改良Kamikawa吻合术在近端胃切除术后消化道重建中的应用

Application of modified Kamikawa anastomosis in digestive tract reconstruction after proximal gastrectomy

目的近端胃切除术后的消化道重建采用食管残胃双肌瓣吻合(Kamikawa吻合),可以显著降低吻合口相关并发症,减少患者术后反流性食管炎的发生,但因其操作复杂,影响了该术式的普及。山西长治医学院附属长治市人民医院胃肠外科团队对Kamikawa吻合术式进行了改良,通过优化手术步骤,降低了手术难度。本研究探讨改良Kamikawa吻合术的安全性和有效性。方法采用描述性病例系列研究方法。病例入组标准为经术前胃镜活组织病理学检查及影像学检查,证实为未发生转移的食管胃结合部癌、胃上部癌,肿瘤直径<4 cm;术前临床分期为cT1~3N1M0。排除标准为术前接受新辅助化疗、合并严重心肺疾病、营养状况差难以耐受手术以及临床资料不完整者。收集2019年4月至2020年12月期间,长治医学院附属和济医院胃肠外科(8例)和长治医学院附属长治市人民医院胃肠外科(17例)在近端胃切除术中采用改良Kamikawa吻合术的25例食管胃结合部癌和胃上部癌患者的临床资料,其中男性21例,女性4例,年龄(63.0±7.8)岁,开腹手术3例,腔镜手术22例。改良Kamikawa吻合术的改良内容:(1)应用食管胃结合部全系膜切除理念,以利于淋巴结的彻底清扫和便于进行手工吻合和包埋;(2)吻合口直径根据食管断端口径进行选择,在2.5~3.5 cm之间,以减少吻合口狭窄的发生;(3)使用超声刀将食管残端切开,既可防止食管残端出血、又可将食管黏膜、肌层与外膜紧密贴合,防止食管黏膜回缩;(4)使用倒刺线将残胃底和食管进行连续缝合固定胃底,以减少在狭小空间繁琐、困难的间断缝合;(5)使用两根倒刺线进行吻合口前后壁的连续缝合并完成肌瓣的缝合固定。分析手术安全性相关指标以及术后并发症(采用Clavien-Dindo分级)、食管反流症状和食管炎(洛杉矶分级)发生情况。通过术后随访胃食管反流症状量表(GERD)评分、胃镜、多体位消化道造影等手段,评估残胃动力和抗反流效果。结果25例患者均完成改良Kamikawa吻后术。手术时间(5.8±1.8)h,术中出血量(89.2±11.8)ml,术后住院时间(13.8±2.9)d。术后发生吻合口狭窄3例(12.0%),为Clavien-DindoⅢ级,经内镜下扩张治疗后痊愈。术后上消化道造影显示并出现反流症状1例(4.0%),为Clavien-DindoⅠ级,胃镜检查未见其有反流性食管炎征象,洛杉矶分级为A级。所有患者均未发生吻合口出血、局部感染和死亡。术后6个月,食管胃反流测量表GERD评分为(2.7±0.6)分,与术前(2.4±1.0)分相比,差异无统计学意义(t=-1.495,P=0.148)。结论改良Kamikawa吻合术在近端胃切除术中的应用安全可行,具有良好的抗反流效果。

Objective Traditional Kamikawa anastomosis in digestive tract reconstruction after proximal gastrectomy can greatly decrease the anastomosis-related complications and reduce the incidence of reflux esophagitis,but its complexity limits the wide application.To decrease the complexity of Kamikawa anastomosis,the surgical team of Changzhi People's Hospital of Shanxi Changzhi Medical College improved this technique by using novel notion and reduced surgical procedures.This study aims to evaluate the efficacy and safety of modified Kamikawa anastomosis in digestive tract reconstruction after proximal gastrectomy.Methods A descriptive cohort study was carried out.Case enrollment criteria:(1)upper gastric carcinoma or esophagogastric junction carcinoma without distant metastasis was confirmed by preoperative gastroscopic biopsy and imaging examination;(2)tumor diameter was less than 4 cm;(3)preoperative clinical staging was cT1-3N1M0.Exclusion criteria:(1)patients received preoperative neoadjuvant chemotherapy;(2)patients had severe heart or lung disease,or poor nutritional status so that they could not tolerate surgery.Clinical data of 25 patients with upper gastric carcinoma or esophagogastric junction carcinoma who underwent modified Kamikawa anastomosis in digestive tract reconstruction in Heji Hospital(8 cases)and Changzhi People's Hospital(17 cases)from April 2019 to December 2020 were retrospectively collected.Of 25 patients,21 were male and 4 were female,with mean age of 63.0(49 to 78)years;3 underwent open surgery and 22 underwent laparoscopic surgery.The modified Kamikawa anastomosis was as follows:(1)the novel notion of total mesangial resection of the esophagogastric junction was applied to facilitate the thorough removal of lymph nodes and facilitate hand-sewn anastomosis and embedding;(2)the diameter of the anastomotic stoma was selected according to the diameter of the esophageal stump,between 2.5 and 3.5 cm,to reduce the occurrence of anastomotic stenosis;(3)an ultrasonic scalpel was used to incise the esophageal stump,which could not only prevent bleeding of the esophageal stump,but also closely seal the esophageal mucosa,muscle layer and serosa to prevent esophageal mucosa retraction;(4)barbed suture was used to suture the remnant stomach fundus and esophagus to fix the stomach fundus in order to reduce the cumbersome and difficult intermittent sutures in a small space;(5)two barbed sutures were used to continuously suture the front and back walls of the anastomosis and complete the suture and fixation of the muscle flap.Relevant indicators of surgical safety,postoperative complications(using the Clavien-Dindo classification),esophageal reflux symptoms and the occurrence of esophagitis(using Los Angeles classification)were analyzed.The gastroesophageal reflux disease(GERD)score,gastroscopy,multi-position digestive tract radiography during postoperative follow-up were used to evaluate the residual gastric motility and anti-reflux efficacy.Results Modified Kamikawa anastomosis in digestive tract reconstruction after proximal gastrectomy was successfully performed in 25 patients.The surgical time was(5.8±1.8)hours,the intraoperative blood loss was(89.2±11.8)ml,and the average hospital stay was(13.8±2.9)days.Three cases(12.0%)developed postoperative anastomotic stenosis as Clavien-Dindo grade III and were healed after endoscopic dilation treatment.Postoperative upper gastrointestinal radiography showed 1 case(4.0%)with reflux symptoms as Clavien-Dindo grade I.Gastroscopy showed no signs of reflux esophagitis,and its Los Angeles classification was A grade.No anastomotic bleeding,local infection and death were found in all the patients.At postoperative 6-month of follow-up,GERD score showed no significant difference compared to pre-operation(2.7±0.6 vs.2.4±1.0,t=-1.495,P=0.148).Conclusion Modified Kamikawa anastomosis in digestive tract reconstruction after proximal gastrectomy is safe and feasible with good anti-reflux efficacy.