胃癌近端胃切除联合不同抗反流消化道重建方式疗效评估的多中心回顾性研究

A multicenter retrospective study on the efficacy of different anti-reflux reconstruction methods after proximal gastrectomy for gastric cancer

目的探讨胃癌近端胃切除后不同抗反流消化道重建方式的临床效果。方法回顾性收集2016年9月至2021年8月在中国11家医疗中心就诊的338例近端胃切除后行抗反流消化道重建的胃癌患者的临床资料,男性273例,女性65例,年龄(63±10)岁(范围:28~91岁)。其中管状胃食管吻合159例(管状胃组),空肠双通道重建107例(双通道组),食管胃双肌瓣技术吻合72例(双肌瓣组)。记录手术时间、术后住院时间、术后早期并发症及分级、术后营养状态,根据洛杉矶分级法对术后12个月胃镜下反流性食管炎进行分级,Visick分级标准评估术后生活质量。分别采用方差分析、混合线性模型、Kruskal-Wallis秩和检验、χ^(2)检验和Fisher确切概率法进行多组间比较,两两比较采用Bonferroni法校正。结果双肌瓣组手术时间明显长于管状胃组和双通道组[(352±63)min比(221±66)min,(352±63)min比(234±61)min,P均<0.01]。管状胃组、双肌瓣组、双通道组术后Clavien-Dindo并发症分级系统Ⅱ级及以上并发症发生率分别为17.0%(27/159)、9.7%(7/72)、10.3%(11/107)(χ^(2)=3.51,P=0.173)。三种重建方式术后体重指数变化趋势的差异有统计学意义(F=9.78,P<0.01)。管状胃组术后6个月和12个月的体重指数较术前的下降幅度高于双肌瓣组(均数差值:1.721 kg/m2,P<0.01;均数差值:2.429 kg/m2,P<0.01),双通道组术后12个月体重指数下降幅度高于双肌瓣组(均数差值:1.319 kg/m2,P=0.027)。三组手术前后血红蛋白水平、白蛋白水平变化的差异均无统计学意义(P值均>0.05)。术后12个月双通道组反流性食管炎的发生率为12.9%(4/31),低于双肌瓣组的45.9%(17/37)(χ^(2)=8.63,P=0.003)。双肌瓣组术后Visick 2~4级不适症状的比例为10.4%(7/67),低于管状胃组的34.6%(27/78)(χ^(2)=11.70,P=0.018),但与双通道组的22.2%(8/36)差异无统计学意义(P>0.05)。结论双肌瓣技术手术时间长于管状胃吻合及双通道重建,但术后早期并发症发生率相当。双肌瓣技术更有利于患者术后营养状态和生活质量的改善,其优势相较于管状胃吻合更加明显。双通道重建术后反流性食管炎发生风险低于双肌瓣技术。

Objective To examine the clinical efficacy of 3 anti-reflux methods of digestive tract reconstruction after proximal gastrectomy for gastric cancer.Methods The clinical data and follow-up data of gastric cancer patients who underwent anti-reflux reconstruction after proximal gastrectomy in 11 medical centers of China from September 2016 to August 2021 were retrospectively collected,including 273 males and 65 females,aging of(63±10)years(range:28 to 91 years).Among them,159 cases were performed with gastric tube anastomosis(GTA),107 cases with double tract reconstruction(DTR),and 72 cases with double-flap technique(DFT),respectively.The duration of operation,length of postoperative hospital stay and early postoperative complications(referring to Clavien-Dindo classification)of different anti-reflux reconstruction methods were assessed.Body mass index,hemoglobin and albumin were used to reflect postoperative nutritional status.Reflux esophagitis was graded according to Los Angeles criteria based on the routinely gastroscopy within 12 months after surgery.The postoperative quality of life(QoL)was evaluated by Visick score system.The ANOVA analysis,Kruskal-Wallis rank sum test,χ^(2) test and Fisher′s exact test were used for comparison between multiple groups,and further comparison among groups were performed with LSD,Tamhane′s test or Bonferroni correctedχ^(2) test.The mixed effect model was used to compare the trends of Body mass index,hemoglobin and albumin over time among different groups.Results The operation time of DFT was significantly longer than that of GTA and DTR((352±63)minutes vs.(221±66)minutes,(352±63)minutes vs.(234±61)minutes,both P<0.01).The incidence of early complications with Clavien-Dindo gradeⅡtoⅤin GTA,DFT and DTR groups was 17.0%(27/159),9.7%(7/72)and 10.3%(11/107),respectively,without significant difference among these three groups(χ^(2)=3.51,P=0.173).Body mass index decreased more significantly in GTA than DFT group at 6 and 12 months after surgery(mean difference=1.721 kg/m2,P<0.01;mean difference=2.429 kg/m2,P<0.01).body mass index decreased significantly in DTR compared with DFT at 12 months after surgery(mean difference=1.319 kg/m2,P=0.027).There was no significant difference in hemoglobin or albumin fluctuation between different reconstruction methods perioperative.The incidence of reflux esophagitis one year after surgery in DTR group was 12.9%(4/31),which was lower than that in DFT(45.9%(17/37),χ^(2)=8.63,P=0.003).Follow-up of postoperative quality of life showed the incidence of Visick grade 2 to 4 in DFT group was lower than that in GTA group(10.4%(7/67)vs.34.6%(27/78),χ^(2)=11.70,P=0.018),while there was no significant difference between DFT and DTR group(10.4%(7/67)vs.22.2%(8/36,P>0.05).Conclusions Compared with GTA and DTR,DFT is more time-consuming,but there is no significant difference in early complications among three methods.DFT reconstruction is more conducive to maintain postoperative nutritional status and improve QoL,especially compared with GTA.The risk of reflux esophagitis after DTR reconstruction is lower than that of DFT.