腹腔镜近端胃切除Kamikawa吻合术与间置空肠双通道吻合术近期临床疗效

Short-term clinical efficacy of Kamikawa anastomosis and jejunal interposed double channel anastomosis in laparoscopic proximal gastrectomy

目的探讨腹腔镜近端胃切除Kamikawa吻合术与间置空肠双通道吻合术近期临床疗效。方法采用回顾性队列研究方法。收集2018年3月至2020年12月国内2家医学中心收治的68例(长治医学院附属长治市人民医院63例、长治医学院附属和济医院5例)食管胃结合部和胃上部肿瘤行腹腔镜近端胃切除术患者的临床病理资料;男57例,女11例;年龄为62(39~78)岁。68例患者中,35例行腹腔镜近端胃切除Kamikawa吻合术设为Kamikawa组,33例行腹腔镜近端胃切除置空肠双通道吻合术设为双通道组。观察指标:(1)术中情况。(2)术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后chew‑wun wu特殊症状量表评分、术后反流性食管炎、吻合口狭窄情况。随访时间截至2021年12月。正态分布的计量资料以x±s表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann‑Whitney U检验,等级资料比较采用非参数秩和检验。计数资料以绝对数表示,组间比较采用χ^(2)检验或Fisher确切概率法。结果(1)术中情况。68例患者均顺利完成腹腔镜近端胃切除联合D1+淋巴结清扫术。Kamikawa组和双通道组患者手术时间、术中出血量分别为(5.15±0.31)h、(89±11)mL和(4.21±0.11)h、(142±20)mL,两者上述指标比较,差异均有统计学意义(t=2.81,-2.34,P<0.05);消化道重建时间、淋巴结清扫数目分别为(1.95±0.13)h、(30.4±2.4)枚和(1.69±0.76)h、(28.0±2.4)枚,两者上述指标比较,差异均无统计学意义(t=1.79,0.73,P>0.05)。(2)术后情况。Kamikawa组和双通道组患者术后首次肛门排气时间、引流管放置时间、术后住院时间分别为(3.03±0.12)d、(5.46±0.22)d、(13.00±0.50)d和(4.42±0.21)d、(9.97±0.76)d、(16.46±0.92)d,两者上述指标比较,差异均有统计学意义(t=-5.80,-5.58,3.40,P<0.05);引流管放置(有、无)分别为32、3例和33、0例,两者比较,差异无统计学意义(P>0.05)。术后并发症Clavien‑Dindo分级(1级、2级、3级、4级)分别为31、0、4、0例和27、3、1、2例,两者比较,差异有统计学意义(Z=-6.28,P<0.05);Kamikawa组和双通道组患者术后吻合口狭窄、反流症状、吻合口瘘、胰瘘、肺部感染分别为4、2、0、0、0例和0、1、3、1、2例,两者上述指标比较,差异均无统计学意义(P>0.05);两组患者术后均未发生切口感染、腹腔出血、淋巴瘘、胃瘫并发症。Kamikawa组4例围手术期发生吻合口狭窄患者中,2例经1次胃镜球囊扩张治疗后病情好转;2例经4次胃镜球囊扩张治疗后病情好转。(3)随访情况。68例患者均获得随访,随访时间为术后3、6、12个月。Kamikawa组和双通道组患者术后12个月chew‑wun wu特殊症状量表评分分别为(16.8±0.7)分和(14.6±0.7)分,两者比较,差异有统计学意义(t=2.20,P<0.05);发生≥Grade B级反流性食管炎分别为2例和1例,两者比较,差异无统计学意义(P>0.05);均未发生吻合口狭窄。结论腹腔镜近端胃切除Kamikawa吻合术与间置空肠双通道吻合术治疗食管胃结合部和胃上部肿瘤安全、可行,前者术中出血量少,术后首次肛门排气时间、引流管放置时间、术后住院时间均更短,术后生命质量更高。

Objective To investigate the short-term clinical efficacy of Kamikawa anastomosis and jejunal interposed double channel anastomosis in laparoscopic proximal gastrectomy.Methods The retrospective cohort study was conducted.The clinicopathological data of 68 patients with esophagogastric junctional tumors and upper gastric tumors who underwent laparoscopic proximal gastrectomy in two medical centers,including 63 cases in the Changzhi People's Hospital Affiliated to Changzhi Medical College and 5 cases in the Heji Hospital Affiliated to Changzhi Medical College,from March 2018 to December 2020 were collected.There were 57 males and 11 females,aged 62(range,39‒78)years.Of 68 patients,35 patients undergoing Kamikawa anastomosis in laparoscopic proximal gastrectomy were allocated into Kamikawa group,and 33 patients undergoing jejunal interposed double channel anastomosis in laparoscopic proximal gastrectomy were allocated into double channel group.Observation indicators:(1)intraoperative situations;(2)postoperative situations;(3)follow-up.The patients were followed up by outpatient examinations and telephone interview to detect the postoperative score of chew-wun wu special symptoms,postoperative reflux anastomotic esophagitis and anastomotic stenosis up to December 2021.Measurement data with normal distri-bution were represented as Mean±SD,and comparison between groups was performed by the t test.Measurement data with skewed distribution were represented as M(range),and comparison between groups was conducted by Mann-Whitney U test.Comparison of ordinal data was performed by nonparametric rank sum test.Count data were expressed as absolute numbers,and comparison between groups was conducted using the chi-square test or Fisher exact probability method.Results(1)Intraoperative situations.All the 68 patients successfully underwent laparoscopic proximal gastrectomy combined with D1+lymph node dissection.The operation time and volume of intraoperative blood loss of the Kamikawa group were(5.15±0.31)hours and(89±11)mL,versus(4.21±0.11)hours and(142±20)mL of the double channel group,respectively,showing significant differences between the two groups(t=2.81,‒2.34,P<0.05).The digestive tract reconstruction time and the number of lymph node dissection were(1.95±0.13)hours and 30.4±2.4 of the Kamikawa group,versus(1.69±0.76)hours and 28.0±2.4 of the double channel group,respectively,showing no significant difference between the two groups(t=1.79,0.73,P>0.05).(2)Postoperative situations.The time to postoperative first flatus,duration of drainage tube placement,duration of postoperative hospital stay were(3.03±0.12)days,(5.46±0.22)days,(13.00±0.50)days of the Kamikawa group,versus(4.42±0.21)days,(9.97±0.76)days,(16.46±0.92)days of the double channel group,showing significant differences in the above indicators between the two groups(t=‒5.80,‒5.58,3.40,P<0.05).Cases with or without drainage tube placement were 32 and 3 of the Kamikawa group,versus 33 and 0 of the double channel group,respectively,showing no significant difference between the two groups(P>0.05).Cases with grade 1,grade 2,grade 3,grade 4 complications of Clavien‐Dindo classification were 31,0,4,0 of the Kamikawa group,versus 27,3,1,2 of the double channel group,respectively,showing a significant difference between the two groups(Z=‒6.28,P<0.05).Postoperative anastomotic stenous,reflux symptoms,anastomotic fistula,pancreatic fistula,pulmonary infection were found in 4,2,0,0,0 case of the Kamikawa group and 0,1,3,1,2 cases of the double channel group,respectively.There was no significant difference in the above indicators between the two groups(P>0.05).There was no complication of incisional infection,abdominal hemorrhage,lymphatic fistula or gastroparesis in either group.Of the 4 patients with perioperative anastomotic stenosis in the Kamikawa group,2 cases were improved after once gastroscopic balloon dilatation,2 cases were improved after 4 times of gastro-scopic balloon dilatation.(3)Follow‐up.All the 68 patients were followed up at postoperative 3,6,12 months.The scores of chew-wun wu special symptoms scale at postopertaive 12 months of the Kamikawa group and double channel group were 16.8±0.7 and 14.6±0.7,respectively,showing a significant difference between the two groups(t=2.20,P<0.05).There were 2 cases of grade B reflux esophagitis and 1 case of grade B reflux esophagitis,respectively,showing no significant difference between the two groups(P>0.05).There was no anastomotic stenosis occurred in either group.Conclusions Laparoscopic proximal gastrectomy with Kamikawa anastomosis or jejunal interposed double channel anastomosis is safe and feasible for esophagogastric junction tumors and upper gastric tumors.The Kamikawa anastomosis has less volume of intraoperative blood loss,shorter time to postoperative first flatus,duration of drainage tube placement and postoperative hospital stay,higher quality of postoperative lfe.