食管前壁全层固定并胃管引导法在腹腔镜食管空肠Overlap吻合术中的应用价值

Application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy

目的探讨食管前壁全层固定并胃管引导法在腹腔镜食管空肠Overlap吻合术中的应用价值。方法食管前壁全层固定并胃管引导的食管空肠Overlap吻合术适用于术前临床分期为进展期胃癌(cT1b~4aN0~3M0)、肿瘤侵犯食管长度<3 cm、行腹腔镜全胃根治术并食管空肠Overlap吻合术的患者。手术关键步骤如下:在食管空肠Overlap吻合前使用1枚钛夹固定食管前壁全层,并在胃管引导下使用直线切割闭合器进行食管空肠侧侧吻合,在检查确认吻合器进入食管正确腔道后取出钛夹,采用双倒刺线缝合关闭共同开口。本文采用描述性病例系列研究方法,回顾性分析2021年5月至2023年6月于广东省中医院胃肠外科、广州中医药大学第一附属医院胃肠外科行腹腔镜下全胃根治术,且吻合方式均为食管前壁全层固定并胃管引导的Overlap食管空肠吻合术患者的临床资料。结果共收集42例患者,均成功完成腹腔镜下全胃根治术,无中转开腹,无围手术期死亡。食管空肠吻合时间为17(15~25)min,手术时间、术中出血量分别为(258.8±38.0)min和50(20~200)ml,术中食管“假道”发生率为0,无术中并发症。术后胃管拔除时间为2(1~5)d,全流时间以及术后住院时间分别为4(1~8)d和8(4~21)d,无术后吻合口出血、吻合口狭窄等其他相关并发症。1例(2.4%)患者出现Clavien-DindoⅢb级并发症,为术后腹腔出血,经二次手术探查证实为胃十二指肠动脉破裂出血,给予术中缝扎止血、扩容、输血等治疗后,于术后第15天好转出院。3例(7.1%)患者出现Clavien-DindoⅡ级并发症,分别为吻合口漏、乳糜漏、肺部感染各1例,经抗感染、延长引流管留置时间等保守治疗后好转出院。结论采用食管前壁全层固定并胃管引导法的改良Overlap食管空肠吻合术能够缩短食管空肠吻合时间,避免食管“假道”发生,且不增加吻合口相关并发症发生率。

Objective To explore the application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy.Methods Overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance is suitable for patients with advanced gastric cancer(clinical stage:cT1b~4aN0~3M0)and esophageal invasion<3 cm,who underwent radical total gastrectomy+overlap esophagojejunostomy.The main operation procedure was performed as follows:A titanium clip was used for fixation of the full anterior wall of esophagus before overlap esophagojejunostomy,and the side‐to‐side esophagojejunostomy was performed with the linear stapler under the guidance of gastric tube.Then the titanium clip was removed after confirming that the correct cavity was entered.Finally,the common outlet was closed by two barbed sutures.A descriptive case series study was conducted.The clinical data of patients who underwent laparoscopic radical gastrectomy and overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance in Guangdong Provincial Hospital of Chinese medicine and the First Affiliated Hospital of Guangzhou University of Chinese medicine from May 2021 to June 2023 were retrospectively analyzed.Results A total of 42 patients were collected,and all of them were successfully completed laparoscopic total radical gastrectomy without conversion to laparotomy or perioperative death.The esophagojejunostomy time,operative time,intraoperative blood loss was 17(5‐25)minutes,(258.8±38.0)minutes and 50(20‐200)ml,respectively.The incidence of esophageal false lumen was 0%,and there were no intraoperative complications.The time of gastric tube removal,initial fluid diet intake and the duration of postoperative hospital were 2(1‐5),4(1‐8)and 8(4‐21)days,respectively.There were no postoperative anastomotic hemorrhage,anastomotic stenosis and other related complications.One patient(2.38%)developed a Clavien‐Dindo IIIb complication,which was abdominal hemorrhage after operation.The second surgical exploration confirmed that the patient was bleeding due to gastroduodenal artery rupture.After intraoperative suture hemostasis,fluid expansion,blood transfusion and other treatments,the patient was discharged on the 15th day after the operation.Three patients(7.14%)developed Clavien‐Dindo grade II complications,including anastomotic leakage,chylous leakage and pulmonary infection,and were discharged after conservative treatment such as anti‐infection and prolonged retention of drainage tube.Conclusions Laparoscopic overlap method for intracorporeal esophagojejunostomy with anterior esophageal wall fixation and gastric tube guidance can shorten the time of esophagojejunostomy and prevent the occurrence of false lumen,and do not increase anastomose‐related complications.