全腹腔镜远端胃癌根治术后消化道重建方式的对比

Comparison of various methods of digestive tract reconstruction after totally laparoscopic distal gastrectomy

目的：比较全腹腔镜远端胃癌根治术（totally laparoscopic distal gastrectomy,TLDG）中不同吻合方式的围手术期情况及短期临床疗效,探讨不同消化道重建方式在TLDG术中的应用价值。方法：选取2014年1月1日至2014年12月31日行TLDG的49例患者,其中11例采用三角吻合（delta-shaped组）,14例采用BillrothⅡ式吻合（B-Ⅱ组）,11例采用Roux-en-Y吻合（R-Y组）,13例采用un-cut Roux-en-Y吻合（un-cut组）。回顾分析四组患者围手术期相关指标及随访情况。结果：四组患者在性别、年龄、术中失血量、术后恢复排气时间、术后住院时间、术后病理分期等方面差异均无统计学意义（P〉0.05）;但吻合时间差异有统计学意义（P〈0.05）,经两两组间比较,un-cut组[（92.23±3.86）min]较R-Y组[（76.91±2.91）min]、delta-shaped组[（75.91±4.54）min]、B-Ⅱ组[（70.00±3.13）min]长。delta-shaped组中1例术后出现吻合口出血,1例发生吻合口漏,均保守治疗后痊愈;B-Ⅱ组中4例于术后6个月复查胃镜时发现胆汁反流,其中2例合并吻合口溃疡;R-Y组中1例发生切口感染,1例出现短暂的胃瘫,均经治疗后痊愈;un-cut组未发生并发症。随访6~12个月,均未发现复发及远处转移。结论：TLDG术中采用的四种重建方式均是安全、可行的。BillrothⅡ式吻合更符合生理,并发症较少;un-cut Roux-en-Y式吻合既可解决BillrothⅡ式吻合术后容易出现的碱性反流、吻合口溃疡、盲袢综合征等并发症,又解决了Roux-en-Y吻合术后出现的功能性胃排空延迟、Roux潴留综合征,且手术难度、吻合时间并不显著增高,可成为较好的选择。

Objective： A comparison of perioperative and short-term clinical effectiveness among patients receiving different anastomosis treatment for distal gastric cancer was done to explore the application of various methods in reconstruction of totally laparoscopic distal gastrectomy（ TLDG）. Methods： From Jan. 2014 to Dec. 2014,49 patients with distal gastric cancer were admitted to the General Hospital of PLA to receive digestive tract reconstruction after TLDG. The 49 patients were divided into four groups. 11 patients receiving delta-shaped anastomosis were classified as Group D,14 patients receiving Billroth Ⅱ were classified as Group B-Ⅱ,11 patients receiving Roux-en-Y anastomosis were classified as Group R-Y and 13 patients receiving un-cut Roux-en-Y anastomosis were classified as Group un-cut R-Y. The perioperative condition and follow-up observation of four groups were compared using retrospective methods. Results： No significant difference was found in gender composition,age,blood loss,exhaust time,postoperative hospital stay and postoperative pathologic staging among the four groups（ P 〉 0. 05）. However,it showed significant intergroup differences in anastomotic time（ P 〈 0. 05）,Group un-cut [（ 92. 2 ± 3. 86） min]〉 Group R-Y [（ 76. 91 ± 2. 91） min]〉 Group D [（ 75. 91 ± 4. 54） min]〉 Group B-Ⅱ [（ 70. 00 ± 3. 13） min]. One patient developed anastomotic leakage and another developed anastomotic bleeding in Group D. Both patients recovered after conservative treatment. In Group B-Ⅱ,bile reflux was found in four patients by gastroscope after6 months of operation with two patients having stomal ulcer. One patient of Group R-Y suffered from incision infection and one other patient suffered from gastroparesis syndrome. Both patients recovered after treatment. No complications occurred in Group un-cut R-Y.Meanwhile,recurrence or distant metastasis was not found during the short-term follow-up of 6-12 months in all the groups. Conclusions： Each surgical procedure has two sides. So far,there is no uniform standard of digestive tract reconstruction in TLDG. According to this comparison,un-cut Roux-en-Y anastomosis may be safer and more feasible in future.