胃癌根治术后特殊外科并发症的预防要点

The key points of prevention for special surgical complications after radical operation of gastric cancer

我国胃癌发病率高．规范化根治手术是目前治疗胃癌的主要方法。胃癌术后并发症、尤其是一些特殊并发症的发生，直接影响患者的预后，甚至造成病死率的上升。但这些特殊并发症发生率较低，医务工作者常因认识不足而延误诊疗。这些特殊并发症包括：（1）Petersen疝：为Roux—en—Y消化道重建后Roux袢与横结肠系膜的间隙形成的腹内疝，较为罕见，其可以迅速导致坏疽性肠梗阻。由于发生率较低，临床症状无特异性，临床往往不够重视，故后果十分严重。一旦诊断应立刻进行急诊手术。建议术中常规关闭Petersen间隙，以避免Petersen疝的发生。（2）淋巴漏：亦称乳糜漏。由于乳糜池是腹腔内广泛的淋巴管网络向膈肌角逐渐集中而成．故术中清扫淋巴结时易破坏周围淋巴网络而导致。术中使用超声刀可以在一定程度上降低淋巴漏风险。如果术中发现淋巴漏．可及时给予缝扎处理。治疗包括全肠外营养、内环境维持和补充白蛋白以及尝试性夹管观察。（3）十二指肠残端瘘：是胃大部切除术后影响患者恢复及导致死亡的严重并发症之一。术中对于十二指肠残端的正确处理，是预防十二指肠残端瘘的关键因素之一，建议术中常规行十二指肠残端荷包包埋。该并发症的处置关键在于及早获得正确诊断并采取有效的止血措施。（4）Roux．Y肠袢血供障碍：主要预防原则为术中注意肠管边缘血管弓的血供。（5）空肠残端大荷包导致吻合口梗阻：为远端胃癌根治术后行Roux-en—Y吻合术时．抵钉座置入残胃，将吻合器从远端空肠残端置入行胃空肠吻合，最后关闭残端，予以大荷包包埋．其包埋的空肠残端可疝人胃腔导致内疝并引发吻合口梗阻。我们建议采取间断交锁缝合并将残端固定于胃壁，可以避免该并发症的发生。

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include （1） Peterson hernia： It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. （2） Lymphatic leakage： It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. （3）Duodenal stump leakage： It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis. （4） Blood supply disorder of Roux-Y intestinal loop： Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. （5） Anastomotic obstruction by big purse of jejunal stump： When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.