空肠间置代胃术的前瞻性随机对照研究

A Prospective Randomized Study on the Method of Reconstruction after Total Gastrectomy

目的:探讨空肠原位间置代胃术在全胃切除术后消化道重建中的价值。方法:以12例健康人为对照,将140例胃癌全胃切除术病人按消化道重建术式不同分为4组。A组:食管空肠Roux鄄y吻合术;B组:食管空肠“P”襻加Roux鄄y吻合术;C组:食管空肠Hunt鄄Lawrence吻合术;D组:食管空肠原位间置代胃术。比较4组病人术后的生活质量、预后营养指数(PNI)、体重、血液营养学指标、胃肠激素水平及免疫功能,并以此判断各术式之优劣。结果:D组病人的PNI、体重和血液营养学指标(血清铁、转铁蛋白、Hb)均优于A、B、C组(P<0.05);D组餐后30min的胆囊收缩素(CCK)水平及自然杀伤细胞(NK)、CD4、CD8及CD4/CD8值与对照组相似,而均优于A、B、C组(P<0.05)。差异均具显著性。结论:空肠原位间置代胃术是一较合理的重建术式。空肠“P”形构造不仅具有代胃之功能,且可降低十二指肠液逆蠕动冲力,防止反流性食管炎的发生;食糜通过十二指肠刺激CCK等胃肠激素的分泌,有利于消化及营养的吸收;仅切断一端空肠及适度大小的代胃,保持了空肠与系膜原有的联系,既简化了手术,又保证了间置代胃空肠之血运,使吻合口无缺血坏死之忧。

Objective:To assess prospectively the value of jejunal interposition after total gastrectomy.Methods:One hundred and forty patients undergoing total gastrectomy for gastric carcer were divided into Roux-en-Y esophagojejunostomy(n=35,group A),P pouch with Roux-en-Y esophagojejunostomy(n=35,group B),Hunt-Lawrence esophagojejunostomy(n=35,group C),and orthotopic jejunal interposition esophagojejunostomy(n=35,group D);and their quality of life,prognostic nutritional index(PNI),body weight,serum nutritional parameters,gastrointestinal hormone levels and immunological state were evaluated and compared between the groups and also with12normal persons as controls.Results:The quality of life,PNI,body weight and serum nutritional parameters(serum iron,transferrin saturation and hemoglobin)were better in group D than that in groups A,B and C(P<0.05).The levels or NK cells,CD4,CD8and CD4/CD8ratio in group D were similar to that of the control group,but significantly higher than that of groups A,B and C(P<0.05).Conclusions:Orthotopic jejunal interposition is a reasonable G-I reconstruction method after total gastrectomy.The construction of a'P'pouch serves as a food reservoir as the stomach;the procedure retains the duodenal passage and secretion of the G-I hormones,which guarantee digestion of the food and absorption of the nutrients.