腔内非离断式Roux-en-Y吻合术在腹腔镜全胃切除术消化道重建中的应用

Application of intracorporeal uncut Roux-en-Y anastomosis in digestive tract reconstruction after laparoscopic total gastrectomy

目的探讨腔内非离断式(Uncut)Roux-en-Y(URY)吻合术应用于腹腔镜全胃切除术消化道重建的安全性、可行性及近期疗效。方法2015年11月至2018年1月间,福建省立医院肿瘤外科对67例胃癌患者行腹腔镜全胃切除术腔内URY吻合术重建消化道,男性41例,女性26例;年龄50~81(61.9±7.4)岁,体质指数(23.4±3.2)kg/m^2;其中胃贲门部癌19例,胃体癌33例,胃底癌15例;肿瘤大小(3.4±2.3)cm;BorrmannⅠ型22例,Ⅱ型15例,Ⅲ型21例,Ⅳ型9例;高、中分化腺癌29例,低分化腺癌23例,印戒细胞癌15例。行常规腹腔镜下胃癌D2根治术后,采用Echelon-flex腔镜关节头直线型切割闭合器在幽门环下方2cm闭合离断十二指肠,在食管胃结合部上方离断食管;腹腔镜直视下完成URY吻合消化道重建:(1)食管空肠侧侧吻合:食管闭合端左下缘开窗0.5cm,距离Treitz韧带约25cm处空肠上提至食管下端,在对系膜缘侧开窗0.5cm,直线切割闭合器两臂分别经食管、空肠开窗处置入,切割闭合完成侧侧吻合;关闭食管空肠共同开口,完成食管空肠吻合,形成食糜流出道。(2)空肠侧侧Braun吻合:分别距食管空肠吻合口约10cm处输入袢近端空肠和35~40cm输出袢远端空肠对系膜缘分别开窗0.5cm,行近远端空肠侧侧吻合;关闭共同开口形成胆胰十二指肠液流出道。(3)闭合食管空肠吻合口输入袢空肠:距食管空肠吻合口2~3cm输入袢空肠无刀片直线闭合器(ATS45NK)闭合,阻断胆胰十二指肠液反流。收集这组病例临床资料进行回顾性系列研究,观察手术及消化道功能恢复情况、围手术期并发症,术后营养状态;通过术后随访时的内镜及影像学检查,评估吻合口功能及肿瘤复发等相关指标。结果67例患者均成功完成手术。手术时间(259.4±38.5)min,消化道重建时间(38.2±13.2)min,术中出血量(73.4±38.4)ml;淋巴结清扫数(36.2±14.2)枚,上切缘距肿瘤上缘(3.3±1.2)cm,上切缘距齿状线(1.2±0.7)cm,上切缘阳性1例(1.5%),经再次切除为阴性。辅助切口平均长度(3.2±0.4)cm。术后肠道排气时间(52.8±26.4)h,进食流质时间(64.8±28.8)h,术后住院时间(8.4±2.5)d。术后并发症发生率10.4%(7/67),其中Clavien-Dindo分级Ⅲa级4例,分别为食管空肠吻合口漏2例、十二指肠残端漏1例和腹腔感染1例,均予保守治疗痊愈。67例均完成随访,术后12个月营养指数为53.4±4.2,食管空肠吻合口直径(3.9±0.6)cm,Roux-en-Y滞留综合征发生率3.0%(2/67),反流性食管炎发生率4.5%(3/67),无食管空肠吻合口输入袢闭合再通,无吻合口狭窄、梗阻、无吻合口肿瘤复发。结论腹腔镜全胃切除术腔内URY吻合术重建消化道安全可行,术后消化道功能恢复快,近期疗效好。

Objective To explore the safety,feasibility and short-term efficacy of intracavitary uncut Roux-en-Y(URY)anastomosis in digestive tract reconstruction following laparoscopic total gastrectomy(LTG).Methods From November 2015 to January 2018,67 gastric cancer patients underwent intracavitary URY following LTG to reconstruct the digestive tract at Oncological Surgery Department of Fujian Provincial Hospital.There were 41 males and 26 females with age of 50 to 81(61.9±7.4)years and body mass index(BMI)of(23.4±3.2)kg/m^2.Among 67 patients,19 were gastric cardia carcinomas,33 were gastric body carcinomas,and 15 were gastric fundus carcinomas;tumor size was(3.4±2.3)cm;22 were Borrmann type Ⅰ,15 were type Ⅱ,21 were type Ⅲ,and 19 were type Ⅳ;29 were highly or moderately differentiated adenocarcinoma,23 were lowly differentiated adenocarcinoma,and 15 were signet-ring cell carcinoma.After conventional laparoscopic D2 radical gastrectomy,the duodenum was closed and dissociated at 2 cm below the pyloric ring using the Echelon-flex endoscopic articulated linear Endo-GIA stapler,and the esophagus was dissociated above the esophagogastric junction(EGJ).URY and digestive tract reconstruction were performed under the direct vision of laparoscope:(1)Side-to-side esophagojejunostomy: An incision of 0.5 cm was made in the left lower edge of the esophageal closed end;jejunum about 25 cm distal away from the Treitz ligament was elevated to the lower end of esophagus;another incision of 0.5 cm was made in the contralateral of mesenteric side;both arms of the linear Endo-GIA stapler were inserted into the windows opened through esophagus and jejunum respectively to complete side-to-side anastomosis.The common opening of esophagus and jejunum was closed to complete esophagojejunostomy,forming the chyme outflow tract.(2)Side-to-side Braun jejunojejunostomy: Incisions of 0.5 cm were made in the proximal jejunum about 10 cm away from the esophagojejunal anastomosis and 35-40 cm away from the contralateral of mesenteric side of distal jejunum respectively for proximal-distal side-to-side jejunojejunostomy.The common opening was closed to form the biliopancreatic duodenal juice outflow tract.(3)Closure of the input loop jejunum in the esophagojejunal anastomosis: The input loop jejunum 2-3 cm away from the esophagojejunal anastomosis was closed using the non-blade linear stapler(ATS45NK),and the biliopancreatic duodenal juice reflux was blocked.Clinical data of these patients were collected for retrospective case series study.Surgical and digestive tract functional recovery,perioperative complications,as well as postoperative nutritional status were observed.Moreover,related indexes,such as anastomosis function and tumor recurrence were evaluated through endoscopic and imaging examinations during postoperative follows-up.Results All the 67 patients completed the surgery successfully.The mean operative time was(259.4±38.5)minutes,digestive tract reconstruction time was(38.2±13.2)minutes,intraoperative blood loss was(73.4±38.4)ml,and number of harvested lymph node was 36.2±14.2.The mean distance from upper resection margin to upper tumor edge was(3.3±1.2)cm,distance from upper resection margin to dentate line was(1.2±0.7)cm,and 1 case had positive upper incisal margin,which became negative after the second resection.Moreover,the average length of the auxiliary incision was(3.2±0.4)cm.The mean postoperative intestinal exhaust time was(52.8±26.4)hours,time to liquid diet was(64.8±28.8)hours,and postoperative hospital stay was(8.4±2.5)days.The morbidity of postoperative complication was 10.4%(7/67).Among these 7 cases,4 cases were grade IIIa of Clavien-Dindo classification,including 2 with esophagojejunal anastomosis leakage,1 with duodenal stump leakage,and 1 with abdominal infection,and all these patients were recovered after conservative treatment.All the 67 patients were followed up.The mean nutrition index 12 months after surgery was 53.4±4.2,diameter of esophagojejunal anastomosis was(3.9±0.6)cm,the incidence of Roux-en-Y stasis syndrome was 3.0%(2/67),and the incidence of reflux esophagitis was 4.5%(3/67).No patient had recanalization of the closed input loop of esophagojejunal anastomosis,anastomotic stenosis,obstruction,or tumor recurrence at anastomosis.Conclusion Intracavitary URY anastomosis following LTG for digestive tract reconstruction is safe and feasible,leading to fast postoperative recovery of digestive tract function and favorable short-term efficacy.