改良Overlap法食管空肠吻合在全腹腔镜根治性全胃切除术中的应用价值

Application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy

目的：探讨改良Overlap法食管空肠吻合在全腹腔镜根治性全胃切除术中的应用价值。方法：采用回顾性横断面研究方法。收集2015年1月至2017年12月上海交通大学医学院附属瑞金医院收治的32例采用改良Overlap法行全腹腔镜根治性全胃切除术食管空肠吻合胃上部癌患者的临床病理资料。Overlap法改良要点：行消化道重建时主刀医师站位于患者右侧，悬吊左半肝，离断食管前顺时针旋转，调整食管开孔位置，预制作空肠襻，采用45.0 mm直线切割吻合器和倒刺线关闭共同开口。术后肿瘤病理学分期为ⅠA期患者予随访监测，其中有淋巴结转移的患者予XELOX方案化疗；ⅠB、Ⅱ期无淋巴结转移患者予口服S-1单药。观察指标：（1）手术及术后恢复情况。（2）随访和生存情况。采用门诊和电话方式进行随访，了解患者术后辅助治疗、远期并发症及生存情况。随访时间截至2018年3月。正态分布的计量资料采用±s表示，偏态分布的计量资料采用M（范围）表示。结果：（1）手术及术后恢复情况：32例患者均顺利完成全腹腔镜根治性全胃切除术，食管空肠吻合采用改良Overlap法。32例患者手术时间为（227±19）min，食管空肠吻合时间为（22±7）min，术中出血量为（69±11）mL，术后肛门首次排气时间为（2.1± 0.5）d，术后首次进食流质食物时间为（3.4±0.4）d，术后首次进食半流质食物时间为（4.9±0.6）d，术后引流管拔除时间为（7.5±1.7）d。32例患者术后均未发生吻合口相关并发症，仅1例患者于术后5 d发生十二指肠残端漏，经持续三腔冲洗保守治疗后痊愈。术后病理学检查情况：32例患者淋巴结清扫数目为 （32±4）枚；肿瘤TNM分期：ⅠA期1例，ⅠB期5例，ⅡA期7例，ⅡB期11例，ⅢA期6例，ⅢB期1例， ⅢC期1例。32例患者术后住院时间为（8.1±2.1）d。（2）随访和生存情况：32例患者均获得术后随访，随访时间为3-38个月，中位随访时间为18个月。随访期间，除1例ⅠA期患者外，其余31例患者行术后辅助治疗；患者均可进食普通软性食物，无明显进食哽噎感和胸骨后烧灼感等症状，术后半年复查胃镜结果示吻合口通畅。1例患者因上颌窦恶性肿瘤于术后9个月死亡，1例于术后20个月复查时发现肿瘤肝转移，带瘤生存，其余患者无肿瘤复发、转移。结论：改良Overlap法应用于全腹腔镜根治性全胃切除术食管空肠吻合安全可行，近期疗效较好。

Objective：To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy （TLTG）. Methods：The retrospective crosssectional study was conducted. The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected. The main points of the modified Overlap method： surgeons stood on the right of patients when digestive tract reconstruction, suspension of left half liver and clockwise rotation before esophageal transection were performed, regulating esophageal opening position and building jejunal loop, and then closing openings using 45.0 mm EndoGIA and barbed wire. Patients who were diagnosed as ⅠA stage by postoperative pathological examination were followed up; patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in ⅠB and Ⅱ stages without lymph node metastases underwent oral S-1 single agent. Observation indicators： （1） surgical and postoperative recovery situations; （2） followup and survival situations. Followup using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy, longterm complications and survival up to March 2018. Measurement data with normal distribution were represented as ±s, and measurement data with skewed distribution were described as M （range）. Results： （1） Surgical and postoperative recovery situations： all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy. The operation time, esophagojejunostomy time, volume of intraoperative blood loss, time to initial anal exsufflation, time for initial fluid diet intake, time for initial semifluid diet intake and time of postoperative drainagetube removal were respectively （227±19）minutes, （22± 7）minutes, （69±11）mL, （2.1±0.5）days, （3.4±0.4）days, （4.9±0.6）days and （7.5±1.7）days. There was no anastomotic stomarelated complication in 32 patients. One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous threecavity irrigation and conservative treatment. Results of postoperative pathological examination： number of lymph node dissected in 32 patients was 32±4. TNM staging： 1, 5, 7, 11, 6, 1 and 1 patients were detected respectively in ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB and ⅢC. Duration of postoperative hospital stay of 32 patients was （8.1±2.1）days. （2） Followup and survival situations： 32 patients were followed up for 3-38 months, with a median time of 18 months. During the followup, in addition to 1 patient in IA stage, 31 patients underwent postoperative adjuvant therapy; patients can take the common soft food, without symptoms of choking and burning feelings, and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency. One patient died of malignant tumor of maxillary sinus at 9 months postoperatively, 1 was detected liver metastasis at 20 months postopeartively and survived with tumor, the other patients had no tumor recurrence or metastasis. Conclusion：The modified Overlap esophagojejunostomy is safe and feasible in TLTG, with good shortterm outcomes.