腹腔镜胃癌远端胃切除术后消化道重建术式选择

Digestive tract reconstruction after laparoscopic distal gastrectomy for gastric cancer

腹腔镜胃癌远端胃切除术后重建方式包括BillrothⅠ、BillrothⅡ和Roux-en-Y 3种。BillrothⅠ式简单易行,接近正常解剖生理,一直被作为最常用的吻合方式。BillrothⅡ式可作为当肿瘤侵犯幽门管或十二指肠时的一种选择,但其反流相关并发症较多。Roux-en-Y式虽复杂,但在抗胆汁反流方面优于BillrothⅠ/Ⅱ式,同时其在改善生活质量方面是一种较理想的方式。在吻合途径上主要分为小切口辅助和完全腹腔镜下重建,前者由于术野受限,可能会导致吻合产生张力或副损伤,特别对于肥胖患者。而完全腹腔镜下可全程监视,能有效避免这些风险,但也面临着术中肿瘤定位困难、手术时间长、难度大、费用高等问题。各种方式和途径各有利弊,应在不违反消化道重建原则的基础上,根据术者经验和患者情况做出最优化的选择。

The standard reconstruction methods after laparoscopic distal gastrectomy include Billroth Ⅰ/Ⅱ anastomosis and Roux-en-Y gastrojejunostomy.Billroth Ⅰ anastomosis has been most commonly performed due to its technical simplicity and physiological similarity.Billroth Ⅱ anastomosis could be used when the tumor invades the pyloric canal or duodenum,but it is associated with reflux-related complications.Roux-en-Y reconstruction is complicated,but superior to others in terms of less bile reflux compared with Billroth Ⅰ/Ⅱ procedures.It is preferred as the better procedure to improve postoperative quality of life （QOL）.In the way of anastomotic approach,extracorporeal anastomosis via mini-laparotomy may cause forceful tension and injuries to the structures around the anastomosis because of limited vision,especially in an obese patient.However,in totally laparoscopic gastrectomy （TLG）,the whole anastomotic procedure could be clearly viewed,so such tension and injuries could be obviated.Nevertheless,intracorporeal anastomosis is related to straits of intraoperative localization of the tumor,longer operation time,technical difficulties in intracorporeal anastomosis,and additional costs.Each procedure or approach has their own merits and dismerits,we should make an optimal choice without violating the principles of digestive tract reconstruction to recover the food intake,body weight,nutritional status and improve the QOL according to the experiences of surgeons and the actual situation of patient.