食管胃结合部腺癌切除后消化道重建的体会与思考

Experience and thoughts on digestive tract reconstruction after radical resection of adenocarcinoma of the esophagogastric junction

在食管胃结合部腺癌(AEG)的外科治疗策略中, 淋巴结清扫范围、手术入路选择、肿瘤切除范围及消化道重建等问题一直存在争议, 尤其AEG术后消化道重建面临着诸多挑战。其消化道重建方式与切除范围相关。目前, 全胃切除术后消化道重建方式有Roux-en-Y吻合、空肠间置法及其衍生术式, 依据重建方式不同, 可分为管型吻合、线型吻合以及手工吻合。近端胃切除术后抗反流消化道重建方式主要有食管胃吻合、间置空肠和双通道吻合3类, 目前, 国内较常用的重建方式为双通道吻合。笔者基于间置管状胃及重建胃角抗反流的理念, 提出"Giraffe"吻合, 将人工胃底及His角下移, 保留更多的残胃, 显示了良好的胃排空及抗反流效果。本文中, 我们就AEG术后消化道重建的方式选择和技术要点, 结合自身的临床经验和体会, 对相关问题进行思考和探讨, 并提出, 复合的抗反流机制设计, 可能是未来抗反流重建方式设计的发展趋势, 包括基于保留胃体中部大弯侧的胃电起搏点以增加残胃排空能力、重建的胃底及His角抗反流屏障、间置管状胃发挥缓冲带作用的理念设计的"Giraffe"吻合等。

In the surgical treatment of adenocarcinoma of the esophagogastric junction(AEG),the scope of lymph node dissection,surgical approach selection,extent of tumor resection and digestive tract reconstruction have always been controversial,with the digestive tract reconstruction in AEG facing many challenges especially.The digestive tract reconstruction is related to the extent of resection.At present,the digestive tract reconstruction after total gastrectomy includes Roux-en-Y anastomosis,jejunum interposition and its derivatives.According to different reconstruction methods,they can be divided into tube anastomosis,linear anastomosis and manual anastomosis.Anti-reflux digestive tract reconstruction after proximal gastrectomy mainly includes esophagogastric anastomosis,interposition jejunum and double channel anastomosis.At present,double channel anastomosis is the most common reconstruction method in China.Based on the concept of interposition tubular stomach and reconstruction of gastric angle for anti-reflux,we propose"Giraffe"anastomosis,which moves artificial fundus and His angle downward to retain more residual stomach,showing good gastric emptying and anti-reflux effect.In this paper,combined with our clinical experience and understanding,we discuss the selection and technical key points of digestive tract reconstruction methods in AEG,and suggest that composite anti-reflux mechanism design may be the development trend of anti-reflux reconstruction in the future.The composite mechanism includes the retention of gastric electrical pacemaker in greater curvature of the middle part of gastric body to increase the emptying capacity of residual stomach,the reconstruction of gastric fundus and His angle anti-reflux barrier,and the establishment of an interposition tubular stomach acting as a buffer zone in Giraffe construction,and so on.