Uncut Roux-en-Y吻合在远端胃癌根治术消化道重建中的应用进展

远端胃癌根治术后消化道重建方式是直接影响患者近远期生活质量的重要因素之一。Uncut Roux-en-Y吻合减少了术后胆汁和胰液通过残胃,保留了肠管的连续性和正常肌电传导,有效预防了反流性食管炎、反流性胃炎,尤其是Roux潴留综合征(Roux-en-Y stasis syndrome,RSS)的发生,是胃癌根治术后理想的消化道重建术式。本文将从方法原理、技术优势、临床应用等多个方面介绍Uncut Roux-en-Y吻合技术的发展。     

全胃切除术后消化道重建118例分析

目的:探讨全胃切除术后合理的消化道重建方式.方法:对118例全胃切除术采用了3种不同的术式,观察其手术时间、术后1年饮食状况、消化道症状及营养指标.结果:Orr式空肠食管Roux-en-Y吻合术和P式空肠食管Roux-en-Y吻合术,术后能有效防止反流性食管炎的发生,而前者操作较简单.结论:Orr式空肠食管Roux-en-Y吻合术是胃癌全胃切除术后消化道重建较为合适的术式.     

近端胃癌2种手术方式术后发生反流性食管炎的对比研究

通过对近端胃癌根治术2种不同术式术后发生反流性食管炎的研究,比较全胃切除(不切断缝线结扎Roux-en-Y消化道重建术)较近端胃切除(食管残胃后壁吻合术)对减少反流性食管炎的效果。收集手术治疗的97例近端胃癌患者,其中78例行全胃切除(不切断缝线结扎Roux-en-Y消化道重建术),19例行近端胃切除术(食管残胃后壁吻合术),术后随访1年内反流性食管炎的发生率。术后随访,两组Visick分级差异有统计学意义(P0.05),全胃切除组反流性食管炎发生率为21.8%,显著低于近端胃切除组的63.2%(P0.01)。全胃切除(不切断缝线结扎Roux-en-Y消化道重建术)对减少近端胃癌根治术后反流性食管炎的发生效果更明显。     

双管法消化道重建在胃切除术中的应用

目的 探索一种可选择用于各种胃切除术的消化道重建术式。方法 总结1993年12月至2000年12月应用双管法消化道重建的全胃切除术和近侧、远侧胃大部切除术35例。通过术后随访和上消化道钡餐检查及血液学检查,评估患的生活质量。结果 术后未发现明显倾倒综合征、碱性反流性胃炎或食管炎及Roux-en-Y滞留综合征。Visick分级都为Ⅰ－Ⅱ级（I组24例68．5％,Ⅱ级11例占31．4％）。结论 双管法消化道重建术式接近生理、操作简单、术后并发症较少、生活质量较好,可选择用于各种胃切除术。     

全胃切除术后消化道重建术式的观察

目的:讨论对胃癌全胃切除术不同吻合术式间理想的消化道重建术式。方法:收治的60例胃恶性肿瘤病人,应用三种不同术式施行了全胃切除术,对其手术并发症、术后营养状况及营养指标进行了对比观察。结果:Moynihan式及Roux-Y式吻合术,术后能有效地防止反流性食管炎的发生。结论:Moynihan式及Roux-y式吻合术是胃癌病人施行全胃切除术后消化道重建较为合理的术是选择。     

复发性胃癌手术消化道重建难点及方式合理选择

复发性胃癌采取手术治疗可以显著提高病人的存活率。残胃复发癌的根治性切除率可以达到50%。复发性胃癌或残胃癌手术多采取全残胃切除术,全残胃切除术后最常用的消化道重建是Roux-en-Y（RY）术式。RY+空肠贮袋也是备选方法之一,小贮袋（7～15 cm）具有更明显的临床优势。间置空肠作为全残胃切除消化道重建的推荐术式仅适用于Billroth I式重建后,且残胃复发于非吻合口残胃并获得R0切除的病例。应该根据病人的具体情况合理选择重建术式。     

非离断式Roux-en-Y吻合与BillrothⅡ式吻合在腹腔镜远端胃癌根治术中比较的meta分析

目的:系统评价非离断式Roux-en-Y吻合术与BillrothⅡ式吻合术在腹腔镜远端胃癌根治术中的临床疗效。方法:检索PubMed、Embase、Cochrane图书馆、CBM、VIP、CNKI及万方数据等数据库,收集国内外公开发表的关于两种消化道重建方式在腹腔镜远端胃癌根治术中对比的临床研究,检索时限为建库至2019年10月。对纳入的文献进行资料提取与质量评价,应用RevMan 5.3软件进行meta分析。结果:最终纳入9项研究,共900例患者。meta分析结果显示,在腹腔镜远端胃癌根治术中应用非离断式Roux-en-Y吻合术后排气时间、首次进流质饮食时间及住院时间短(WMD=-0.29,95%CI-0.44^-0.13,P=0.0002;WMD=-0.41,95%CI-0.66^-0.15,P=0.002;WMD=-0.85,95%CI-1.23^-0.47,P<0.00001),术后近期胃排空障碍、远期胆汁反流及反流性胃炎发生率较低(OR=0.41,95%CI 0.19~0.88,P=0.02;OR=0.06,95%CI 0.02~0.19,P<0.00001;OR=0.14,95%CI 0.05~0.42,P=0.0003),两组手术时间、术中消化道重建时间、术中出血量及远期营养状况差异无统计学意义。结论:腹腔镜远端胃癌根治术中应用非离断式Roux-en-Y吻合术是安全、可行的,具有较好的近、远期临床疗效,可有效降低术后近期胃排空障碍、远期胆汁反流及反流性胃炎发生率,临床应用具有一定优势。     

全胃切除术后消化道重建术式的对比观察

目的探讨全胃切除术后合理的消化道重建术式。方法对185例全胃切除术采取了3种不同的术式,对其手术时间、手术并发症、术后半年饮食状况、消化道症状及营养指标进行对比观察。结果反“7”字空肠食管Roux-en-Y吻合术和“P”形空肠袢Roux-en-Y吻合术均具有抗反流性食管炎的作用,且明显优于Lahay吻合术(P<0.01)。反“7”字空肠食管Roux-en-Y吻合术平均手术时间(3h)少于“P”形空肠袢Roux-en-Y吻合术(3.5h)、并发症(10%)也少于后者(13%)。结论反“7”字空肠食管Roux-en-Y吻合术及“P”形空肠袢Roux-en-Y吻合术是全胃切除术后可选择的消化道重建术式。     

胃癌全胃切除术后两种消化道重建术式的比较

目的 探讨全胃切除术后消化道重建方式的选择. 方法我院2001年6月至2006年6月期间对182例胃癌患者全胃切除术后分别行空肠ρ袢代胃术(PRY)69例和非离断式食管空肠改良Roux-en-Y吻合术(URY)113例. 分析手术时间、术后进食情况、消化道症状及营养状况的差异.结果 非离断式食管空肠改良Roux-en-Y吻合术手术时间短于空肠ρ袢代胃术,且无Roux潴留综合征(RSS)发生. 2种术式术后患者营养状况并无明显差异.结论 非离断式食管空肠改良Roux-en-Y吻合术操作简单、并发症少、术后恢复良好,可以推荐作为全胃切除术后的消化道重建术式.     

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目的：探讨全胃切除术后合理的消化道重建方式。方法 自1996年5月至2001年5月，对106例全胃切除术采用了三种不同的术式，对其手术时间、手术并发症、术后1年饮食状况、消化道症状及营养指标进行对比观察。结果：Orr式空肠食管Roux-en-Y吻合术和P式空肠食管Roux-en-Y吻合术，术后能有效地防止反流性食管炎，明显优于Moynihan式吻合术。Orr式空肠食管Roux-en-Y吻合术和P式空肠食管Roux-en-Y吻合术相比，操作更简单，手术时间短，手术并发症也较少。结论：Orr式空肠食管Roux-en-Y吻合术是胃癌全胃切除后消化道重建较为合适的术式。     

全腹腔镜全胃切除腔内消化道重建术式研究进展

随着腹腔镜器械的改进及外科腔镜下技术的提高,腹部微创手术得到快速发展,腹腔镜胃癌手术也正逐渐走向成熟。对于胃上部癌、胃体癌、皮革胃患者来说,全腹腔镜全胃切除术(TLTG)作为一种微创术式被广泛应用于临床,更小的手术创伤使患者更快的康复,明显提高了患者围手术期生活质量,已成为治疗胃癌,特别是早期可切除胃癌的主要方式之一。TLTG的技术要点和难点是如何在全腹腔镜视野下完成消化道重建,全腔镜下食管空肠吻合是TLTG消化道重建的难点,因此探讨TLTG消化道重建方式成为临床工作者的研究重点。本文就TLTG消化道常见术式作一综述,以期更好地为临床术式选择提供参考。     

The examination of the digestive tract in patients with iron-deficiency anemia

According to literature the gastroenterologic consultations for iron-deficiency anemia are quite frequent. The aim was the evaluation of the part played by gastrointestinal examinations for the diagnosis of iron-deficiency anemia. There were 115 patients admitted in the Medical Clinic between 1998-1999, with iron-deficiency anemia in the absence of macroscopic bleeding who carried out upper or lower endoscopy. A digestive lesion which account for iron deficiency anemia was identified in 35% of the cases. In the upper digestive tract there were 60%, in decreasing order of frequency: peptic ulcer, gastric cancer, erosive gastritis, angiodysplasia. In the lower digestive tract were 35% of the cases (colorectal cancer, polyps, angiodysplasia and hemorrhoids). In 5% of the cases there were found synchronization of the digestive tract lesions. So the digestive tract examination is worth doing because it establishes the diagnosis in 35% of the cases with few symptoms. The digestive tract lesions are more frequent in the upper tract, but they are more severe in the lower digestive tract. The possibility of the synchronization of lesions proves the necessity of carrying out the complete examination of the whole digestive tract.     

Surgical resection for gastrointestinal metastatic melanoma

AIM: Metastases of melanoma are frequent. On the gastro-intestinal tract, commonest localizations are small bowel, stomach and colon. Surgical treatment of digestive metastases from melanoma is not well known and its value is still debated. PATIENTS AND METHODS: Medical records of 10 patients (six female and four male) operated for metastatic melanoma to gastro-intestinal tract were reviewed to determine results of surgery. RESULTS: Gastro-intestinal metastases were symptomatic in eight patients (abdominal pain in three, bowel obstruction in three, abdominal mass and obstructive jaundice in one each). Two patients had anemia. Diagnosis has been suggested by imaging in seven patients and endoscopy in three. All patients were operated on by laparotomy for resection of metastases located on small bowel in four patients, gallbladder in two, stomach in two and colon in two. Complete resection suppressed symptoms in nine cases. In one patient, resection was incomplete but provided satisfying symptomatic relief. One patient died at day 3; in other patients, median survival was 18 months (range: 3-120). CONCLUSION: In a patient with previous history of melanoma, digestive symptoms indicate morphological explorations due to suspicion of metastases to gastro-intestinal tract. Surgical treatment of these metastases is usually palliative but, in some cases, allows long-term survival.     

毕Ⅱ+Braun吻合与毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的疗效对比研究

目的:对比分析毕Ⅱ式+Braun吻合与单纯毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的安全性及有效性,探讨毕Ⅱ+Braun吻合在胃癌根治术中的优势.方法:回顾分析2015年12月至2018年12月74例行腹腔镜远端胃癌根治术患者的临床资料,其中35例行毕Ⅱ+Braun吻合(毕Ⅱ+Braun组),39例行毕Ⅱ式吻合(毕Ⅱ组).对...     

胆囊切除术前上消化道检查的临床意义

目的: 调查术前上消化道检查对预测胆囊切除术后综合征的意义. 方法: 回顾调查了1997年1月~2000年10月在我院行胆囊切除术的患者1245例,其中522例术前行上消化道内镜检查,178例行上消化道钡餐造影检查,232例行上腹部平片检查.其中53例行胆囊造漏术,764例行胆囊切除术,52例行其他手术. 结果: 上消化道内镜检查发现166例合并浅表性胃炎,36例合并肥厚性胃炎,12例合并萎缩性胃炎,5例合并霉菌性胃炎,6例合并胃息肉,4例合并胃癌,25例合并上消化性溃疡,11例合并十二指肠乳头旁憩室,10例合并十二指肠滞留,2例合并轻中度食道静脉曲张,245例上消化道内镜检查无异常.上消化道钡餐造影检查发现8例合并十二指肠滞留,7例合并十二指肠乳头旁憩室,22例合并上消化性溃疡,141例上消化道钡餐造影检查正常.腹部平片检查对术前诊断无临床指导意义.术后59例产生了并发症及后遗症,如:胆道感染、急性胰腺炎、胆道蛔虫感染、胆瘘、胆道损伤以及肠粘连等. 结论: 胆囊术后综合征的发生与外科技术和其他上消化道并存疾病有关.术前上消化道检查对于预测胆囊术后综合征具有重要意义.     

连续性空肠间置在胃次全切除术消化道重建中的应用研究

目的 探讨胃次全切除术时采用连续性空肠间置完成消化道重建的临床效果。方法 远端胃癌患者34例，随机分成两组，A组16例，B组18例。胃次全切除后，A组行残胃与空肠、十二指肠与空肠的端侧吻合，再行空肠侧侧吻合，将胃空肠吻合的输入袢空肠和十二指肠空肠吻合口的输出袢空肠分别结扎阻断，形成完整的连续性间置空肠代胃。B组行Billroth Ⅱ式消化道重建。比较两组患者术后并发症发生率和死亡率；术后1年比较两组患者的Visiek分级指数、血浆白蛋白水平、每餐进食量和体重，并用胃镜检查残胃和吻合口情况。结果 两组患者术后均未出现并发症。术后1年观察，Visiek分级指数两组比较，u=2．1，P〈0．05；差异有统计学意义。A组所有患者平均每日进食量均在术前水平的85％以上，B组只有14人达到该水平。两组手术前后体重减少值比较，t=-2．181，P〈0．05；差异有统计学意义。两组手术前后血浆白蛋白变化值对比，差异有统计学意义（t=2．125，P〈0．05）；A组在1年后显著增加，与术前相比（t=-2．175，P〈0．05）差异有统计学意义。手术后1年胃镜复查，A组残胃未发现胆汁反流，吻合口通畅，吻合口黏膜和间置空肠无充血、水肿，而B组发现残胃内胆汁潴留11例（61．1％），吻合口炎症13例（72．2％），吻合口溃疡2例（11．1％）。结论 连续性空肠间置能够恢复消化道生理通道并避免反流性胃炎的发生。     

Endoscopic findings in the excluded stomach after Roux-en-Y gastric bypass surgery

HYPOTHESIS: After gastric bypass surgery performed because of morbid obesity, the excluded stomach can rarely be endoscopically examined. With the advent of a new apparatus and technique, possible mucosal changes can be routinely accessed and monitored, thus preventing potential benign and malignant complications. DESIGN: Prospective observational study in a homogeneous population with nonspecific symptoms. SETTING: Outpatient clinic of a large public academic hospital. PATIENTS: Forty consecutive patients (mean +/- SD age, 44.5 +/- 10.0 y ears; 85.0% women) were seen at a mean +/- SD of 77.3 +/- 19.4 months after Roux-en-Y gastric bypass surgery. INTERVENTION: Elective double-balloon enteroscopy of the excluded stomach was performed. MAIN OUTCOME MEASURES: Rate of successful intubation, endoscopic findings, and complications. RESULTS: The excluded stomach was reached in 35 of 40 patients (87.5%). Mean +/- SD time to enter the organ was 24.9 +/- 14.3 minutes (range, 5-75 minutes). Endoscopic findings were normal in 9 patients (25.7%), whereas in 26 (74.3%), various types of gastritis (erythematous, erosive, hemorrhagic erosive, and atrophic) were identified, primarily in the gastric body and antrum. No cancer was documented in the present series. Tolerance was good, and no complications were recorded during or after the intervention. CONCLUSIONS: The double-balloon method is useful and practical for access to the excluded stomach. Although cancer was not noted, most of the studied population had gastritis, including moderate and severe forms. Surveillance of the excluded stomach is recommended after Roux-en-Y gastric bypass surgery performed because of morbid obesity.     

完全腹腔镜远端胃癌D2根治术

近年来,随着腹腔镜手术技术和器械的发展,完全腹腔镜远端胃癌根治术在国内逐渐开展,主要难点问题仍集中于消化道重建。完全腹腔镜远端胃癌根治术的消化道重建方式主要有B-Ⅰ式三角吻合,B-Ⅱ式吻合和Roux-en-Y吻合等。B-Ⅰ式三角吻合法操作简便,但较适合于早期胃癌患者;B-Ⅱ式操作简单,但易出现碱性反流性胃炎;Roux-en-Y吻合能有效避免反流,但术后停滞综合征发生率较高,且全腹腔镜下操作繁琐。笔者2013年9月在国内率先开展全腔镜下胃空肠Uncut Roux-en-Y吻合,该方式既保证了肠道的连续性,降低了停滞综合征的发生率,又有效阻断了胆胰液反流至胃肠吻合口,且全腔镜下实施简便、并发症少,安全有效,值得推荐。     

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??Standardization and technical tips in totally laparoscopic gastrectomy for gastric cancer HUANG Chang-ming??LIN Jian-xian. Department of Gastric Surgery??Fujian Medical University Union Hospital??Fuzhou 350001, China
Corresponding author: HUANG Chang-ming, E-mail??hcmlr2002@163.com
Abstract The application of laparoscopic gastrectomy for gastric cancer has more than 20 years. With the development of technology and equipment??on the basis of the guarantee a radical cure and effect of minimally invasive surgery??to improve the quality of patient's life??more and more centers have carried out the laparoscopic radical gastrectomy for gastric cancer. The standardization of totally laparoscopic radical gastrectomy is according to the open surgery. For a completely lymph node dissection??surgeons need be familiar with the normal anatomy and variation of the blood vessels around the stomach??select the appropriate surgical approach??perform the operation step by step and with the help of team cooperation. At the same time??it is very important of postoperative digestive tract reconstruction. It needs to choose the right cases and method to carry out the totally laparoscopic digestive tract reconstruction??in order to make an better advantage of minimally invasive surgery for gastric cancer.     

胃癌根治术后3种消化道重建术的对比研究

目的:探讨胃癌根治术后3种不同消化道重建术式的应用效果。方法:回顾性分析我院2007年5月—2011年9月完成的胃癌手术147例,按消化道重建方式不同分为袢式Braun吻合术组、Roux-en-Y食管(胃)空肠吻合术组、改良Roux-en-Y食管(胃)空肠吻合术组(改良组)。比较各组患者消化道重建时间、术后并发症发生率及术后1年Visick分级指数。结果:所有病例均顺利完成手术,无手术死亡。消化道重建吻合完成时间Roux-en-Y吻合术组长于Braun吻合术组和改良组。Braun吻合术组的吻合口溃疡、碱性反流胃炎、倾倒综合征发生率均明显高于Roux-en-Y吻合术组及改良组,差异有统计学意义(P<0.05);而Roux-en-Y吻合术组的Roux-en-Y滞留综合征发生率明显高于改良组,差异有统计学意义(P<0.05);术后1年Visick分级改良组Ⅰ级例数明显高于另外两组,Ⅲ级例数明显低于另外两组,差异有统计学意义(P<0.05)。结论:改良Roux-en-Y食管(胃)空肠吻合术能明显改善患者的生活质量,是胃癌术后消化道重建较合适的术式。