生物肌瓣在腹腔镜根治性近端胃切除食管胃吻合术中的应用价值

Application value of biological muscle flap in laparoscopic radical proximal gastrectomy with esophagogastric anastomosis

目的探讨生物肌瓣在腹腔镜根治性近端胃切除食管胃吻合术中的应用价值。方法采用回顾性描述性研究方法。收集2023年5―8月西安交通大学第一附属医院收治的10例食管胃结合部腺癌患者的临床病理资料;均为男性;年龄为(65±5)岁。患者均行腹腔镜根治性近端胃切除食管胃吻合术。消化道重建采用食管胃生物肌瓣吻合术。观察指标:(1)手术及早期并发症情况。(2)随访及晚期并发症情况。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术及早期并发症情况。10例患者均顺利完成手术,无中转开腹,手术时间为(166±18)min,消化道吻合方式为端侧吻合、Overlap吻合分别为1、9例,消化道重建时间为(40±12)min,淋巴结清扫数目为(24±6)枚,术中出血量为(41±9)mL,术后肛门首次排气时间为(3.4±0.5)d,术后首次进食流质食物时间为(4.1±1.0)d,术后住院时间为(8.3±0.7)d。4例患者术后发生早期并发症,其中1例术后第2天发生肺部感染(Clavien-DindoⅡ级),给予抗菌药物治疗5 d后肺部感染灶吸收;2例术后第3天发生胸闷、气短症状,胸腔B超检查提示胸腔少-中量积液,给予胸腔穿刺抽液,积极治疗后症状好转,胸腔积液消失;1例术后第3周进食固体食物时出现哽咽感,上消化道造影检查提示吻合口轻度狭窄(Clavien-DindoⅠ级),给予保守治疗后好转。10例患者术后第7天行上消化造影检查均无吻合口瘘、吻合口狭窄发生,平卧位及头低30°体位均无造影剂反流征。(2)随访及晚期并发症情况。10例患者均获得随访,随访时间为59.5(31.0~127.0)d,食管反流量表评分为(1.4±0.3)分。随访期间,1例患者术后40 d行胃镜检查提示反流性食管炎(洛杉矶分级为B级、Clavien-DindoⅠ级),无烧心、反酸等临床症状,24 h-pH监测结果示直立位时发生24次反流,仰卧位时发生15次反流,无长反流;24 h内总反流时间为75 min;DeMeester评分为38.3分;食管压力测定结果示食管收缩形态正常,吻合口松弛欠佳。9例患者无反流性食管炎等并发症。结论生物肌瓣应用于腹腔镜根治性近端胃切除食管胃吻合术安全、可行,近期疗效满意。

Objective To investigate the application value of biological muscle flap in laparo-scopic radical proximal gastrectomy with esophagogastric anastomosis.Methods The retrospec-tive and descriptive study was conducted.The clinicopathological data of 10 patients with adeno-carcinoma of esophagogastric junction who were admitted to The First Affiliated Hospital of Xi′an Jiaotong University from May 2023 to August 2023 were collected.All patients were males,aged(65±5)years.All patients underwent laparoscopic radical proximal gastrectomy and esophagogastric anastomosis with digestive tract reconstruction using the esophagogastric biological muscle flap.Observation indicators:(1)surgical situations and early complications;(2)follow-up and late com-plications.Measurement data with normal distribution were represented as Mean±SD,and measure-ment data with skewed distribution were represented as M(range).Count data were described as absolute numbers.Results(1)Surgical situations and early complications.All 10 patients success-fully completed the surgery without conversion to open surgery,and the operation time was(166±18)minutes.Cases with digestive tract reconstruction as end-to-side anastomosis and Overlap anas-tomosis were 1 and 9,respectively.The time of digestive tract reconstruction,the number of lymph node dissected,volume of intraoperative blood loss,time to postoperative first anal exhaust,time to postoperative first intake of liquid food,duration of postoperative hospital stay were(40±12)minutes,24±6,(41±9)mL,(3.4±0.5)days,(4.1±1.0)days,(8.3±0.7)days in the 10 patients.Of 4 cases with postoperative early complications,1 case developed pulmonary infection(Clavien-Dindo gradeⅡ)on the second day after surgery,with pulmonary infection absorbed after 5 days of antibiotic treat-ment.Two cases experienced chest distress and shortness of breath on the third day after surgery,with the diagnosis of a small to moderate amount of pleural effusion after chest B-ultrasound examination.After pleural puncture and active treatment,the symptoms of them were improved and the pleural effusion disappeared.There was 1 case with choking sensation when eating solid food,which was started from the third week after surgery.Upper gastrointestinal imaging revealed mild anastomotic stenosis of Clavien-Dindo gradeⅠin the patient,who was improved after conservative treatment.On the 7th day after surgery,all 10 patients underwent upper gastrointestinal angiography,and no anastomotic leakage or stenosis occurred.There was no sign of contrast agent reflux in the supine position and 30°head down position.(2)Follow-up and late complications.All 10 patients were followed up for 59.5(range,31.0-127.0)days.The esophageal reflux scale score of 10 patients was 1.4±0.3.During the follow-up,1 case underwent gastroscopy on 40 days after surgery,which showed reflux esophagitis with Los Angeles grade as B and the Clavien-Dindo grade asⅠ.There was no clinical symptom such as heartburn or acid reflux.Results of 24-hour pH monitoring showed that the patient experienced 24 instances of reflux in an upright position and 15 instances of reflux in a supine position,with no prolonged reflux.The total reflux time within 24 hours was 75 minutes.The DeMeester score was 38.3.Results of esophageal pressure measurement showed that the esophageal contraction morphology was normal,but the anastomotic opening was not well relaxed.The rest of 9 cases had no complication such as reflux esophagitis.Conclusion Biological muscle flap applied in the laparoscopic radical proximal gastrectomy with esophagogastric anastomosis is safe and feasible,with satisfied short-term efficacy.