腹腔镜根治性近端胃或全胃切除术中3种不同吻合器钉座置入方法的对比研究

A Comparative Study of Three Imbedding Methods of Anastomat Nail Seat in Laparoscopic Radical Proximal or Total Gastrectomy

目的探讨腹腔镜根治性近端胃或全胃切除术中3种吻合器钉座置入方法的优缺点。方法回顾分析我院2014年5月~2015年12月由同一组医生完成的53例腹腔镜根治性近端胃或全胃切除的临床资料,将17例采用辅助小切口置入吻合器钉座设为A组,16例采用经口置入钉钻系统(Or Vil)设为B组,20例采用反穿刺技术(reverse puncture device,PRD)设为C组,比较3组患者手术时间、钉座置入时间、术中出血、术后排气时间、住院时间、腹部切口长度、食管近切缘长度。结果 53例均顺利完成手术,围手术期无死亡。3组术中出血量[(158.8±34.4)ml vs.(136.2±33.0)ml vs.(160.2±35.6)ml,F=2.57,P=0.087]、肛门排气时间[2.0(1.0~12.5)d vs.1.5(1.0~2.5)d vs.1.5(1.0~3.0)d,χ~2=4.405,P=0.111]和并发症发生率[11.8%(2/17)vs.18.8%(3/16)vs.25.0%(5/20),χ~2=1.052,P=0.591]差异无统计学意义。A组钉座置入时间(18.5±4.8)min最短,显著短于B组(34.9±8.8)min(q=10.465,P<0.05)和C组(23.1±5.1)min(q=3.099,P<0.05)。C组食管切缘长度(4.5±0.5)cm最长,与B组(4.4±0.6)cm相比无统计学差异(q=0.583,P>0.05),但显著长于A组(2.5±1.0)cm(q=11.856,P<0.05)。B组切口长度(4.3±0.5)cm最短,与C组(4.5±0.6)cm相比无统计学差异(q=0.662,P>0.05),但显著短于A组(8.6±2.1)cm(q=13.704,P<0.05)。A组手术时间(208.5±24.4)min,显著短于B组(232.8±23.4)min(q=4.577,P<0.05),但与C组(214.5±17.0)min比较无统计学差异(q=1.193,P>0.05)。结论 3种吻合器钉座置入方法均安全可靠,辅助切口置入钉座可选择合适患者开展;Or Vil、RPD能避免体形限制,获得更长切缘;RPD操作更为简便,可作为腹腔镜下食管-残胃(空肠)吻合中理想的钉座置入方法进行推广。

Objective To investigate the advantages and disadvantages of three imbedding methods of anastomat nail seat in laparoscopic radical proximal or total gastrectomy. Methods Clinical data of a total of 53 cases of laparoscopie radical proximal subtotal or total gastrectomy in our hospital by the same team of doctors from May 2014 to December 2015 were compared. The Group A included 17 cases receiving small assisted incision imbedding into nail seat of the anastomat, the group B included 16 cases treated by the OrVil, and the Group C included 20 cases treated by reverse puncture technique （RPD）. The operation time, nail seat imbedding time, intraoperatve blood loss, postoperative exhaust time, length of stay, length of abdominal incision and length of esophageal proximal incisional margin in the three groups were compared. Results All the operations were smoothly completed in the 53 cases, without fatal case during the perioperative period. No statistical significance was found in the intraoperatve blood loss [（158.8±34.4） ml vs. （136.2 ±33.0） ml vs. （160.2 ±35.6） ml, F =2.57, P =0.087], postoperative exhaust time [2.0 （1.0-12.5） d vs. 1.5 （1.0-2.5） d vs. 1.5 （1.0-3.0） d,χ^2 =4.405, P=0. 111], and incidence of complications [11.8% （2/17） vs. 18.8% （3/16） vs. 25.0% （5/20）,χ^2=1.052, P=0.591~ in the three groups. The nail seat imbedding time of the Group A was the shortest [ （ 18.5 ± 4.8 ） min ] , significantly shorter than that of the Group B [ （34.9 ± 8.8 ） mini and Group C [ （23.1 ± 5.1 ） min] （q = 10. 465, P 〈 0.05 ; q = 3. 099, P 〈 0.05 ）. The length of esophageal proximal ineisional margin was the longest in the groupC [（4.5 ±0.5） cm], significantly longer than that of the GroupA [（2.5 ±1.0） cm] （q=11.856, P〈O. 05） , but the difference between the Group C and Group B [ （4.4 ±0.6） cm ] had no statistical significance （ q = 0. 583, P 〉 0. 05 ）. The incision length of the Group B was the shortest [ （4.3 ±0. 5 ） cm ], significantly shorter than that of the Group A [ （ 8.6 ± 2.1） cm] （q = 13. 704, P 〈0.05）, but the difference between the Group C [ （4.5 ±0.6） cm] and Group B had no statistical significance （ q = 0. 662, P 〉 0. 05 ）. The operation time of the Group A [ （208.5 ± 24.4） min] was the shortest, significantly shorter than that of the Group B [（232.8 ±23.4） min] （q=4.577, P〈0.05）, but the difference between the Group C [（214.5 ±17.0） min] and Group A had no statistical significance （q = 1. 193, P 〉 0. 05）. Conclusions All the three imbedding methods of anastomat nail seat are safe and reliable, and the assisted incision imbedding into nail seat can be performed on appropriate patients. The OrVil and RPD can avoid the limit of somatotype and get a longer incisional margin. The RPD operation is simpler and takes shorter time, and can be popularized as an ideal nail seat imbedding method in laparoscopic lower esophageal-vestige stomach anastomosis.