食管残胃斜角吻合加单肌瓣成形术在腹腔镜近端胃切除术中的应用

Feasibility of single valvuloplastic esophagogastrostomy technique for laparoscopic proximal gastrectomy

目的:探讨腹腔镜近端胃切除后食管残胃斜角吻合加单肌瓣成形术(OSF)进行消化道重建的可行性。方法:在残胃闭合钉下缘2 cm处用蓝色笔标记2.5 cm×3.5 cm的反“コ”形的单肌瓣,在黏膜下层与浆肌层间隙仔细游离制作肌瓣。在其尾侧1 cm的残胃前壁切开胃壁全层,制作一个1.0 cm小孔,四周缝合4针作支持线。紧贴食管右侧切开食管全层,缝合一针食管全层防止吻合时直线闭合切割器误入食管黏膜下层。直线闭合切割器从食管右侧壁向食管左侧倾斜与食管纵轴成30°,进行食管背侧与胃前壁斜角吻合,其重建之后更接近生理的His角。在约4 cm处夹闭切割闭合器进行吻合,共同开口缝合3针支撑线,直线切割闭合器关闭共同开口。牵拉单肌瓣向小弯侧,用可吸收线缝合固定肌瓣两角。倒刺线从肌瓣的尾侧大弯侧向小弯侧连续缝合,之后继续沿着小弯侧向头侧缝合,最后缝合肌瓣的贲门侧,完成整个单肌瓣抗反流重建。结果:回顾性收集2022年1月至2023年5月期间接受根治性胃切除术并采用OSF法重建的11例SiewertⅡ型的食管胃结合部癌患者临床资料。其中,男性7例,女性4例,年龄(69.9±7.8)岁,体质指数为(21.7±7.2)kg/m 2,肿瘤长径为(2.1±0.6)cm。全组11例患者均顺利完成OSF重建。中位手术时间275(270~428)min,中位OSF重建时间112(80~140)min,中位失血量50(20~400)ml。术后病理显示,肿瘤TNM分期为0~Ⅰ期胃癌7例,Ⅱ~Ⅲ期4例。术后中位4(4~7)d进食,中位7(6~9)d出院。术后进食前常规进行上消化道造影,可见吻合口通畅。共3例出现术后并发症,分别为肺炎、胆囊炎和吻合口狭窄,均经保守治疗好转。全组均未出现Grade B以上的胃食管反流症状,所有患者均不需服用抗反流药物。结论:OSF是一种安全可行的食管残胃重建方法。

Objective:To investigate the feasibility of oblique overlap anastomosis plus single flap valvuloplasty(OSF)for reconstruction after laparoscopic proximal gastrectomy.Methods:The C-shaped seromuscular flap(2.5×3.5 cm),which was 2 cm from the top of the remnant stomach,was extracorporeally created on the anterior wall of the remnant stomach.The stomach was opened approximately 1.0 cm above the lower edge of the mucosal flap.Four supporting stitches were sutured around the hole and the right wall of the esophageal stump was incised with a support suture to prevent the linear stapler from entering the submucosa.Liner stapler was inclined to the left side of the esophagus at an angle of about 30 degrees to the longitudinal axis of the esophagus for oblique anastomosis between the dorsal side of the esophagus and the anterior stomach and then esophagogastrostomy was performed with the length of anastomosis was 4 cm.Entry hole was suture with 3 stitches and then the linear stapler was used for closing the entry hole.Finally,the seromuscular flap was closed using barbed sutures.Results:Clinical data of 11 patients with Siewert type II esophagogastric junction adenocarcinoma who underwent radical gastrectomy and reconstruction by OSF between January 2022 and May 2023 were retrospectively collected.There were 7 males and 4 females.The average age was(69.9±7.8)years,the BMI was(21.7±7.2)kg/m 2 and the tumor size was(2.1±0.6)cm.OSF reconstruction was successfully completed in all 11 patients.The median operative time was 275(270-428)minutes,the time for OSF reconstruction was 112(80-140)minutes,and the blood loss was 50(20-400)ml.The pathological stage was 0-I in 7 cases and II-III in 4 cases.The patients were fed on the 4th day(4-7 days)and discharged from hospital on the 7th day(6-9 days)after surgery.No patient had gastroesophageal reflux symptoms of grade B and above,and no patient took anti-reflux medicine.Conclusions:OSF is a safe and feasible treatment for Siewert type II esophagogastric junction adenocarcinoma.