不同消化道重建方式在腹腔镜辅助远端胃癌根治术中的应用效果比较

Comparison of the effects of different digestive tract reconstruction methods in laparoscopic assisted radical gastrectomy for distal gastric cancer

目的探讨非离断式Roux-en-Y吻合、Roux-en-Y吻合及BillrothⅡ-Braun吻合在腹腔镜辅助远端胃癌根治术中应用的可行性、安全性及疗效。方法采用回顾性病例对照研究方法,以唐山市协和医院2016年5月至2019年10月行腹腔镜辅助远端胃癌根治术的71例远端胃癌患者为研究对象,根据消化道重建方式的不同分为非离断式Roux-en-Y吻合组(Uncut RY组,29例);Roux-en-Y吻合组(RY组,24例);BillrothⅡ-Braun吻合组(BⅡ-Braun组,18例)。比较3组手术时间、吻合时间、术中出血量、术后排气时间、术后住院时间、主要并发症情况及术后1年营养状况指标的变化。采用SPSS18.0统计软件处理数据,计量资料采用Kolmogorov-Smirnov检验正态性,符合正态分布的计量资料以x±s表示,不符合正态分布的计量资料以M(Q_(1),Q_(3))表示,正态分布的计量资料组间比较采用方差分析;非正态分布的计量资料组间比较采用非参数秩和检验;计数资料以例(%)表示,组间比较采用χ^(2)检验或Fisher确切概率法。结果Uncut RY组、RY组及BⅡ-Braun组手术时间分别为(196.0±28.8)、(201.0±28.5)、(186.4±26.1)min,吻合时间分别为(56.2±13.9)、(57.8±12.9)、(51.5±10.0)min,术中出血量分别为(285.2±85.4)、(280.1±78.4)、(273.3±79.6)mL,术后排气时间分别为(52.5±14.4)、(53.9±14.6)、(46.2±9.4)h,术后住院时间分别为(12.6±2.8)、(12.1±3.0)、(12.8±2.6)d,3组比较差异均无统计学意义(F值分别为1.41、1.33、0.12、1.89、0.35,P值分别为0.251、0.271、0.890、0.158、0.709)。Uncut RY组、RY组及BⅡ-Braun组术后并发症:吻合口漏发生例数分别为0、1、1例,腹腔出血发生例数分别为1、1、0例,胆汁反流性胃炎发生例数分别为2、1、5例,吻合口溃疡发生例数分别为0、0、1例,3组比较差异均无统计学意义(P值分别为0.510、1.000、0.063、0.254);Roux-en-Y滞留综合征发生例数分别为0、6、0例,3组比较差异有统计学意义(P=0.001)。Uncut RY组、RY组及BⅡ-Braun组术后1年营养状况指标的变化,体质量下降分别为4.00(2.00,5.50)、3.00(1.25,4.75)、3.00(1.75,4.25)kg,血红蛋白水平下降分别为(5.62±8.20)、(6.63±6.84)、(5.33±7.79)g/L,血清白蛋白水平下降分别为1.00(-2.50,7.00)、3.00(-1.25,6.75)、6.00(-3.25,7.50)g/L,3组比较差异均无统计学意义(统计量值分别为H=1.42、F=0.18、H=2.43,P值分别为0.492、0.839、0.297)。结论作为远端胃癌根治术的消化道重建方式,非离断式Roux-en-Y吻合能降低Roux-en-Y滞留综合征的发生率,并且不增加手术风险,不影响术后营养状态,是一种安全可行的胃肠道重建方式。

Objective To evaluate the feasibility,safety and efficacy of uncut Roux-en-Y anastomosis,Roux-en-Y anastomosis and Billroth Ⅱ plus Braun anastomosis in laparoscopic-assisted distal gastrectomy for distal gastric cancer.Methods In the retrospective cohort study,71 cases of laparoscopic-assisted distal gastrectomy for distal gastric cancer from May 2016 to October 2019 in Tangshan Union Medical College Hospital were selected as the study subject.According to the different reconstruction methods of digestive tract,they were divided into:non disconnected Roux-en-Y anastomosis group(Uncut RY group,29 cases);Roux-en-Y anastomosis group(RY group,24 cases);Billroth Ⅱ-braun anastomosis group(BⅡ-Braun group,18 cases).The operation time,digestive tract reconstruction time,intraoperative blood loss,the time to flatus,length of hospital stay,incidence of complication and the changes of nutritional index 1 year after surgery were observed.SPSS 18.0 software was used process the data,the measurement data conforming to normal distribution by Kolmogorov-Smirnov test was expressed by x±s deviation,the measurement data dose not meet the normal distribution was expressed by the median(interquartile range)(M(Q_(1),Q_(3))).Analysis of variance was used to compare the measurement data of normal distribution;Nonparametric rank sum test was used for the comparison between measurement data groups with non normal distribution;Count data were expressed in cases(%),and χ^(2) test or Fisher exact probability method was used for composition comparison between groups.Results In Uncut group,RY group and BⅡ-Braun group,the operation time were(196.0±28.8)min,(201.0±28.5)min and(186.4±26.1)min,respectively,the digestive tract reconstruction time were(56.2±13.9)min,(57.8±12.9)min and(51.5±10.0)min,respectively,the intraoperative blood loss were(285.2±85.4)mL,(280.1±78.4)mL and(273.3±79.6)mL,respectively,the time to flatus were(52.5±14.4)h,(53.9±14.6)h and(46.2±9.4)h,respectively,the length of hospital stay were(12.6±2.8)d,(12.1±3.0)d and(12.8±2.6)d,respectively,there were no significant differences among the three groups(F values were 1.41,1.33,0.12,1.89 and 0.35,respectively;P values were 0.251,0.271,0.890,0.158 and 0.709,respectively).Postoperative complications in Uncut group,RY group and BⅡ-Braun group:The number of cases of anastomotic leakage was 0,1 and 1,respectively.The number of cases of abdominal bleeding was 1,1 and 0,respectively.The number of cases of bile reflux gastritis was 2,1 and 5,respectively,and the number of cases of anastomotic ulcer was 0,0 and 1,respectively.There were no significant differences among the three groups(Fisher's exact test,P values were 0.510,1.000,0.063 and 0.254,respectively).The number of cases of Roux-en-Y retention syndrome was 0,6 and 0,respectively.There were significant differences among the three groups(Fisher's exact test,P=0.001).Nutritional index:the weight loss were 4.00(2.00,5.50)kg,3.00(1.25,4.75)kg and 3.00(1.75,4.25)kg respectively,decreases of hemoglobin level were(5.62±8.20)g/L,(6.63±6.84)g/L and(5.33±7.79)g/L,respectively,decreases of albumin level were 1.00(-2.50,7.00)g/L,3.00(-1.25,6.75)g/L and 6.00(-3.25,7.50)g/L,respectively.There were no significant differences among the three groups(Statistic value were χ^(2)=1.42,F=0.18 and χ^(2)=2.43,respectively,P values were 0.492,0.839 and 0.297,respectively).Conclusion As a digestive tract reconstruction method for radical resection of distal gastric cancer,uncut Roux-en-Y anastomosis can reduce the incidence of Roux-en-Y retention syndrome without increasing the operation risk and affecting the postoperative nutritional status.It is a safe and feasible gastrointestinal tract reconstruction method.