摘要目的 探讨食管空肠半端端吻合在腹腔镜辅助根治性全胃切除术Roux-en-Y消化道重建中的应用价值.方法 采用回顾性队列研究方法.收集2012年1月至2015年12月第三军医大学西南医院收治的205例行腹腔镜辅助根治性全胃切除术胃腺癌患者的临床资料.140例患者采用食管空肠端侧吻合行Roux-en-Y消化道重建,设为对照组;65例患者采用食管空肠半端端吻合行Roux-en-Y消化道重建,设为研究组.依据第3版日本《胃癌治疗指南》,行腹腔镜D2淋巴结清扫术.观察指标:(1)手术情况:手术完成情况,手术时间,消化道重建时间,术中出血量,术中食管空肠吻合口相关并发症(狭窄、出血)发生例数.(2)术后情况:术后肛门首次排气时间,术后引流管拔除时间,术后食管空肠吻合口相关并发症(狭窄、出血、吻合口瘘)发生例数,术后非食管空肠吻合口相关并发症(肺部感染、胸腔积液、切口感染、腹腔脓肿、腹腔出血、十二指肠残端瘘、肠梗阻、腹内疝)发生例数,术后住院时间.(3)随访情况.采用门诊或电话方式进行随访,了解患者术后生存及肿瘤复发、转移情况.随访时间截至2016年4月.正态分布的计量资料以(x)±s表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用非参数检验.计数资料比较采用x2检验.等级资料比较采用非参数检验.结果 (1)手术情况:对照组和研究组胃腺癌患者均成功完成腹腔镜辅助根治性全胃切除术Roux-en-Y消化道重建.对照组和研究组患者手术时间分别为(254±57)min和(233±55) min,消化道重建时间分别为(53±10) min和(41 ±9) min,两组患者上述指标比较,差异均有统计学意义(t=2.508,8.191,P＜0.05).对照组患者术中食管空肠吻合口相关并发症(狭窄、出血)发生例数分别为8、0例,研究组患者为0、1例,两组患者比较,差异无统计学意义(x2=0.983,P＞0.05).对照组8例术中食管空肠吻合口狭窄患者中,4例未作特殊处理;其余4例中,1例拆除吻合口,重新行食管空肠端侧吻合,3例因吻合平面较高,将空肠残端与远端空肠行侧侧吻合.研究组1例术中食管空肠吻合口出血患者行加强缝合吻合口后,出血停止.(2)术后情况:对照组胃腺癌患者术后食管空肠吻合口相关并发症(狭窄、出血、吻合口瘘)发生例数分别为11、0、6例,研究组患者分别为0、0、1例,两组患者比较,差异有统计学意义(x2=6.232,P＜0.05).对照组患者术后非食管空肠吻合口相关并发症(肺部感染、胸腔积液、切口感染、腹腔脓肿、腹腔出血、十二指肠残端瘘、肠梗阻、腹内疝)发生例数分别为2、1、2、1、1、1、1、0例,研究组患者分别为1、1、1、0、1、0、1、1例,两组患者比较,差异无统计学意义(x2=0.184,P ＞0.05).对照组11例术后食管空肠吻合口狭窄患者中,5例未作特殊处理;其余6例经内镜下球囊扩张治疗后均好转.术后食管空肠吻合口瘘患者经充分引流、抗感染、对症等治疗后好转.肺部感染患者经抗感染治疗后好转.胸腔积液、切口感染、腹腔脓肿、十二指肠残端瘘患者经充分引流、抗感染、对症等治疗后好转.对照组腹腔出血患者行二次手术治疗后出血停止,研究组腹腔出血患者经止血、对症等治疗后出血停止.肠梗阻、腹内疝患者行二次手术治疗后好转.(3)随访情况:205例患者中,192例获得术后随访,其中对照组130例,研究组62例.随访时间为4～51个月,中位随访时间为28个月.随访期间,对照组和研究组患者分别有19例和8例死亡,23例和10例肿瘤复发、转移.结论 采用食管空肠半端端吻合行腹腔镜辅助根治性全胃切除术Roux-en-Y消化道重建安全可行,消化道重建时间短,术后食管空肠吻合口相关并发症较少.

abstractsObjective To investigate the application value of semi-end-to-end esophagojejunal anastomosis for the Roux-en-Y digestive tract reconstruction after laparoscopy-assisted total gastrectomy (LATG).Methods The retrospective cohort study was conducted.The clinical data of 205 gastric adenocarcinoma patients who underwent LATG at the Southwest Hospital of the Third Military Medical University from January 2012 to December 2015 were collected.Among 205 patients,140 who underwent Roux-en-Y digestive tract reconstruction with end-to-side esophagojejunal anastomosis were allocated into the control group,and 65 who underwent Rouxen-Y digestive tract reconstruction with semi-end-to-end esophagojejunal anastomosis were allocated into the study group.All the patients underwent LATG according to Japanese gastric cancer treatment guidelines (ver.3).Observation indicators included:(1) surgical situations:operation completion,operation time,time of digestive tract reconstruction,volume of intraoperative blood loss and number of patients with intraoperative esophagojejunal anastomosis-site complications (anastomosis-site stenosis and bleeding).(2) Postoperative situations:time to initial anal exsufflation,time of postoperative drainage tube removal,number of patients with postoperative esophagojejunal anastomosis-site complications (anastomosis-site stenosis,bleeding and leakage),number of patients with postoperative non-esophagojejunal anastomosis-site complications (pulmonary infection,pleural effusion,wound infection,abdominal abscess,intra-abdominal bleeding,duodenal stump fistula,intestine obstruction and internal abdominal hernia) and duration of postoperative hospital stay.(3) Follow-up situations.Follow-up using outpatient examination or telephone interview was performed to detect the survival of patients and tumor recurrence or metastasis up to April 2016.Measurement data with normal distribution were represented as (x) ± s and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test.Comparison of count data was analyzed using the chi-square test,and ranked data was analyzed using the nonparametric test.Results (1) Surgical situations:all the patients received successful LATG and Roux-en-Y digestive tract reconstruction.Operation time and time of digestive tract reconstruction were (254 ± 57) minutes,(53 ± 10)minutes in the control group and (233 ± 55)minutes,(41 ± 9)minutes in the study group,respectively,with statistically significant differences between the 2 groups (t =2.508,8.191,P ＜ 0.05).Number of patients with intraoperative anastomosis-site stenosis and bleeding (esophagojejunal anastomosis-site complications) was respectively 8,0 in the control group and 0,1 in the study group,with no statistically significant difference between the 2 groups (x2 =0.983,P ＞ 0.05).Of 8 patients with anastomosis-site stenosis in the control group,4 didn't receive special treatment,1 underwent end-to-side esophagojejunal anastomosis again after dismantling anastomosis-site and 3 underwent side-to-side anastomosis between jejunal stump and distal jejunum again due to higher anastomosis-site surface.One patient with intraoperative anastomosis-site bleeding in the study group underwent strengthening suture of anastomosis-site and then bleeding was stopped.(2) Postoperative situations:number of patients with anastomosis-site stenosis,bleeding and leakage (postoperative esophagojejunal anastomosis-site complications) was respectively 11,0,6 in the control group and 0,0,1 in the study group,with a statistically significant difference between the 2 groups (x2=6.232,P ＜ 0.05).Number of patients with pulmonary infection,pleural effusion,wound infection,abdominal abscess,intra-abdominal bleeding,duodenal stump fistula,intestine obstruction and internal abdominal hernia was respectively 2,1,2,1,1,1,1,0 in the control group and 1,1,1,0,1,0,1,1 in the study group,with no statistically significant difference between the 2 groups (x2 =0.184,P ＞ 0.05).Of 11 patients with postoperative anastomosis-site stenosis in the control group,5 didn't received special treatment and 6 were improved through endoscopic balloon dilatation.Patients with postoperative anastomosis leakage were improved after adequate drainage,anti-infection and symptomatic treatments.Patients with pulmonary infection were improved after anti-infection treatment.Patients with pleural effusion,wound infection,abdominal abscess and duodenal stump fistula were improved after adequate drainage,anti-infection and symptomatic treatments.Bleeding of patients with intra-abdominal bleeding in the control group was controlled by reoperation,and hemostasis and symptomatic treatment were conducted for patients with intra-abdominal bleeding in the study group.Patients with intestine obstruction and internal abdominal hernia were improved after reoperation.(3) Follow-up situations:among 205 patients,192 were followed up for 4-51 months with a median time of 28 months,including 130 in the control group and 62 in the study group.During the follow-up,death and tumor recurrence or metastasis were respectively detected in 19,23 patients in the control group and 8,10 patients in the study group.Conclusion Semi-end-to-end esophagojejunal anastomosis is safe and feasible for the Roux-en-Y digestive tract reconstruction after LATG,with advantages of shorter time of digestive tract construction and fewer postoperative esophagojejunal anastomosis-site complications.