全3D腹腔镜远端胃切除术BillrothⅡ联合Braun吻合与Roux-en-Y吻合的近期疗效分析

Short-term efficacy of BillrothⅡ+Braun anastomosis versus Roux-en-Y anastomosis in totally three-dimensional laparoscopic distal gastrectomy

目的比较全3D腹腔镜远端胃切除术BillrothⅡ联合Braun吻合与Roux-en-Y吻合的近期疗效。方法采用回顾性队列研究方法。收集2016年1月至2020年1月解放军总医院第一医学中心收治的140例胃癌病人的临床病理资料;男105例,女35例;中位年龄为55岁,年龄范围为23~84岁。140例病人中,54例行全3D腹腔镜远端胃切除BillrothⅡ联合Braun吻合消化道重建术,设为BillrothⅡ+Braun组;86例行全3D腹腔镜远端胃切除Roux-en-Y吻合消化道重建术,设为Roux-en-Y组。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解病人术后3个月残胃炎及严重程度、胆汁反流、反流性食管炎情况。随访时间截至2020年4月。正态分布的计量资料以x±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x^(2)检验或Fisher确切概率法。等级资料比较采用Mann-Whitney U检验。结果(1)手术情况:140例病人均行全3D腹腔镜远端胃切除术。BillrothⅡ+Braun组和Roux-en-Y组病人手术时间,术中出血量(<50 mL、50~200 mL、>200 mL),淋巴结清扫数目分别为(233±39)min,15、35、4例,(30±13)枚和(240±52)min,25、51、10例,(27±10)枚,两组病人比较,差异均无统计学意义(t=0.856,x^(2)=0.774,t=1.518,P>0.05)。(2)术后情况:BillrothⅡ+Braun组病人放置引流管,术后首次肛门排气时间,术后并发症严重程度分级(Ⅱ级、Ⅲ级、Ⅳ级、Ⅴ级),术后总体并发症,术后严重并发症,术后住院时间,手术费用,住院总费用分别为38例,(3.5±0.8)d,4、1、0、0例,5例,1例,(9.0±5.0)d,(3.8±1.2)万元,(9.7±2.1)万元,Roux-en-Y组病人上述指标分别为59例,(3.7±1.0)d,9、1、0、1例,11例,2例,(9.0±4.0)d,(4.3±1.0)万元,(9.2±2.1)万元,两组病人手术费用比较,差异有统计学意义(t=2.453,P<0.05),放置引流管、术后首次肛门排气时间、术后并发症严重程度分级、术后总体并发症、术后住院时间、住院总费用比较,差异均无统计学意义(x^(2)=0.049,t=-1.339,Z=0.000,x^(2)=0.409,t=0.197、1.383,P>0.05),术后严重并发症比较,差异无统计学意义(P>0.05)。(3)随访情况:140例病人中,134例获得随访,其中BillrothⅡ+Braun组52例,Roux-en-Y组82例。术后3个月随访结果显示:BillrothⅡ+Braun组和Roux-en-Y组病人残胃炎发生率、胆汁反流发生率、反流性食管炎发生率分别为61.5%(32/52)、38.5%(20/52)、26.9%(14/52)和41.5%(34/82)、22.0%(18/82)、12.2%(10/82),两组病人上述指标比较,差异均有统计学意义(x^(2)=5.131,4.270,4.695,P<0.05)。两组病人残存食物分级(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ级),反流性食管炎严重程度分级(微小病变、A级、B级)分别为42、3、5、2、0例,6、5、3例和67、9、1、5、0例,8、2、0例,两组病人上述指标比较,差异均无统计学意义(Z=-0.156,-1.468,P>0.05)。结论BillrothⅡ联合Braun吻合与Roux-en-Y吻合应用于全3D腹腔镜远端胃癌切除术均安全、可行,行BillrothⅡ联合Braun吻合可降低手术费用,行Roux-en-Y吻合可降低术后短期残胃炎、胆汁反流和反流性食管炎发生率。

Objective To compare the short-term efficacy of BillrothⅡ+Braun anasto-mosis versus Roux-en-Y anastomosis in totally three-dimensional(3D)laparoscopic distal gastrectomy.Methods The retrospective cohort study was conducted.The clinicopathological data of 140 patients with gastric cancer who were admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2020 were collected.There were 105 males and 35 females,aged from 23 to 84 years,with a median age of 55 years.Of the 140 patients,54 patients undergoing totally 3D laparoscopic distal gastrectomy with BillrothⅡ+Braun anastomosis were allocated into BillrothⅡ+Braun group,and 86 patients undergoing totally 3D laparoscopic distal gastrectomy with Roux-en-Y anastomosis were allocated into Roux-en-Y group,respectively.Observation indicators:(1)surgical situations;(2)postoperative situations;(3)follow-up.Follow-up using outpatient examination and telephone interview was conducted to detect remnant gastritis and its severity,bile reflux,reflux esophagitis in the postoperative 3 months up to April 2020.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Comparison of ordinal data was analyzed using the Mann-Whitney U test.Results(1)Surgical situations:140 patients underwent totally 3D laparoscopic distal gastrectomy.The operation time,cases with volume of intraoperative blood loss<50 mL,50 to 200 mL or>200 mL,the number of lymph node dissected were(233±39)minutes,15,35,4,30±13 for the BillrothⅡ+Braun group,respectively,versus(240±52)minutes,25,51,10,27±10 for the Roux-en-Y group,showing no significant difference between the two groups(t=0.856,x^(2)=0.774,t=1.518,P>0.05).(2)Postoperative situations:cases with drainage tube,time to postoperative first flatus,cases with postoperative gradeⅡ,Ⅲ,Ⅳ,Ⅴcomplications,cases with postoperative complications,cases with postoperative severe complications,duration of postoperative hospital stay,surgery cost and total hospitalization cost of the BillrothⅡ+Braun group were 38,(3.5±0.8)days,4,1,0,0,5,1,(9.0±5.0)days,(3.8±1.2)×10^(4)yuan and(9.7±2.1)×10^(4)yuan,respectively.The above indicators of the Roux-en-Y group were 59,(3.7±1.0)days,9,1,0,1,11,2,(9.0±4.0)days,(4.3±1.0)×10^(4)yuan and(9.2±2.1)×10^(4)yuan,respectively.There was a significant difference in the surgery cost between the two groups(t=2.453,P<0.05),while there was no significant difference in cases with drainage tube,time to postoperative first flatus,cases with postoperative gradeⅡ,Ⅲ,Ⅳ,Ⅴcomplications,cases with postoperative complications,duration of postoperative hospital stay or total hospitalization cost between the two groups(x^(2)=0.049,t=‒1.339,Z=0.000,x^(2)=0.409,t=0.197,1.383,P>0.05).There was also no significant difference in cases with postoperative severe complications between the two groups(P>0.05).(3)Follow-up:134 of 140 patients received the follow-up,including 52 cases in the BillrothⅡ+Braun group and 82 cases in the Roux-en-Y group.Results of follow-up within postoperative 3 months showed that the incidence rates of remnant gastritis,bile reflux,reflux esophagitis were 61.5%(32/52),38.5%(20/52),26.9%(14/52)for the BillrothⅡ+Braun group,respectively,versus 41.5%(34/82),22.0%(18/82),12.2%(10/82)for the Roux-en-Y group,showing significant differences between the two groups(χ^(2)=5.131,4.270,4.695,P<0.05).Cases with grade 0,Ⅰ,Ⅱ,Ⅲ,Ⅳresidual food were 42,3,5,2,0 for the BillrothⅡ+Braun group,versus 67,9,1,5,0 for the Roux-en-Y group,showing no significant difference between the two groups(Z=‒0.156,P>0.05).Cases with minimal lesion,grade A,grade B gastritis(severity of gastritis)were 6,5,3 for the BillrothⅡ+Braun group,versus 8,2,0 for the Roux-en-Y group,showing no significant difference between the two groups(Z=‒1.468,P>0.05).Conclusions It is safe and feasible to operate BillrothⅡ+Braun or Roux-en-Y anastomosis in totally 3D laparoscopic distal gastrectomy.BillrothⅡ+Braun anastomosis can reduce the surgical cost.Roux-en-Y anastomosis has advantages in reducing the incidence of reflux esophagitis,bile reflux and reflux gastritis.