十二指肠残端处理对全腹腔镜胃癌根治术后并发症的影响

The impact of duodenal stump management on postoperative complications following totally laparoscopic gastrectomy for gastric cancer

目的评估全腹腔镜胃癌手术中十二指肠残端处理对术后并发症的影响。方法建立前瞻性观察队列,纳入2021年12月至2022年12月于中国医学科学院肿瘤医院接受全腹腔镜胃癌根治术的患者,使用直线切割闭合器离断十二指肠,并行BillrothⅡ式或Roux-en-Y式吻合,十二指肠残端处理采用3-0可吸收倒刺线行连续缝合。主要观察患者术后短期并发症发生情况,分级依据Clavien-Dindo分级标准,并于术后第1、3、5、7天留取流经十二指肠残端的引流液,检测总胆红素和淀粉酶。结果本研究共纳入134例患者,其中63例行十二指肠残端加固,71例未行十二指肠残端加固。两组患者在年龄、性别、体质量指数(body mass index,BMI)、美国东部肿瘤协作组(Eastern Cooperative Oncology Group,ECOG)评分、营养风险(Nutritional Risk Screening 2002,NRS 2002)评分、内科合并症、术前新辅助治疗及TNM分期上,两者差异均无统计学意义。两组均以BillrothⅡ吻合方式为主。在手术时间上,十二指肠残端加固组与未加固组相比差异无统计学意义(160.7±38.2 min vs.156.3±36.6 min,P=0.649)。两组患者总体并发症发生率及严重并发症发生率差异无统计学意义,但十二指肠残端未加固组出现2例十二指肠残端瘘,而加固组无十二指肠残端瘘发生。在术后引流液总胆红素和淀粉酶指标方面,加固组在术后第1、3、5、7天引流液总胆红素和淀粉酶中位数均低于未加固组,且在术后第1天引流液总胆红素测定中两组间差异有统计学意义。结论在全腹腔镜胃癌手术中进行十二指肠残端加固可有效降低十二指肠残端瘘的发生。

Objective To evaluate the impact of duodenal stump management on postoperative complications in totally laparoscopic radical gastrectomy for gastric cancer.Methods A prospective observational cohort was established,including patients who underwent totally laparoscopic radical gastrectomy at the Cancer Hospital of the Chinese Academy of Medical Sciences from Dec.2021 to Dec.2022.The duodenum was transected using a linear cutting stapler,followed by BillrothⅡor Roux-en-Y anastomosis.The duodenal stump was managed with continuous suturing using 3-0 absorbable barbed sutures.The primary outcome was the incidence of short-term postoperative complications,graded according to the Clavien-Dindo classification.Additionally,drainage fluid from the duodenal stump was collected on postoperative days 1,3,5,and 7 for total bilirubin and amylase testing.Results A total of 134 patients were included in the study,with 63 patients undergoing duodenal stump reinforcement and 71 patients not receiving reinforcement.No significant differences were observed between the two groups in terms of age,sex,BMI,ECOG,NRS 2002,medical comorbidities,preoperative neoadjuvant therapy,and TNM stage.Both groups predominantly underwent BillrothⅡanastomosis.There was no significant difference in operative time between the reinforcement group and the non-reinforcement group(160.7±38.2 min vs.156.3±36.6 min,P=0.649).The overall complication rates and severe complication rates were not significantly different between the two groups,but the non-reinforcement group had two cases of duodenal stump fistula,whereas the reinforcement group had none.The median levels of total bilirubin and amylase in the drainage fluid were lower in the reinforcement group than in the non-reinforcement group on postoperative days 1,3,5,and 7,with a significant difference in total bilirubin on the first postoperative day.Conclusion Reinforcement of the duodenal stump in total laparoscopic radical gastrectomy for gastric cancer can effectively reduce the incidence of duodenal stump leakage.