完全腹腔镜全胃切除术多模式改良食管空肠Overlap吻合的单中心152例安全性和可行性分析

Overlap esophagojejunostomy with multi-mode modifications in totally laparoscopic total gastrectomy: safety and feasibility of 152 cases from a single center

目的 Overlap吻合法是目前最受欢迎的腹腔内食管空肠吻合方法之一, 但其在食管残端回缩、吻合器钉砧误入食管"假道"以及共同开口的关闭等方面仍存在挑战。本研究探讨对经典Overlap吻合法进行多模式改良的安全性和可行性。方法采用描述性病例系列研究的方法。分析空军军医大学第二附属医院普通外科2017年2月至2020年6月期间, 由同一手术团队连续在完全腹腔镜全胃切除术后采用多模式改良食管空肠Overlap吻合法的152例胃癌患者的病例资料。多模式改良Overlap吻合法主要包括:(1)在确保肿瘤切缘安全的前提下(肿瘤近切缘距离≥3 cm), 由左向右次全离断食管(保留宽度5~8 mm);标本入袋并移至右中腹, 调整体位, 通过标本重力对腹段食管进行充分牵引;(2)采用"三向牵引"胃管引导方式显露食管腔, 确切置入吻合器钉砧, 完成食管空肠侧侧吻合;(3)以3-0"倒刺线"自背侧向腹侧先"内进内出"单层连续缝合, 后"外进外出"垂直褥式内翻连续缝合, 关闭共同开口。对全组患者结合临床病理特征对围手术期结局和术后并发症等情况进行分析评估。结果 152例患者男女分别为129例和23例, 年龄(60.2±9.1)岁, 体质指数为(23.2±3.1) kg/m2;23例(15.1%)既往有腹部手术史。全组患者肿瘤近切缘长度(3.3±0.3) cm, 21例齿状线受侵, 病理检查近切缘均为阴性。21例齿状线受侵, 肿瘤近切缘长度(3.3±0.3) cm, 病理检查近切缘均为阴性。手术近期结果:手术时间和吻合时间分别为(302.1±39.9) min和(29.8±5.4) min;估计失血量为(87.9±46.4) ml;术后住院时间为(12.3±7.3) d。术后Clavien-Dindo≥Ⅱ级并发症22例(14.5%), 其中胰漏6例, 通过充分引流、抑制胰腺外分泌及肠内营养支持等治疗顺利恢复;肺炎10例, 腹腔感染3例, 通过抗感染及物理治疗后痊愈;吻合口漏2例, 1例因空肠Roux袢张力过高, 侧侧吻合后空肠一侧开口过大所致, 另1例则因术中发生"鼻胃管钉合于侧侧吻合处"的意外情况, 均经充分引流、抗感染、营养治疗后痊愈。1例术后7 d发生Peterson疝并接受二次手术, 终因大范围小肠坏死而死亡。结论多模式改良食管空肠Overlap吻合法简化操作, 降低了食管空肠吻合难度, 是一种安全易行的食管空肠改良吻合方法。

Objective Currently,the Overlap anastomosis is one of the most favored reconstruction methods of intracorporeal esophagojejunostomy(EJS).Despite many advantages of the method,it remains some shortcomings to be improved when it comes to the retraction of the esophagus stump,the insertion of the anvil fork of the linear stapler into a"pseudo"lumen,and the closure of the common entry hole.This study aims to investigate the safety and feasibility of a multi-mode modified Overlap anastomosis.Methods A descriptive case series study was conducted.Medical records of 152 consecutive patients who underwent totally laparoscopic total gastrectomy(TLTG)with our multi-mode modified Overlap EJS method by the same surgical team at our department from February 2017 to June 2020 were retrospectively analyzed.The multi-mode modified Overlap method mainly included(1)After ensuring the safety of tumor resection margin(proximal margin was at least 3 cm from the tumor),the esophagus was partially transected from left to right(with 5-8 mm width esophagus continuation).The specimen was then placed in a plastic bag which was tied up at the mouth using strings with a part of the esophageal wall poking through.Then the plastic bag containing the specimen was transferred to the right lumbar region,while the patient's body position was adjusted so that the abdominal esophagus could be pulled by the gravity of the specimen.(2)Using the"three-direction traction"method.The esophageal lumen was properly exposed,then guided by the gastric tube,the anvil fork was accurately placed into the esophageal lumen for completing the side-to-side EJS.(3)The 3-0 barbed suture was used in the closure of the common entry hole of the stapler from dorsally to ventrally with simple one-layer continuous suture(the stitch going from inside to inside)followed by continuous Lembert's suture(the stitch going from outside to outside).Combined with clinicopathological characteristics,the perioperative outcomes and postoperative complications of the whole group were analyzed and evaluated.Results The study cohort included 129 men and 23 women,with a mean age of(60.2±9.1)years and a mean body mass index(BMI)of(23.2±3.1)kg/m2.Of the 152 patients,23 patients(15.1%)had a history of previous abdominal surgery;dentate line was invaded by tumor in 21 patients(13.8%).The mean length of the proximal resection margin was(3.3±0.3)cm and the postoperative pathological examination indicated negative resection margin tumor.The mean operative time and anastomotic time were(302.1±39.9)minutes and(29.8±5.4)minutes,respectively.The mean estimated blood loss was(87.9±46.4)ml.The mean length of postoperative hospital stay was(12.3±7.3)days.The overall severe postoperative complications(Clavien-Dindo≥II)occurred in 22 patients(14.5%).Six cases of pancreatic leakage were successfully recovered by adequate drainage,inhibition of pancreatic exocrine secretion and nutritional support.Ten cases of pneumonia and three cases of abdominal infection were cured with anti-infection and physical therapy.Two patients developed anastomotic leakage postoperatively.One case was caused by excessive tension of the Roux loop of the jejunum and excessive opening on the side of the jejunum after side-to-side anastomosis,and the other case was caused by an accidental intraoperative occurrence of"nasogastric tube stapled to the side-to-side anastomosis".Both of them recovered after conservative treatment including adequate drainage,anti-infection,and adequate nutritional support.One patient underwent immediate open surgery because of Peterson's hernia 7 days after TLTG,and the patient died due to extensive small bowel necrosis.Conclusions Multi-mode modified overlap method simplifies the operation and reduces the difficulty of EJS.It is a safe and feasible method for EJS.