胃癌根治术后十二指肠残端漏防治

Prevention and treatment of duodenal stump leakage after radical gastrectomy for gastric cancer

胃癌手术后发生十二指肠残端漏主要与其解剖特点以及胃癌的浸润转移程度等有关。十二指肠壁薄、位置固定,血供相对较差,内容物量大并具有腐蚀性,周围汇集着消化系统各种重要解剖结构,仅球部有少许游离度,可供闭合操作的长度有限。十二指肠球部周围是胃下部癌转移发生率最高的部位,当胃下部癌浸润或转移严重时将影响十二指肠球部的游离、闭合等操作,勉强实施则易发生漏。临床症状与漏出现的早晚、内容物漏出量多少、能否有效引流等因素有关。治疗上,控制感染的关键在于有效的引流,合理的营养支持是促进愈合的手段。再手术的目的是放置确切的引流,建立持久的营养支持途径。如果非手术方法能够达到此目的则可不选择手术。术前化疗可使肿瘤缩小,为确切关闭十二指肠残端等操作争取一定的空间,有利于预防十二指肠残端漏的发生。动静脉结合的术前化疗可以使疗效提高到约75.0%。

The occurrence of duodenal stump leakage after gastric cancer surgery is mainly related to its anatomical features, tumor invasion and metastasis. The duodenum wall is thin and fixed. It has poor blood supply, and massive corrosive fluid in it. Also, the duodenum is connected to a variety of important structures of the digestive system, and only the duodenal bulb is mobile, limiting the maneuverability of suture devices for duodenal stump closure. The duodenal bulb is the most common site of metastasis of lower part gastric cancer. When cancer spreads to the duodenal ＇bulb, it will cause difficulty in the dissection and closure of the duodenal stump, leading to a higher risk of duodenal stump leakage. The clinical symptoms are related to the time of leakage occurring, the amount of leakage contents, the establishment of effective drainage, etc. For treatment, the key to the control of infection is effective drainage, and reasonable nutrition support is an essential mean to promote healing. The purpose of a salvage surgery is to place an exact drainage and establish a long-term nutritional supportive route. If the purpose can be achieved by non-operative procedure, the sa｜vage surgery is not necessary. Preoperative chemotherapy inducing tumor shrinkage, would improve the chance to safely suture the duodenal stump, which is of great significance to prevent the duodenal stump leakage. Preoperative chemotherapy via intra-arterial and intravenous administration could higher the response rate to around 75%.