gastrojejunostomy might be better than simple gastrojejunostomy, while stent placement is safer and suitable for predictively short-term survival, poor performance status or senility patients. However, the current available evidences of reconstruction in gastric cancer surgery is still poor in quality and more high-quality large-scale multi-center randomized controlled trials are required to resolve the controversies.