胃上部癌行根治性近端胃切除术食管胃吻合与双通道吻合的临床疗效

Clinical efficacy of radical proximal gastrectomy with esophagogastrostomy and double-tract anastomosis for upper gastric cancer

目的探讨胃上部癌行根治性近端胃切除术食管胃吻合与双通道吻合的临床疗效。方法采用回顾性队列研究方法。收集2018年1月至2020年12月天津医科大学肿瘤医院收治的172例胃上部癌行根治性近端胃切除术病人的临床病理资料;男147例,女25例;中位年龄为62岁,年龄范围为25~81岁。172例病人均行消化道重建,其中83例行食管胃吻合,设为食管吻合组;89例行双通道吻合,设为双通道吻合组。病人均由胃部肿瘤科主诊医师行根治性近端胃切除联合D1+淋巴结清扫术。消化道重建由主刀医师决定行食管胃吻合或双通道吻合。观察指标:(1)手术情况。(2)随访情况。采用门诊、电话或线上App等方式进行随访。术后1个月进行第1次随访,术后2年内每3个月随访1次,术后2~5年每6个月随访1次。采用反流性食管炎问卷调查、胃镜和上消化道造影检查,判断病人胃食管反流和吻合口狭窄情况。随访时间截至2021年2月1日。正态分布的计量资料以x±s表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验。等级资料比较采用非参数秩和检验。计数资料以绝对数表示,组间比较采用χ^(2)检验。结果(1)手术情况:食管胃吻合组病人手术方式(开腹手术、腹腔镜手术、达芬奇机器人手术),淋巴结转移数目,术后住院时间分别为74例、9例、0,2枚(0~15枚),(12±4)d;双通道吻合组病人上述指标分别为65例、15例、9例,3枚(0~28枚),(11±3)d,两组病人上述指标比较,差异均有统计学意义(χ^(2)=10.887,Z=-1.058,t=3.284,P<0.05)。(2)随访情况:172例病人均获得随访,随访时间为2~38个月,中位随访时间为13个月,食管胃吻合组和双通道吻合组病人随访期间胃食管反流、吻合口狭窄分别为58例和14例、10例和1例,两组病人上述指标比较,差异均有统计学意义(χ^(2)=51.743,7.219,P<0.05)。结论胃上部癌行根治性近端胃切除术,双通道吻合更适用于胃大弯侧SiewertⅡ型食管胃结合部腺癌或位置偏下肿瘤;双通道吻合与食管胃吻合比较,不增加并发症,且术后胃食管反流和吻合口狭窄发生率降低。

Objective To investigate the clinical efficacy of radical proximal gastrectomy with esophagogastrostomy and double-tract anastomosis for upper gastric cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 172 patients who underwent radical proximal gastrectomy for upper gastric cancer in Tianjin Medical University Cancer Institute and Hospital from January 2018 to December 2020 were collected.There were 147 males and 25 females,aged from 25 to 81 years,with a median age of 62 years.All the 172 patients underwent digestive reconstruction.Of the 172 patients,83 cases undergoing esophagogastrostomy were allocated into esophagogastrostomy group,89 cases undergoing double-tract anastomosis were allocated into double-tract anastomosis group.Patients were performed radical proximal gastrectomy combined with D_(1)+lymph node dissection by attending surgeons from department of gastric cancer.The operator decided to adopt esophagogastrostomy or double-tract anastomosis for digestive reconstruction.Observation indicators:[1]surgical situations;[2]follow-up.Follow-up using outpatient examination,telephone interview,and online APP was conducted at postoperative 1 month,once three months within postoperative 2 years,and once six months within postoperative 2-5 years.The questionnaires of reflux esophagitis,gastroscopy and upper gastrointestinal angiography were conducted to evaluate gastroesophageal reflux and anastomotic stenosis up to February 1,2021.Measurement data with normal distribution were represented as and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were represented as M[range],and comparison between groups was analyzed using the Mann-Whitney U test Comparison of ordinal data was analyzed using the non-parameter rank sum test.Count data were represented as absolute numbers,and comparison between groups was analyzed using the chi-square test.Results[1]Surgical situations:cases with open,laparoscopic or Da Vinci robotic surgery[surgical method],the number of metastatic lymph node,duration of postoperative hospital stay were 74,9,0,2[range,0-15],[12±4]days for the esophagogastrostomy group,versus 65,15,9,3[range,0-28],[11±3]days for the double-tract anastomosis group,respectively,showing significant differences in the above indicators between the two groups[χ^(2)=10.887,7=-1.058,t=3.284,P<0.05].[2]Follow-up:172 patients were followed up for 2-38 months,with a median follow-up time of 13 months.Cases with gastroesophageal reflux and anastomotic stenosis were 58 and 10 for the esophagogastrostomy group,versus 14 and 1 for the double-tract anastomosis group,respectively,showing significant differences in the above indicators between the two groups[χ^(2)=51.743,7.219,P<0.05].Conclusions For upper gastric cancer patients undergoing proximal radical gastrectomy,double-tract anastomosis is more suitable for Siewert type Ⅱ adenocarcinoma of esophagogastric junction in large curvature or lower located tumor.Compared with esophagogastrostomy,double-tract anastomosis has lower incidence of postoperative gastroesophageal reflux and anastomotic stenosis,without increasing complications.