非离断式Roux-en-Y吻合在腹腔镜远端胃癌根治性切除术中的应用

Application of uncut RouxenY anastomosis in laparoscopic distal radical gastrectomy of gastric cancer

  • 摘要: 目的:探讨非离断式RouxenY吻合在腹腔镜远端胃癌根治性切除术中的应用及临床疗效。
    方法采用回顾性横断面描述性研究方法。收集2014年12月至2015年7月江苏省苏北人民医院收治的23例胃癌患者的临床资料;根据患者个体情况行腹腔镜辅助胃癌根治切除术或完全腹腔镜胃癌根治切除术。观察指标:(1)术中情况:手术时间、非离断式RouxenY吻合时间、术中出血量。(2)术后情况:首次肛门排气时间、恢复饮水时间、进食半流质食物时间、下床活动时间、术后住院时间、并发症发生情况、病理学检查结果。(3)随访结果。采用门诊或电话随访,随访内容包括:术后是否有进食后不适,术后1个月行消化道钡餐检查(吻合口狭窄、闭塞处再通或裂开情况),术后3个月行胃镜检查残胃及吻合口情况,是否发生胃肠道梗阻。随访时间截至2015年11月。正态分布的计量资料采用±s表示。
    结果:(1)手术情况:23例胃癌患者均成功行非离断式RouxenY吻合,其中18例为腹腔镜辅助胃癌根治性切除术,5例为完全腹腔镜胃癌根治性切除术。23例患者手术时间为(165.9±11.6)min,非离断式RouxenY吻合时间为(18.2±2.2)min,术中出血量为(48±6)mL。其中5例全腹腔镜手术患者手术时间为(172.0± 8.5)min,腹腔镜下非离断式RouxenY吻合时间为(26.6±1.5)min,术中出血量为(46±4)mL。2例患者出现吻合口吻合线出血,分别予缝扎止血、钛夹夹闭止血。(2)术后情况:23例患者术后首次肛门排气时间为(2.2±0.4)d,恢复饮水时间为(2.7±0.4)d,进食半流质食物时间为(3.5±0.4)d,下床活动时间为(2.7±0.3)d,术后住院时间为(10.6±1.4)d。全组无围术期死亡患者,术后并发症发生率为8.7% (2/23),其中1例患者为切口感染,1例患者为术后高热,经对症支持治疗后痊愈。23例患者均未出现吻合口瘘、出血等吻合口相关并发症。23例患者术后行上消化道钡剂造影检查示吻合口均通畅且无造影剂渗漏。术后病理学检查:肿瘤直径为(3.2±1.2)cm,淋巴结清扫数目为(30±4)枚/例,上、下切缘均未见癌细胞残留;分化型12例,未分化型11例;T分期:T1期1例,T2期9例,T3期13例;N分期:N0期9例,N1期11例,N2期3例;TNM分期:Ⅰa期1例,Ⅰb期4例,Ⅱ期9例,Ⅲa期6例,Ⅲb期3例。(3)随访结果:23例患者门诊随访3~11个月,1例患者术后3周出现进食后腹上区不适伴呕吐,其余患者均未出现吻合口瘘、出血等吻合口相关并发症。
    结论:非离断式RouxenY吻合安全、可行,作为一种改良的吻合方式,是腹腔镜远端胃癌根治术后消化道重建较为理想的手术方式。

     

    Abstract: Objective:To investigate the application and clinical effect of uncut RouxenY (uncut RY) anastomosis in laparoscopic distal radical gastrectomy of gastric cancer.
    Methods:The retrospective crosssectional study was adopted. The clinical data of 23 patients with gastric cancer who were admitted to the Northern Jiangsu People′s Hospital from December 2014 to July 2015 were collected. All the 23 patients underwent laparoscopyassisted distal gastrectomy (LADG) and total laparoscopic distal gastrectomy (TLDG) according to the individual situations. The indexes of observation were collected, including (1) intraoperative indexes: operation time, uncut RY anastomosis time and volume of inraoperative blood loss, (2) postoperative indexes: time to anal exsufflation, time for initial water intake, time for semifluid diet intake, time for outoffbed activity, duration of hospital stay, occurrence of complications and results of pathological examination, (3) results of followup. The followup was performed by outpatient examination and telephone interview up to November 2015, including postoperative discomfort after diet intake, barium meal examination of gastrointestinal tract at postoperative month 1 (anastomotic stenosis, recanalization and dehiscence of occlusion), detecting situations of gastric remnant and anastomotic stoma at postoperative month 3 by gastroscopy and occurrence of gastrointestinal obstruction. Measurement data with normal distribution were presented as ±s.
    Results: (1) Intraoperative situations: all the 23 patients underwent successful uncut RY anastomosis, including 18 receiving LADG and 5 receiving TLDG. The operation time, uncut RY anastomosis time and volume of intraoperative blood loss were (165.9±11.6)minutes, (18.2±2.2)minutes, (48±6)mL in all the 23 patients and (172.0±8.5)minutes, (26.6±1.5)minutes, (46±4)mL in 5 patients with TLDG, respectively. Two patients received hemostatic treatment using suture and hemostatic forceps due to anastomotic bleeding. (2) Postoperative situations: time to anal exsufflation, time for initial water intake, time for semifluid diet intake, time for outoffbed activity, duration of hospital stay and incidence of complications in all the 23 patients were (2.2±0.4)days, (2.7± 0.4)days, (3.5±0.4)days, (2.7±0.3)days, (10.6±1.4)days and 8.7%(2/23), respectively. No patient was dead in the perioperative period. Two patients complicated with incisional infection and high fever were cured by symptomatic treatment, without occurrence of anastomotic leakage, bleeding and anastomoticrelated complications. All the patients received postoperative barium meal examination of upper gastrointestinal tract, with unblocked anastomotic stoma and without leakage of barium meal. Diameter of tumor and number of lymph node dissected were (3.2±1.2)cm and 30±4, with negative upper and lower resection margins. Numbers of patients with tumor differentiation, T stage, N stage and TNM stage were 12 and 11 in differentiated and undifferentiated tumors, 1,9 and 13 in T1, T2 and T3 stages, 9, 11 and 3 in N0, N1and N2 stages, 1, 4, 9, 6 and 3 in Ⅰa, Ⅰb, Ⅱ, Ⅲa and Ⅲb stages, respectively. (3) All the 23 patients were followed up by outpatient examination for 3-11 months. One patient had discomfort in upper abdomen with vomiting at postoperative week 3, and no anastomotic leakage, bleeding and anastomoticrelated complications were occurred in other patients.
    Conclusion As a modified anastomotic method, uncut RY anastomosis is safe and feasible, and it is also an ideal method of digestive tract reconstruction after laparoscopic distal radical gastrectomy.

     

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