Prevention and treatment of complications in laparoscopic gastrointestinal reconstruction anas-tomosis after proximal gastrectomy
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摘要:
腹腔镜食管空肠（胃）吻合术的解剖位置特殊,空间狭窄,操作难度大,术中并发症发生率高,在食管胃结合部腺癌根治术中,这个问题尤为突出。伴随腹腔镜技术日趋成熟,掌握腹腔镜食管空肠（胃）吻合术中并发症的预防及处理方法可以更好地完成手术操作、缩短手术时间、减少术中和术后并发症的发生。笔者查阅相关文献并结合团队经验,概述腹腔镜食管空肠（胃）吻合术的相关并发症,总结其预防和处理技巧,旨在提高手术成功率,降低手术并发症发生率。
Abstract:The incidence of intraoperative complications is high in laparoscopic esophago-jejunostomy (esophagogastrostomy), due to the unique anatomical location, confined space, and operational difficulty of the surgical procedure, especially in the radical resection of adenocarcinoma of esophagogastric junction. With the increasing maturity of laparoscopic technology, mastering the strategies of prevention and treatment of complications in laparoscopic esophagojejunostomy (esophagogastrostomy) can enhance surgical performance, reduce operation time, and minimize intraoperative and postoperative complications. Based on relevant literatures and team′s experience, the authors overview of the related complications of laparoscopic esophagojejunostomy (esophago-gastrostomy) and summarize the prevention and treatment techniques, in order to improve the success rate of the operation and reduce the incidence of surgical complications.
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近年,食管胃结合部腺癌（adenocarcinoma of eso⁃phagogastric junction,AEG）的发病率呈上升趋势[1‑3]。2018年1项关于胃及食管癌的全世界调查数据显示：东亚地区贲门癌的发病率较高,占全世界新发贲门癌比例的67.1%,其发病率较2012年显著升高[4‑5]。因此,AEG的治疗越来越受重视,外科治疗是AEG主要的根治性手段,外科医师亦一直在积极探索,旨在实现AEG患者更长的生存时间及更好的生命质量。
外科治疗的关键环节包括肿瘤切除、淋巴结清扫及消化道重建。由于肿瘤位置特殊,在临床实践过程中,AEG外科治疗的关键环节仍存在诸多争议,且其诊断与治疗存在胃外科与胸外科的部分交叉。AEG的Siewert分型广泛应用于国内临床实践中,是外科治疗决策的基石[6]。目前,Siewert Ⅰ型与Siewert Ⅲ型AEG的外科治疗已基本达成共识,Ⅰ型AEG参照食管癌的处理原则,Ⅲ型AEG参照胃癌的处理原则。Siewert Ⅱ型AEG仍存在较多争议,包括手术入路、切除范围、淋巴结的清扫程度及食管切缘长度等。近年来,腹腔镜微创手术治疗AEG在临床上广泛开展,其技术也日益成熟[7‑10]。已有的研究结果显示：腹腔镜手术不仅具有术中出血量少、住院时间短、术后并发症发生率降低、术后恢复快等优势,而且可以达到良好的肿瘤学疗效[11‑14]。
然而,由于手术涉及纵隔,位置狭小、被周围脏器阻挡,消化道重建是手术的难点之一,且手术操作难度大,术中并发症发生率较高,特别是在进行食管胃或食管空肠高位吻合的过程中,操作空间狭小的问题更为突出。有学者通过腹腔镜经腹膈肌入路,获得更大的手术视野和操作空间,降低消化道重建难度[15‑18]。既往研究介绍了诸多腹腔镜食管空肠（胃）吻合术的改良方法,通过双倒刺线缝合牵引食管残端、胃管引导吻合等方式能够有效防止食管残端回缩、假道形成,降低消化道重建难度[19‑20]。然而,尽管众多学者提出各种消化道重建的改良手术方式,但对于食管空肠（胃）吻合术中相关并发症及其预防和处理方法尚缺乏系统的总结。笔者查阅相关文献并结合团队经验,概述腹腔镜食管空肠（胃）吻合术的相关并发症,总结其预防和处理技巧,旨在提高手术成功率,降低手术并发症发生率。
一、吻合口血供问题
吻合口相关并发症常见吻合口出血、缺血、漏及狭窄等,是胃肠外科医师主要关注点。已有的研究结果显示：吻合口相关并发症发生率为3.3%~28.8%,其可能严重影响患者术后康复和近、远期疗效,甚至导致非计划再次手术或患者死亡[21‑23]。术中进行吻合口检查可以发现吻合口相关并发症,术中胃镜对其诊断与治疗具有重要作用,可提高吻合的安全性。Park等[24]探索胃癌切除术吻合后进行内镜检查的安全性和有效性,结果显示：与未进行内镜检查组患者比较, 内镜检查组吻合口相关并发症较少。这提示吻合后进行内镜检查可以减少早期吻合口并发症的发生。
吻合口血供问题包括吻合口出血和吻合口缺血。若发现术中吻合口出血的情况,可以结合术中胃镜探查,定位出血点并及时处理。已有的研究结果显示：腹腔镜胃癌手术吻合后结合术中胃镜检查可以减少术后吻合口出血的发生,并且可以通过术中胃镜确认吻合口质量,减少术后留置胃管情况,具有减轻患者术后不适感、促进患者术后恢复等作用[25]。吻合口缺血被认为是术后吻合口瘘发生的重要因素,其包括食管、空肠或胃缺血[26‑29]。缺血原因常见有血管损伤和张力过大。血管损伤包括过度裸化和意外损伤等,吻合口张力过大会导致血管痉挛缺血。部分术后吻合口瘘患者可能需要二次手术,术中应根据具体情况进行修补、造瘘、吻合口切除或重新吻合。在食管空肠吻合后,建议常规对吻合口进行检查,若吻合口血运差或局部缺血坏死,则应切除坏死组织并重新进行吻合。Czerwonko等[30]提出遵循“侧侧吻合”以及“常规进行空肠造瘘”和“早期口服饮食”等六大原则可以减少食管胃吻合口缺血和吻合口瘘等并发症。Mingol⁃Navarro等[31]提出在食管胃切除术前进行胃缺血调节可以降低吻合口瘘、吻合口出血的风险；胃缺血调节主要指采用血管造影栓塞、腹腔镜血管结扎或分离使胃底提前对缺血情况的适应。
笔者中心经验：（1）避免过度裸化,在游离食管、空肠或胃的过程中,既要充分游离系膜,减少吻合口张力,也要注意保护供应血管,避免缺血。（2）吻合过程中,应注意团队配合,精细操作,避免意外损伤,导致缺血。腹腔镜胃癌根治术中若发现食管空肠吻合口空肠段缺血坏死,应切除坏死段空肠肠管,拆除原吻合口,同时需向上游离切除部分食管,将食管残端与空肠进行手工吻合。见图1,2。此时食管残端可能回缩至纵隔腔内,导致置入吻合器操作困难,笔者建议这种情况下行食管空肠高位手工吻合术。吻合后应检查吻合口及肠管血运,若吻合后再次出现空肠肠管坏死、吻合口缺血,建议继续将缺血段肠管切除后再次进行手工吻合,直至血运正常。部分情况下,肠管轻度缺血表现,可能为静脉淤血,若确认血供完好,可先观察,必要时切开边缘静脉,降低静脉压力后观察肠管血运情况。术后常规进行抗凝治疗,同时观察胃管、腹腔引流液,术后可复查胸腹部增强CT进行评估,必要时在术后24~48 h进行二次手术。在腹腔镜全胃切除术中,建议在体外辅助小切口下进行Roux‑en‑Y吻合,即体外完成空肠侧侧吻合以及空肠吻合襻的制作,以便更好地观察空肠肠管的血运。在确认空肠肠管血运无障碍的情况下,重建气腹,在腹腔镜下行食管空肠Overlap吻合术。
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图 1 食管空肠吻合口空肠段缺血坏死及其处理技巧 1A：双倒刺线牵引并胃管指引下行食管空肠Overlap吻合；1B：食管空肠吻合口缺血样改变；1C：空肠段呈缺血样改变；1D：拆除原食管空肠吻合口；1E：体外切除坏死空肠段,制作空肠手工吻合襻；1F：重建气腹,行腹腔镜下食管空肠手工吻合Figure 1. Ischemia necrosis of the jejunal segment of esophagojejunal anastomosis and its treatment techniques 1A: Double barbed suture traction and gastric tube guidance for esophagojejunal Overlap anastomosis; 1B: Ischemic‑like changes at the esophagojejunostomy anastomosis; 1C: The jejunal segment exhibits ischemic‑like changes; 1D: Dismantling of the original esophagusjejunal anastomosis; 1E: Extracorporeal resection of the necrotic segment of jejunum to creat a manual jejunal anastomotic loop; 1F: Re‑establish pneumoperitoneum and perform laparoscopic manual esophagojejunal anastomosis![]()
图 2 意外损伤所致吻合口缺血及其处理技巧 2A：因器械损伤食管空肠吻合口旁空肠系膜血管弓；2B：食管空肠吻合口旁空肠部分肠管坏死；2C：从右向左用超声刀切开已缝合的膈肌；2D：直线切割闭合器离断坏死段肠管；2E：拆除原食管空肠吻合口；2F：将坏死段肠管取出体外；2G：体外制作空肠手工吻合襻；2H：重建气腹,在体内行食管空肠手工吻合术；2I：缝合切开的膈肌Figure 2. Anastomotic ischemia caused by accidental injury and its management techniques 2A: The mesenteric vascular arch of the jejunum adjacent to the esophagojejunal anastomosis due to instrument‑induced damage; 2B: Partial intestinal necrosis of the jejunum adjacent to the esophagojejunal anastomosis; 2C: Cutting the sutured diaphragm with an ultrasonic scalpel from right to left; 2D: Disconnection of the necrotic segment of jejunum by linear stapler; 2E: Dismantling of the original esophagojejunal anastomosis; 2F: Extracting the necrotic segment of intestinal tract; 2G: Making manual jejunal anastomosis loop in vitro; 2H: Re‑establishing pneumoperitoneum and performing manual esophagojejunal anastomosis in vivo; 2I: Suturing the incised diaphragm二、吻合度欠佳
腹腔镜食管空肠（胃）吻合术中,由于视野受限、位置狭小、操作难度大,可能导致吻合度欠佳,造成吻合口漏等严重并发症。在高位吻合时,这个问题更为明显[32]。在吻合视野较差或操作欠佳的情况下,建议行注气试验检查吻合口,即在吻合口周围灌注适量0.9%氯化钠溶液并从胃管内打入适量空气,观察吻合口附近有无水泡出现,若有,说明注气试验阳性,提示吻合口缝合不牢靠,需要重新缝合加固。既往的研究结果显示：全胃切除术或食管切除术后进行食管吻合口加固缝合安全、可行,并强调了加固吻合口的必要性[33‑34]。
笔者中心经验：在注气试验阳性的情况下,需重新缝合加固吻合口,并再次行注气试验,若试验结果仍为阳性,可以选择切开并悬吊左侧膈肌,在左侧腋前线第6或第7肋间隙置入胸腔操作孔进行高位消化道重建。该方法可以有效扩大视野,避免“筷子效应”,使吻合更加顺利,增加吻合口安全性,降低消化道重建难度[35⁃36]。见图3。另外,为增加吻合口安全性,建议高位吻合的患者留置空肠营养管,术后早期进行肠内营养,有助于术后恢复[37⁃40]。
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图 3 吻合口注气试验阳性及其处理技巧 3A：加固缝合食管空肠吻合口；3B：注气试验阳性；3C：切开膈肌,使消化道重建视野开阔,再次进行缝合加固Figure 3. Positive results of gas injection test at the anastomotic site and its treatment techniques 3A: Reinforcing and suturing the esophagojejunal anastomosis; 3B: Positive results of gas injection test; 3C: Cutting the diaphragm to broaden the view for gastrointestinal reconstruction, and suturing and reinforcing the diaphragm三、食管切缘阳性
切缘肿瘤受累与术后的不良预后相关,术中快速冷冻切片病理学检查结果对于切缘诊断具有重要的临床意义,其常见于AEG手术[41‑42]。在全胃切除术中,除了实现规范化的淋巴结清扫,还应确保食管近端切缘病理学检查结果阴性,方可进行消化道重建[43‑44]。Ryu等[45]提出切缘阳性是导致腹腔镜辅助远端胃切除术术中转开腹原因之一。对于食管胃连接处恶性肿瘤患者,在腹腔镜全胃切除术消化道重建前建议常规剪取离体组织的食管切缘进行术中快速冷冻切片病理学检查。若检查结果为阳性,则需向上游离切除食管,再次送检,直至检查结果为阴性方可进行吻合。在多次向上切除食管后,此时食管回缩,位置高,腹腔镜食管空肠高位吻合难度较大。如何安全、有效进行高位食管空肠吻合,避免中转开胸、开腹是重点和难点。
笔者中心经验：腹腔镜AEG根治术中,若食管切缘术中快速冷冻切片病理学检查结果为阳性,需向上切除食管0.5 cm,再次送检,直至连续2次切缘结果为阴性再进行吻合。见图4。在多次切除食管后,食管回缩至纵隔,使用吻合器操作困难,吻合视野狭窄。此时建议切开左侧膈肌,在左侧腋前线第6或第7肋间隙处置入胸腔操作孔,在胸腔操作孔辅助操作下进行食管空肠手工吻合。笔者中心采用该重建方法可以有效避免中转开腹,确保近端切缘阴性,操作可行,具有较好的应用前景[46]。
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图 4 食管切缘阳性及其处理技巧 4A：经胸腔主操作孔向上离断食管0.5 cm；4B：经胸腔主操作孔行食管空肠手工吻合；4C：食管空肠高位吻合Figure 4. Positive of esophageal resection margin and its treatment techniques 4A: Disconnection of esophagus upwards by 0.5 cm through the transthoracic operating port; 4B: Performing manual anastomosis of the esophagus and jejunum through the transthoracic operating port; 4C: Performing high anastomosis of the esophagus and jejunum四、吻合器误钉合胃管
腹腔镜食管空肠（胃）吻合术中,由于吻合视野狭窄,使用胃管指引行食管空肠吻合术时容易出现吻合器误钉合胃管等一系列相关并发症[47]。既往研究分享1例腹腔Roux‑en‑Y吻合术中吻合器钉合胃管的并发症,强调腹腔镜手术过程中有效团队合作的重要性[48]。
笔者中心经验：在吻合时手术医师应重视与麻醉医师或者巡回护士的配合。为避免术中吻合器钉合胃管,主刀医师应待巡回护士或麻醉医师将胃管退至安全距离再击发吻合器,并在激发吻合器后巧用胃管观察吻合是否进入食管真实腔道,形成流程化的胃管引导,避免吻合器钉合胃管。即采用胃管进行引导、检查和观察,更好地完成食管空肠或食管胃吻合。如术中发现吻合器钉合胃管,应尝试在腹腔镜直视下拆除。见图5。或拆开吻合口、在直视下拆除胃管后重新吻合；或在胃镜协助下拆除胃管。若术后发现胃管被钉合而无法拔除,不宜强行拔除胃管,应在胃镜下明确钉合程度,根据情况选择内镜下处理或手术处理[29]。
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图 5 吻合器误钉合胃管及其处理技巧 5A：食管空肠吻合后,检查时发现胃管与黏膜钉在一起；5B：食管空肠吻合后,确证胃管与黏膜钉在一起；5C：用剪刀拆除钉合处Figure 5. Misplacement of gastric tube with stapler and its handling techniques 5A: After esophagojejunal anastomosis, it is found that the gastric tube is stapled together with the mucosa; 5B: It is confirmed that the gastric tube is stapled together with the mucosa; 5C: Using scissors to remove the stapled area五、食管假道吻合
近端胃癌腹腔镜手术中,食管空肠（胃）高位吻合时,在狭窄的空间里进行Overlap吻合,由于食管黏膜下层间隙疏松,吻合器钉砧臂容易误入该间隙,形成食管假道[32]。为避免食管黏膜下假道形成,推荐在吻合时置入胃管,全层切开食管,通过食管切开处引出胃管,在胃管引导下辨认食管腔来避免假道吻合[29]。Chen等[49]前期探索发现改良的OGT‑Overlap 食管空肠吻合术具有潜在的降低手术难度和风险的价值,能有效避免食管假道的发生。其全国多中心RCT正在开展,笔者期待其结果能够为食管空肠吻合术提供宝贵见解。
笔者中心经验：（1）为了避免食管假道的发生,使用超声刀在食管开口时应保证全层切开,且切口长度足够。（2）使用胃管引导,采用缝线缝合食管前壁全层或者钛夹固定食管前壁全层再进行吻合,可以有效暴露食管管腔,缩短食管空肠吻合时间。（3）吻合后要反复检查,若发现吻合器钉砧误入食管假道,应在胃管的指引下用超声刀切开假道黏膜,再使用缝线关闭共同开口。见图6。
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图 6 食管假道吻合及其处理技巧 6A：食管空肠吻合；6B：食管空肠吻合后；6C：检查时发现吻合进入假道；6D：在胃管的引导下用超声刀切开假道黏膜,将构成隔膜的黏膜层切开Figure 6. Esophageal pseudo‑anastomosis and its treatment techniques 6A: Esophagojejunal anastomosis; 6B: After esophagojejunal anastomosis; 6C: The anastomosis enters a pseudo‑anastomosis; 6D: Under the guidance of gastric tube, an ultrasonic scalpel is used to incise the mucosa of the pseudo‑anastomosis, and cut through the mucosal layer forming the diaphragm六、结语
食管空肠（胃）高位吻合难度大,术中并发症发生率高。对于术中出现吻合度欠佳、吻合口血供问题、食管切缘阳性者,需要加固吻合口或重新吻合。对于需要重新吻合的患者,笔者建议：腹腔镜下切开左侧膈肌、悬吊膈肌并置入左侧胸腔辅助操作孔,可获得开阔的手术视野、良好的操作角度,有利于高位食管空肠（胃）吻合。对于术中食管假道吻合、吻合器误钉合胃管等情况,笔者建议：提前预防,密切配合,在吻合前全层切开食管,固定食管前壁（使用钛夹或缝线）,吻合完成后仔细检查吻合口。笔者期待：随着腹腔镜技术的推广,腹腔镜胃切除术后消化道重建技术不断发展和进步,食管空肠（胃）吻合术中并发症的预防和处理有进一步的总结和改进。
所有作者均声明不存在利益冲突熊文俊, 林泽宇, 陈妍, 等. 近端胃癌腹腔镜手术消化道重建吻合术相关并发症的预防和处理[J]. 中华消化外科杂志, 2024, 23(12): 1497-1504. DOI: 10.3760/cma.j.cn115610-20241106-00487.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20241106-24487 -
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图 1 食管空肠吻合口空肠段缺血坏死及其处理技巧 1A：双倒刺线牵引并胃管指引下行食管空肠Overlap吻合；1B：食管空肠吻合口缺血样改变；1C：空肠段呈缺血样改变；1D：拆除原食管空肠吻合口；1E：体外切除坏死空肠段,制作空肠手工吻合襻；1F：重建气腹,行腹腔镜下食管空肠手工吻合
Figure 1. Ischemia necrosis of the jejunal segment of esophagojejunal anastomosis and its treatment techniques 1A: Double barbed suture traction and gastric tube guidance for esophagojejunal Overlap anastomosis; 1B: Ischemic‑like changes at the esophagojejunostomy anastomosis; 1C: The jejunal segment exhibits ischemic‑like changes; 1D: Dismantling of the original esophagusjejunal anastomosis; 1E: Extracorporeal resection of the necrotic segment of jejunum to creat a manual jejunal anastomotic loop; 1F: Re‑establish pneumoperitoneum and perform laparoscopic manual esophagojejunal anastomosis
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图 2 意外损伤所致吻合口缺血及其处理技巧 2A：因器械损伤食管空肠吻合口旁空肠系膜血管弓；2B：食管空肠吻合口旁空肠部分肠管坏死；2C：从右向左用超声刀切开已缝合的膈肌；2D：直线切割闭合器离断坏死段肠管；2E：拆除原食管空肠吻合口；2F：将坏死段肠管取出体外；2G：体外制作空肠手工吻合襻；2H：重建气腹,在体内行食管空肠手工吻合术；2I：缝合切开的膈肌
Figure 2. Anastomotic ischemia caused by accidental injury and its management techniques 2A: The mesenteric vascular arch of the jejunum adjacent to the esophagojejunal anastomosis due to instrument‑induced damage; 2B: Partial intestinal necrosis of the jejunum adjacent to the esophagojejunal anastomosis; 2C: Cutting the sutured diaphragm with an ultrasonic scalpel from right to left; 2D: Disconnection of the necrotic segment of jejunum by linear stapler; 2E: Dismantling of the original esophagojejunal anastomosis; 2F: Extracting the necrotic segment of intestinal tract; 2G: Making manual jejunal anastomosis loop in vitro; 2H: Re‑establishing pneumoperitoneum and performing manual esophagojejunal anastomosis in vivo; 2I: Suturing the incised diaphragm
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图 3 吻合口注气试验阳性及其处理技巧 3A：加固缝合食管空肠吻合口；3B：注气试验阳性；3C：切开膈肌,使消化道重建视野开阔,再次进行缝合加固
Figure 3. Positive results of gas injection test at the anastomotic site and its treatment techniques 3A: Reinforcing and suturing the esophagojejunal anastomosis; 3B: Positive results of gas injection test; 3C: Cutting the diaphragm to broaden the view for gastrointestinal reconstruction, and suturing and reinforcing the diaphragm
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图 4 食管切缘阳性及其处理技巧 4A：经胸腔主操作孔向上离断食管0.5 cm；4B：经胸腔主操作孔行食管空肠手工吻合；4C：食管空肠高位吻合
Figure 4. Positive of esophageal resection margin and its treatment techniques 4A: Disconnection of esophagus upwards by 0.5 cm through the transthoracic operating port; 4B: Performing manual anastomosis of the esophagus and jejunum through the transthoracic operating port; 4C: Performing high anastomosis of the esophagus and jejunum
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图 5 吻合器误钉合胃管及其处理技巧 5A：食管空肠吻合后,检查时发现胃管与黏膜钉在一起；5B：食管空肠吻合后,确证胃管与黏膜钉在一起；5C：用剪刀拆除钉合处
Figure 5. Misplacement of gastric tube with stapler and its handling techniques 5A: After esophagojejunal anastomosis, it is found that the gastric tube is stapled together with the mucosa; 5B: It is confirmed that the gastric tube is stapled together with the mucosa; 5C: Using scissors to remove the stapled area
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图 6 食管假道吻合及其处理技巧 6A：食管空肠吻合；6B：食管空肠吻合后；6C：检查时发现吻合进入假道；6D：在胃管的引导下用超声刀切开假道黏膜,将构成隔膜的黏膜层切开
Figure 6. Esophageal pseudo‑anastomosis and its treatment techniques 6A: Esophagojejunal anastomosis; 6B: After esophagojejunal anastomosis; 6C: The anastomosis enters a pseudo‑anastomosis; 6D: Under the guidance of gastric tube, an ultrasonic scalpel is used to incise the mucosa of the pseudo‑anastomosis, and cut through the mucosal layer forming the diaphragm
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