腹腔镜胃癌根治术十二指肠残端采用单荷包缝合加固的疗效观察

Efficacy of reinforcement on duodenal stump using single purse - string suture during laparoscopic radical gastrectomy for gastric cancer

目的探讨腹腔镜下胃癌根治术行单荷包缝合加固十二指肠残端预防十二指肠残端漏的效果.方法采用描述性病例系列研究方法,回顾性收集2013年1月至2016年12月在复旦大学附属中山医院普通外科行腹腔镜根治性全胃切除术(LTG,Roux-en-Y重建)与腹腔镜根治性远端胃大部切除术(LDG,Roux-en-Y或BillrothⅡ重建),并同时行腹腔镜下单荷包缝合十二指肠残端包埋加固的211例胃癌患者临床病例资料.男136例,女75例,年龄(57.5±11.1)(24~87)岁,肿瘤分布于胃上部1/3、胃中部1/3、胃下部1/3的患者分别为62、68和81例.其中83例行全胃切除术,128例行远端胃大部切除术;107例行Roux-en-Y重建,104例行BillrothⅡ重建.十二指肠残端行腹腔镜下单荷包缝合包埋加固具体操作步骤:(1)使用3-0单股可吸收缝线在距离十二指肠残端1.0~1.5cm处做浆肌层荷包;(2)将荷包线打一个活结;(3)使用腔镜下针持或抓钳将十二指肠残端塞入荷包;(4)将荷包线的活结收紧,再打4~5个结加固.术后并发症分级依据Clavien-Dindo分级标准,统计早期并发症的发生率.结果全部患者均顺利完成手术,腹腔镜下单荷包缝合加固十二指肠残端用时(5.1±1.6)(3.6~10.2)min.术后早期发生并发症31例(14.7%),其中外科相关并发症27例(12.8%),包括腹腔感染7例(3.3%)、胰漏6例(2.8%)、伤口感染4例(1.9%)、胃瘫4例(1.9%)、腹腔出血2例(0.9%)、肠梗阻2例(0.9%)、淋巴漏2例(0.9%),未发生十二指肠残端漏;内科相关并发症4例(1.9%),包括肺部感染3例(1.4%)、心血管事件1例(0.5%).1例腹腔出血患者经再手术治疗后痊愈,其他并发症患者经保守治疗后均顺利出院.Clavien-Dindo分级Ⅲa级以上并发症共4例(1.9%).结论腹腔镜胃癌根治手术行Roux-en-Y或BillrothⅡ重建后十二指肠残端的单荷包缝合加固可以预防十二指肠残端漏的发生.

Objective To evaluate the efficacy of reinforcement on duodenal stump using single purse-string suture during laparoscopic radical gastrectomy for gastric cancer in preventing duodenal stump leakage. Methods A descriptive cohort study was conducted to retrospectively collect clinical data of 211 patients with gastric adenocarcinoma who underwent laparoscopic radical gastrectomy with Roux-en-Y or Billroth Ⅱ reconstruction and reinforcement on duodenal stump using laparoscopic single purse - string suture in Zhongshan Hospital of Fudan University between January 2013 and December 2016. Of 211 patients, 136 were male and 75 were female with mean age of (57.5±11.1)(24 to 87) years. Tumors locating at gastric upper 1/3, middle 1/3 and low 1/3 were found in 62, 68 and 81 patients respectively. Eighty-three cases underwent total gastrectomy, 128 underwent distal subtotal gastrectomy, 107 underwent Roux reconstruction and 104 underwent Billroth Ⅱ reconstruction. The procedure of reinforcement on duodenal stump using single purse - string suture during laparoscopic radical gastrectomy was as follows:(1) after cutting the duodenal stump to about 2.0 cm in length, use a 3-0 single-strand absorbable suture to make a muscle layer purse at a distance of 1.0 to 1.5 cm from the duodenal stump;(2) use the purse line to make a slipknot;(3) push the duodenum stump into the purse with a needle holder or grasper;(4) tighten the knot of the purse string, and then make 4 to 5 knots for reinforcement. Postoperative complications were defined and graded according to the Clavien-Dindo grading criteria, and the incidence of early complications was recorded. Clinicopathologic features and postoperative outcomes were analyzed. Results All patients completed operations successfully. The mean time of laparoscopic single purse-string suture was (5.1 ±1.6)(3.6 to 10.2) minutes. Postoperative early complication occurred in 31 cases (14.7%), of whom 27 cases developed surgery-related complications (12.8%), including 7 cases (3.3%) of peritoneal infection, 6 (2.8%) of pancreatic leakage, 4 (1.9%) of wound infection, 4 (1.9%) of gastroplegia, 2 (0.9%) of peritoneal hemorrhage, 2 (0.9%) of intestinal obstruction, 2 (0.9%) of lymphatic leakage, and no duodenal stump leakage;while 4 cases (1.9%) developed internal non-surgical complication, including 3 cases (1.4%) of pulmonary infection and 1 (0.5%) of cardiovascular event. The patient with peritoneal hemorrhage was healed after re-operation and all other patients were discharged uneventfully after conservative treatment. Four cases (1.9%) developed complications beyond grade Ⅲ a of Clavien - Dindo criteria. Conclusion Reinforcement on duodenal stump using laparoscopic single purse-string suture during laparoscopic radical gastrectomy with Roux-en-Y or Billroth Ⅱ reconstruction is simple and effective, and can prevent the risk of development of duodenal stump leakage.