改良Overlap吻合与传统辅助切口吻合在腹腔镜全胃根治术中的临床疗效

Clinical efficacy between modified Overlap anastomosis and traditional auxiliary incision anastomosis in laparoscopic total gastrectomy

目的:探讨改良Overlap吻合与传统辅助切口吻合在腹腔镜全胃根治术中的临床疗效。方法:采用回顾性队列研究方法。收集2016年1月至2018年12月福建医科大学附属第二医院收治的115例胃癌患者的临床病理资料;男62例,女53例;中位年龄为62岁,年龄范围为27~83岁。115例患者中,51例使用直线切割闭合器并采用改良Overlap法行全腹腔镜全胃切除术,设为改良Overlap组;64例患者使用圆形吻合器行腹腔镜辅助全胃切除术,设为传统辅助组。观察指标:(1)手术情况。(2)术后情况。(3)吻合口相关并发症情况。(4)随访情况。采用门诊或电话方式随访,了解患者肿瘤复发情况和生存情况。随访时间截至2019年12月。正态分布的计量资料以±s表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ^2检验或Fisher确切概率法。等级资料比较采用秩和检验。结果:(1)手术情况:改良Overlap组患者手术时间、食管空肠吻合时间、术中出血量、淋巴结清扫数目、上切缘长度、辅助切口长度分别为(234.0±11.0)min,(29.4±2.1)min、(53±14)mL、(42±13)枚、(2.0±0.3)cm、(5.1±0.4)cm;传统辅助组患者上述指标分别为(231.0±11.0)min、(29.2±2.2)min、(50±13)mL、(40±10)枚、(2.2±0.4)cm、(8.2±0.4)cm。两组患者辅助切口长度比较,差异有统计学意义(t=-43.098,P<0.05);两组患者手术时间、食管空肠吻合时间、术中出血量、淋巴结清扫数目、上切缘长度比较,差异均无统计学意义(t=1.168,0.460,0.990,1.127,-1.926,P>0.05)。(2)术后情况:改良Overlap组患者术后疼痛程度(轻度、中度、重度),术后首次肛门排气时间,术后首次进食流质食物时间,术后住院时间分别为40、9、2例,(2.9±1.0)d,(4.8±2.2)d,(11.7±2.8)d;传统辅助组患者上述指标分别为31、27、6例,(3.9±1.4)d,(6.5±2.5)d,(13.0±3.1)d,两组患者上述指标比较,差异均有统计学意义(Z=-3.217,t=-4.344,-3.888,-2.261,P<0.05)。(3)吻合口相关并发症情况:改良Overlap组患者发生吻合口瘘、吻合口出血、吻合口狭窄分别为1例、1例、0;传统辅助组患者上述指标均为1例,两组患者上述指标比较,差异均无统计学意义(P>0.05)。吻合口瘘经鼻胃导管行肠内营养支持处理后痊愈,并进行消化道造影检查确认。吻合口出血经积极止血处理后好转。吻合口狭窄经抗炎、消肿等对症处理后好转。(4)随访情况:115例患者中,109例获得随访。51例改良Overlap组患者中,48例获得随访,随访时间为15.0~45.0个月,中位随访时间为33.5个月。64例传统辅助组患者中,61例获得随访,随访时间为16.0~46.0个月,中位随访时间为27.0个月。改良Overlap组无肿瘤复发患者,传统辅助组1例患者肿瘤复发肝转移,并带瘤生存,两组患者肿瘤复发情况比较,差异无统计学意义(P>0.05)。所有随访患者无死亡。结论:与传统辅助切口吻合比较,腹腔镜全胃根治术中采用改良Overlap吻合,患者切口小、术后恢复好。

Objective:To intestigate the clinical efficacy between modified Overlap anastomosis and traditional auxiliary incision anastomosis in laparoscopic total gastrectomy.Methods:The retrospective cohort study was conducted.The clinicopathological data of 115 patients with gastric cancer who were admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to December 2018 were collected.There were 62 males and 53 females,aged from 27 to 83 years,with a median age of 62 years.Of 115 patients,51 patients undergoing totally laparoscopic total gastrectomy with modified Overlap anastomosis using linear stapler were divided into modified Overlap group and 64 patients undergoing laparoscopic assisted total gastrectomy with traditional auxiliary incision anastomosis using circular stapler were divided into traditional assisted group.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)anastomotic complications;(4)follow-up.Follow-up using outpatient examination or telephone interview was conducted to detected tumor recurrence and survival of patients up to December 2019.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Comparison of ranked data was analyzed using the rank sum test.Results:(1)Surgical situations:the operation time,time of esophagojejunostomy,volume of intraoperative blood loss,the number of lymph node dissected,length of proximal incisional margin and length of auxiliary incision of the modified Overlap group were(234.0±11.0)minutes,(29.4±2.1)minutes,(53±14)mL,42±13,(2.0±0.3)cm and(5.1±0.4)cm,respectively.The above indicators of the traditional assisted group were(231.0±11.0)minutes,(29.2±2.2)minutes,(50±13)mL,40±10,(2.2±0.4)cm and(8.2±0.4)cm,respectively.There was significant difference in the length of auxiliary incision between the two groups(t=-43.098,P<0.05),and there was no significant difference in the operation time,time of esophagojejunostomy,volume of intraoperative blood loss,the number of lymph node dissected,length of proximal incisional margin between the two groups(t=1.168,0.460,0.990,1.127,-1.926,P>0.05).(2)Postoperative situations:cases with mild,moderate,severe pain(postoperative pain degree),time to first flatus,time to initial fluid diet intake,duration of postoperative hospital stay of the modified Overlap group were 40,9,2,(2.9±1.0)days,(4.8±2.2)days,(11.7±2.8)days,respectively.The above indicators of the traditional assisted group were 31,27,6,(3.9±1.4)days,(6.5±2.5)days,(13.0±3.1)days,respectively.There were significant differences in the above indicators between the two groups(Z=-3.217,t=-4.344,-3.888,-2.261,P<0.05).(3)Anastomotic complications:cases with anastomotic leakage,cases with anastomotic bleeding,cases with anastomotic stenosis of the modified Overlap group were 1,1,0,respectively.The above indicators of the traditional assisted group were all 1.There was no significant difference in the above indicators between the two groups(P>0.05).Cases with anastomotic leakage were cured after the treatment of enteral nutritional support through nasogastric catheterization,which were confirmed by gastroenterography.Cases with anastomotic bleeding were improved by active hemostatic therapy.Cases with anastomotic stenosis were improved after the symptomatic treatment of anti-inflammatory and anti-swelling.(4)Follow-up:109 of the 115 patients were followed up.Forty-eight of 51 patients in the modified Overlap group were followed up for 15.0-45.0 months,with a median follow-up time of 33.5 months.Sixty-one of 64 patients in the traditional assisted group were followed up for 16.0-46.0 months,with a median follow-up time of 27.0 months.There was no tumor recurrence in the modified Overlap group.One patient in the traditional assisted group had tumor recurrence with liver metastasis and survived with tumor.There was no significant difference in tumor recurrence rate between the two groups(P>0.05).There was no patient died during the follow-up.Conclusion:Compared with traditional auxiliary incision anastomosis,patients undergoing total laparoscopic total gastrectomy with modified Overlap anastomosis have small incision,good postoperative recovery.