不同消化道重建方式在腹腔镜远端胃大部切除术中的应用价值

Application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy

目的：探讨不同消化道重建方式在腹腔镜远端胃大部切除术（LDG）中的应用价值。方法： 采用回顾性队列研究方法。收集2010年6月至2015年4月福建医科大学附属第一医院收治的164例早期胃癌患者的临床病理资料。164例患者均行LDG，其中45例术中消化道重建方式采用Billroth Ⅰ吻合，设为Billroth Ⅰ吻合组；39例采用Braun吻合（Billroth Ⅱ吻合），设为Billroth Ⅱ吻合组；44例采用传统Roux-en-Y吻合，设为Roux-en-Y吻合组；36例采用非离断Roux-en-Y吻合，设为非离断Roux-en-Y吻合组。观察指标：（1）手术及术后恢复情况。（2）术后短期并发症情况。（3）随访情况。采用门诊或电话方式进行随访，随访内容为患者术后营养学和术后长期并发症发生情况，随访时间截至2017年5月。正态分布的计量资料x±s表示，多组间比较采用方差分析，两两比较采用Tukey hsd检验；计数资料以频数和百分比表示，组间比较采用χ^2检验；等级资料采用非参数秩和检验。结果：（1）手术及术后恢复情况：4组患者均成功施行LDG。Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组、非离断Roux-en-Y吻合组患者的手术方式全腹腔镜远端胃大部切除术分别为0、29、13、15例，腹腔镜辅助远端胃大部切除术分别为45、10、31、21例；消化道重建时间分别为（42±7）min、（55±8）min、（64±8）min、（51±6）min；4组患者上述指标比较，差异均有统计学意义（χ^2=21.628，F=74.441，P〈0.05）。（2）术后短期并发症情况：Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组、非离断Roux-en-Y吻合组患者术后分别有2、2、3、1例发生短期并发症，4组比较，差异无统计学意义（χ^2=0.840，P〉0.05）。（3）随访情况：Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组、非离断Roux-en-Y吻合组患者术后均获得随访，随访时间分别为（10.8±3.5）个月、（10.9±3.4）个月、（11.3±3.2）个月、（11.2±2.2）个月，4组比较，差异无统计学意义（F=0.200，P〉0.05）。①Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组、非离断Roux-en-Y吻合组患者术后1年营养学指标比较：体质量改变率分别为93%±7%、91%±7%、90%±7%、90%±9%，血红蛋白改变率分别为94%±9%、97%±11%、 95%±9%、97%±9%，总蛋白改变率分别为101%±9%、99%±7%、98%±7%、99%±7%，白蛋白改变率分别为101%±10%、103%±7%、100%±10%、103%±9%，4组患者上述指标比较，差异均无统计学意义（F=1.182，0.724，1.050，0.971，P〉0.05）。②164例患者术后1年中，47例发生胃潴留（并发症严重程度1、2、3、4级分别为27、12、6、2例），87例发生残胃炎（并发症严重程度1、2、3、4级分别为53、24、10、0例），38例发生胆汁反流（并发症严重程度均为1级）。38例发生胆汁反流的患者中，33例合并残胃炎，残胃炎和胆汁反流有相关性（r=0.396，P〈0.05）。Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组、非离断Roux-en-Y吻合组患者术后1年发生胃潴留分别为16、9、21、1例，发生残胃炎分别为35、30、13、9例，发生胆汁反流分别为16、18、3、1例，4组患者上述指标比较，差异均有统计学意义（χ^2=21.261，41.103，30.469，P〈0.05）。非离断Roux-en-Y吻合组患者胃潴留发生情况分别与Billroth Ⅰ吻合组、Billroth Ⅱ吻合组、Roux-en-Y吻合组比较，差异均有统计学意义（x2=12.958，6.675，20.065，P〈0.05）。Roux-en-Y吻合组患者残胃炎发生情况分别与Billroth Ⅰ吻合组、Billroth Ⅱ吻合组比较，差异均有统计学意义（χ^2=20.831，18.587，P〈0.05）；非离断Roux-en-Y吻合组分别与Billroth Ⅰ吻合组、Billroth Ⅱ吻合组比较，差异均有统计学意义 （x2=22.452，20.220，P〈0.05）。Roux-en-Y吻合组患者胆汁反流情况分别与Billroth Ⅰ吻合组、Billroth Ⅱ吻合组比较， 差异均有统计学意义（χ^2=10.942，16.926，P〈0.05）；非离断Roux-en-Y吻合组分别与Billroth Ⅰ吻合组、Billroth Ⅱ吻合组比较，差异均有统计学意义（χ^2=12.958，18.620，P〈0.05）。结论：LDG术中 采用Roux-en-Y吻合术和非离断Roux-en-Y吻合术行消化道重建，其改善术后残胃炎和胆汁反流均优于Billroth Ⅰ式吻合术和Billroth Ⅱ式吻合术，且非离断Roux-en-Y吻合术能有效降低术后胃潴留的发生。

Objective：To investigate the application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy （LDG）. Methods：The retrospective cohort study was conducted. The clinicopathological data of 164 with early gastric cancer （GC） who were admitted to the First Affiliated Hospital of Fujian Medical University between June 2010 and April 2015 were collected. Of 164 patients undergoing LDG, 45 receiving BillrothⅠ （BⅠ） anastomosis, 39 receiving Billroth Ⅱ （BⅡ） anastomosis, 44 receiving Roux-en-Y anastomosis and 36 receiving uncut Roux-en-Y anastomosis were allocated into the BⅠ group, BⅡgroup, RY group and uncut RY group, respectively. Observation indicators： （1） surgical and postoperative recovery situations; （2） postoperative shortterm complications situations; （3） followup situations. Followup using outpatient examination and telephone interview was performed to detect postoperative nutriology and longterm complications up to May 2017. Measurement data with normal distribution were represented as x±s. Comparison among groups was analyzed using the ANOVA, and pairwise comparisons were done by the Tukey hsd test. Count data were described as the frequency and percentage, and comparisons among groups were analyzed the chisquare test or Fisher exact probability. Ordinal data were analyzed by the Kruskal Wallis test. Results：（1） Surgical and postoperative recovery situations： patients in 4 groups underwent successfully LDG. Cases undergoing total LDG and assisted LDG and digestive tract reconstruction time in the BⅠ, BⅡ, RY and uncut RY groups were respectively 0, 29, 13, 15 and 45, 10, 31, 21 and （42±7）minutes, （55±8）minutes, （64±8）minutes, （51± 6）minutes, with statistically significant differences among 4 groups （χ^2=21.628, F=74.441, P〈0.05）. （2） Postoperative shortterm complications situations： 2, 2, 3 and 1 patients in the BⅠ, BⅡ, Roux-en-Y and uncut Roux-en-Y groups had respectively postoperative shortterm complications, showing no statistically significant difference among 4 groups （χ^2=0.840, P〉0.05）. （3） Followup situations： all patients were followed up, and followup time in the BⅠ, BⅡ, RY and uncut RY groups were respectively （10.8±3.5）months, （10.9± 3.4）months, （11.3±3.2）months and （11.2±2.2）months, with no statistically significant difference among 4 groups （F=0.200, P〉0.05）. ① Comparisons of postoperative 1year nutritional indexes： rates of changes in body mass index （BMI）, hemoglobin （Hb）, total protein （TP） and albumin were respectively 93%±7%, 91%±7%, 90%±7%, 90%±9% and 94%±9%, 97%±11%, 95%±9%, 97%±9% and 101%±9%, 99%±7%, 98%±7%, 99%±7% and 101%±10%, 103%±7%, 100%±10%, 103%±9% in the BⅠ, BⅡ, RY and uncut RY groups, showing no statistically significant difference among 4 groups （F=1.182, 0.724, 1.050, 0.971, P〉0.05）. ② Of 164 patients within 1 year postoperatively, 47 were complicated with gastric retention （27, 12, 6 and 2 with severity in grade 1, 2 , 3 and 4）, 87 with residual gastritis （53, 24, 10 and 0 with severity in grade 1, 2 , 3 and 4）, and 38 with bile reflux （severity in grade 1）. Of 38 patients with bile reflux, 33 were combined with residual gastritis, showing a correlation between residual gastritis and bile reflux （r=0.396, P〈0.05）. Cases with gastric retention, residual gastritis and bile reflux within 1 year postoperatively were respectively 16, 9, 21, 1 and 35, 30, 13, 9 and 16, 18, 3, 1 in the BⅠ, BⅡ, RY and uncut RY groups, showing statistically significant differences among 4 groups （χ^2=21.261, 41.103, 30.469, P〈0.05）. There were statistically significant differences in gastric retention occurrence between uncut RY group and BⅠgroup or BⅡgroup or RY group （χ^2=12.958, 6.675, 20.065, P〈0.05）, and in residual gastritis occurrence between RY group and BⅠgroup or BⅡgroup （χ^2=20.831, 18.587, P〈0.05） and between uncut RY group and BⅠgroup or BⅡgroup （χ^2=22.452, 20.220, P〈0.05）. There were statistically significant differences in bile reflux occurrence between RY group and BⅠgroup or BⅡgroup （χ^2=10.942, 16.926, P〈0.05）, and between uncut RY group and BⅠgroup or BⅡgroup （x2=12.958, 18.620, P〈0.05）. Conclusion：Roux-en-Y and uncut Roux-en-Y anastomoses are superior to BⅠand BⅡanastomoses in improving residual gastritis and bile reflux in the postoperative digestive tract reconstruction of LDG, and uncut Roux-en-Y anastomosis can effectively reduce occurrence of postoperative gastric retention.