食管空肠π吻合在全腹腔镜全胃切除术中的应用价值

Application value of the π-shaped esophagojejunostomy in totally laparoscopic total gastrectomy

目的：探讨食管空肠π吻合在全腹腔镜全胃切除术中应用的安全性及可行性。 方法：采用回顾性横断面研究方法。收集2016年5—8月南京医科大学第一附属医院收治的6例胃癌患者的临床病理资料。患者均行全腹腔镜全胃切除术，游离食管和胃，清扫淋巴结，行食管空肠π吻合，再行肠肠吻合完成腹腔镜下消化道重建。观察指标：（1）手术情况：中转开腹情况、手术时间、食管空肠π吻合时间、术中出血量、淋巴结清扫数目。（2）术后情况：术后首次下床活动时间、术后肛门首次排气时间、术后首次进流质食物时间、术后腹腔引流管拔除时间、术后并发症、术后住院时间。（3）术后病理学检查情况。（4）随访和生存情况。采用门诊方式进行随访，随访内容为吻合口狭窄情况、患者生存、肿瘤转移和复发情况。随访时间截至2016年11月。正态分布的计量资料以±s表示。 结果：（1）手术情况：6例患者均成功施行全腹腔镜全胃切除食管空肠π吻合手术，无中转开腹和围术期死亡患者。6例患者手术时间为（282± 49）min，食管空肠π吻合时间为（37±9）min，术中出血量为（37±8）mL，淋巴结清扫数目为（39±9）枚/例。（2）术后情况：6例患者术后首次下床活动时间为（44±38）h，术后肛门首次排气时间为（72±21）h，术后首次进流质食物时间为（6.5±1.1）d，术后腹腔引流管拔除时间为（11±7）d。6例患者无术后出血、十二指肠残端瘘及死亡等并发症发生。1例患者出现吻合口瘘，于CT检查引导下行腹腔穿刺引流，并行肠内营养管置入加强营养支持及抗感染治疗等对症处理，痊愈出院。6例患者术后住院时间为（15±7）d。（3）术后病理学检查情况：患者pTNM 分期：ⅠA 期3例、 ⅡA 期1例、ⅡB期1例、ⅢA期1例。（4）随访和生存情况：6例患者均获得术后随访，随访时间为3-6个月，中位随访时间为4个月。随访期间，复方泛影葡胺消化道造影检查结果示6例患者吻合口均通畅，无胃癌术后复发、转移和死亡患者。

Objective：To explore the safety and feasibility of the πshaped esophagojejunostomy in totally laparoscopic total gastrectomy. Methods：The retrospective crosssectional study was conducted. The clinicopathological data of 6 patients with gastric cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University between May 2016 and August 2016 were collected. All the 6 patients underwent totally laparoscopic total gastrectomy, operation procedures included esophagus and stomach mobilization, lymph node dissection, πshaped esophagojejunostomy, and then laparoscopic digestive tract reconstruction after jejunojejunal anastomosis. Observation indicators included： （1） surgical situations： conversion to open surgery, operation time, time of πshaped esophagojejunostomy, volume of intraoperative blood loss, number of lymph node dissected; （2） postoperative situations： time for initial outofbed activity, time of initial anal exsufflation, time of initial liquiddiet intake, time of abdominal drainage tube removal, postoperative complications and duration of postoperative hospital stay; （3） postoperative pathological examination; （4） followup and survival situations. Followup using outpatient examination was performed to detect the anastomotic stenosis, patients′ survival and tumor metastasis and recurrence up to November 2016. The measurement data with normal distribution were represented as ±s. Results：（1） Surgical situations： all the 6 patients underwent successful totally laparoscopic total gastrectomy using the πshaped esophagojejunostomy, without conversion to open surgery and perioperative death. Operation time, time of πshaped esophagojejunostomy, volume of intraoperative blood loss and number of lymph node dissected were respectively （282±49）minutes, （37±9）minutes, （37±8）mL and 39±9. （2） Postoperative situations： time for initial outofbed activity, time of initial anal exsufflation, time of initial liquiddiet intake, time of abdominal drainage tube removal and duration of postoperative hospital stay of 6 patients were （44± 38）hours, （72±21）hours, （6.5±1.1）days, （11±7）days and （15±7）days, respectively. Six patients were not complicated with postoperative hemorrhage, duodenal stump fistula and death. One patient with anastomotic fistula was cured by abdominal puncture drainage under guidance of computed tomography （CT）, enteral nutrition and antibiotic therapy, and then was discharged from hospital. （3） Postoperative pathological examination： pTNM staging showed that stageⅠA, ⅡA, ⅡB and ⅢA were detected in 3, 1, 1 and 1 patients, respectively. （4） Followup and survival situations： 6 patients were followed up for 3- 6 months, with a median time of 4 months. During followup, results of compound meglumine diatrizoate gastrointestinal radiography showed that there were smooth anastomoses, and no tumor recurrence or metastasis and death. Conclusion：The πshaped esophagojejunostomy is safe and feasible in totally laparoscopic total gastrectomy.