Overlap吻合在胃癌腹腔镜远端胃切除术BillrothⅠ式消化道重建中的应用价值

Application of Overlap anastomosis to Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy in gastric cancer

目的探讨腹腔镜远端胃切除术Overlap吻合BillrothⅠ式消化道重建在胃癌中的应用价值。方法回顾性分析2015年1月至2016年1月期间于吉林大学中日联谊医院新民院区接受腹腔镜远端胃切除D2根治术的68例T1~2期胃癌患者临床资料。病例入组标准:(1)术前经胃镜及病理确诊为胃癌并无远处转移;(2)肿瘤为T1~2期,直径<3 cm;(3)病灶定位于胃窦部、距离幽门>1 cm,且未侵及M区;(4)术后病理判断为R0切除;(5)无腹部手术史。根据吻合方式分为Overlap吻合组(23例)和传统BillrothⅠ式吻合组(45例)。两组均完成D2淋巴结清扫及远端胃切除术。Overlap吻合组在腔镜下直线吻合器离断十二指肠及胃,选择残余胃大弯吻合线开口,根据十二指肠与残胃之间张力,在十二指肠残端上缘处选取吻合线开口,分别置入腔镜下吻合器,完成残胃后壁与十二指肠上壁之间的吻合;关闭共同开口,同时切除十二指肠残端,完成消化道重建。传统BillrothⅠ吻合组于腔镜下离断十二指肠后关闭气腹,取上腹正中切口9~12 cm,将远端胃拖出体外直视下完成肿瘤切除、标本取出及BillrothⅠ式消化道重建。采用独立样本t检验(计量资料)和χ^2检验(计数资料)比较两组患者术中及术后情况。结果68例胃癌患者中,男性39例,女性29例,年龄(65.5±10.2)岁。Overlap吻合组与传统Billroth Ⅰ式吻合组基线资料的差异均无统计学意义(均P>0.05)。两组均完成腹腔镜手术,无中转开腹。Overlap吻合组与传统BillrothⅠ式吻合组比较,手术时间[(149.8±10.1)min比(169.8±15.3)min,t=5.658,P=0.008]和消化道重建的吻合时间[(31.2±3.8)min比(36.3±3.3)min,t=3.389,P=0.003]均缩短,腹部切口长度[(4.5±0.9)cm比(11.0±2.3)cm,t=13.244,P=0.004]更短,差异均具有统计学意义(均P<0.01)。而两组术中出血量[(92.9±22.4)ml比(87.0±17.3)ml,t=1.186,P=0.366]、淋巴结清扫数目[(28.4±5.7)枚比(27.3± 5.2)枚,t=0.838,P=0.383]、术后排气时间[(4.4±2.1)d比(4.2±1.8)d,t=0.391,P=0.563]、术后住院时间[(11.3±3.8)d比(12.5±3.4)d,t=1.289,P=0.317]及术后并发症发生率[4.3%(1/23)比6.7%(3/45),χ^2=0.148,P=0.701]差异均无统计学意义(均P>0.05)。术后随访(28±10)(10~46)个月,两组均无远期并发症发生,无肿瘤复发或死亡。结论腹腔镜远端胃切除术Overlap吻合消化道重建安全、可行,并可有效缩短术中的吻合时间。

Objective To investigate the application value of Overlap anastomosis in Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy in gastric cancer. Methods Clinical data of 68 stage T1-2 gastric cancer patients undergoing laparoscopic distal gastrectomy for D2 radical gastrectomy from January 2015 to January 2016 at China Japan Union Hospital of Jilin University were retrospectively analyzed. Inclusion criteria:(1) no distant metastasis of gastric cancer confirmed by gastroscopy and pathology before surgery;(2) T1-2 tumor with diameter <3 cm;(3) the lesion locating in the antrum of the stomach with distance >1 cm from the pylorus, and no invasion into middle area;(4) R0 resection confirmed by postoperative pathology;(5) no history of abdominal surgery. Among 68 cases,23 cases were in Overlap anastomosis group and 45 cases in Billroth I anastomosis group. D2 lymph node dissection and distal gastrectomy were performed in both groups. In the Overlap anastomosis group, the duodenum and stomach were severed by a linear stapler under endoscopy, and the residual gastric curve anastomotic opening was selected. According to the tension between the duodenum and the remnant stomach, the anastomotic opening was selected at the upper edge of the remnant duodenum, and the anastomosis between the posterior wall of the remnant stomach and the upper wall of the duodenum was completed by placing the stapler under endoscopy. Then the common opening was closed and the remnant duodenum was resected. In the traditional Billroth I anastomosis group, pneumoperitoneum was discontinued after amputation of the duodenum under laparoscopy. The median incision of the upper abdomen was 9-12 cm. The distal stomach was pulled out to complete the excision of specimens, the extraction of specimens and Billroth I digestive tract reconstruction. The intraoperative and postoperative conditions of the two groups were compared with student t test (continuous variable) and chi-square test (categorica variable). Results Of the 68 patients,39 were males and 29 were females,with age of (65.5±10.2)(51 to 77)years. Differences in baseline data between Overlap group and Billroth I group were not statistically significant (all P>0.05). Laparoscopic surgery was successfully performed in both groups without conversion to open operation. As compared with the Billroth I group, the Overlap group had significantly shorter operation time [(149.8±10.1) minutes vs.(169.8±15.3) minutes, t=5.658,P=0.008], shorter anastomotic time of digestive tract reconstruction [(31.2±3.8) minutes vs.(36.3±3.3) minutes, t=3.389, P=0.003] and shorter abdominal incision length [(4.5±0.9) cm vs.(11.0±2.3) cm, t=13.244,P=0.004]. There were no significant differences between two groups in intraoperative blood loss [(92.9±22.4) ml vs.(87.0±7.3) ml,t=1.186,P=0.366], number of lymph node dissected (28.4±5.7 vs. 27.3±5.2, t=0.838, P=0.383), postoperative flatus time [(4.4±2.1) days vs.(4.2±1.8) days, t=0.391, P=0.563], morbidity of postoperative complication [4.3%(1/23) vs. 6.7%(3/45),χ^2=0.148,P=0.701]. All the patients were followed up for 28±10 (10-46) months. There were no long-term complications, recurrence or death in two groups. Conclusion Overlap anastomosis in Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy is safe and effective, and can reduce the anastomosis time.