近端胃癌根治术后三种消化道重建方式近期及远期疗效的比较

Comparison of short- and long-term efficacy of three procedures in postoperative digestive tract ;reconstruction for upper gastric cancer

目的：比较近端胃癌根治性切除术后3种不同切除及重建术式的近期及远期疗效。方法回顾性分析2000年1月至2012年12月间在福建省立医院行根治性手术的191例近端胃癌患者的临床资料，根据不同的切除及重建方式分为TG-RY组（123例，行全胃切除术加Roux-en-Y食管空肠吻合）、PG-EG组（40例，行近端胃切除术加食管残胃吻合）和PG-JI组（28例，行近端胃切除术加功能性空肠间置），比较3组患者临床病理特征、围手术期情况、术后远期胃肠道不适、术后1年营养状况及生存情况。结果 PG-EG组患者平均手术时间为178 min，明显短于TG-RY组的248 min 和PG-JI 组的224 min （P＜0．05）；平均术中出血194 ml，明显少于TG-RY组的323 ml和PG-JI组的265 ml（P＜0．05）。3组患者围手术期并发症和术后住院时间的差异均无统计学意义（均P＞0．05）。术后1年，PG-EG组患者反流发生率为17．5％（7／40），明显高于TG-RY组和PG-JI组[1．6％（2／123）和7．1％（2／28），P＜0．05]；烧心发生率为17．5％（7／40），亦明显高于另外两组[4．9％（6／123）和10．7（3／28），P＜0．05]；TG-RY组患者倾倒综合征生生率为7．3％（9／123），另外两组均无一例倾倒综合征发生（P＜0．05）。术后1年体质量下降率3组间差异无统计学意义（P＞0．05），但TG-RY组血红蛋白和血清蛋白下降率明显高于另外两组（均P＜0．05）。3组患者术后5年生存率的差异无统计学意义（P＞0．05）。结论3种近端胃癌手术方式各有优劣，应根据具体情况合理选择：考虑术后生活质量，PG-JI可作为近端胃切除术后的首选重建方式；但对于肿瘤较大、病期较晚者，TG-RY更加安全；对于年老体弱、对手术耐受力低者，可考虑行PG-EG。

Objective To compare the short-and long-term efficacy of three different procedures used for digestive tract reconstruction after radical gastrectomy for upper gastric cancer. Methods Clinical data of 191 patients with upper gastric cancer undergoing radical gastrectomy in the Fujian Provincial Hospital between January 2000 and December 2012 were analyzed retrospectively. Surgical procedures were classified as total gastrectomy followed by Roux-en-Y esophagojejunostomy （TG-RY, n=123）, proximal gastrectomy followed by esophagogastrostomy （PG-EG, n=40）, and proximal gastrectomy followed by jejunal interposition （PG-JI, n=28）. Clinicopathological characteristics, perioperative and long-term outcomes were compared among the three groups. Results The operative time was shorter （178 vs. 248 and 224 min, P〈0.05）, and the intraoperative blood loss was less（194 vs. 323 and 265 ml, P〈0.05） in PG-EG group than those in TG-RY and PG-JI groups. Early postoperative complications and hospital stay were comparable（both P〉0.05）. With respect to gastrectomy-associated symptoms, reflux and heartburn were more frequent in PG-EG patients, while dumpling syndrome was more frequent after TG-RY. Postoperative weight loss was not significantly different among three procedures （P〉0.05）, however, hemoglobin and serum albumin levels were lower in TG-RY patients （both P〈0.05）. The 5-year survival rate was similar（P〉0.05）. Conclusions Surgeons need to choose the proper procedure according to tumor features and patient condition. PG-JI should be the first choice in terms of fewer complaints and better nutrition. TG-RY tends to be used for larger and more advanced tumors. PG-EG is the most minimally invasive procedure and thus may be suitable for older and high-risk patients.