全胃切除Roux-en-Y加空肠储袋吻合术疗效系统评价

目的 评价全胃切除Roux-en-Y加空肠储袋吻合术的有效性及安全性,为进一步临床研究与循证临床实践提供参考依据。方法 计算机检索有关Roux-en-Y加空肠储袋对比单纯Roux-en-Y的随机对照试验（RCT）资料,检索时间截至2010年10月。由2位研究者逐篇评价纳入研究的质量、交叉核对提取数据,并采用RevMan 5.0软件进行数据处理。结果 共纳入12篇RCT,共577例病人。Meta分析显示：与单纯Roux-en-Y相比,Roux-en-Y加空肠储袋有助于改善术后3个月和6个月的体重,提高术后1和2年的生活质量,降低术后3、6和12~15个月倾倒综合征发生率。另外,两者的手术死亡率、手术并发症发生率及手术时间的差异无统计学意义。结论 Roux-en-Y加空肠储袋与单纯Roux-en-Y吻合术相比在术后近期内存在优势,而远期疗效仍须进一步研究证实。     

全胃切除后非离断式Roux—en—Y空肠储袋消化道重建的临床研究

目的探讨全胃切除术后非离断式Roux-en—Y空肠储袋消化道重建方式的临床效果。方法对168例胃癌患者行全胃切除手术后分别行非离断式Roux-en—Y空肠储袋吻合术（A组，69例）、P型空肠食管Roux-en-Y吻合术（B组，50例）和Orr式空肠食管Roux—en-Y吻合术（C组，49例）进行消化道重建。观察各组患者消化道重建的时间和术后并发症发生率；并对其中无瘤生存超过1年的121例患者的生活质量[术后6和12个月时的体重、进食量、预后营养指数（PNI）和Visick分级指数]进行分析对比。结果A、B、C组消化道重建时间分别为（30±7）min、（57±6）min和（48±6）min；A组时间最短，与B、C组比较差异有统计学意义（P〈0．05）。3组患者术后均顺利恢复，未发生吻合口瘘或十二指肠残端瘘等术后并发症。A、B、C组碱性反流性食管炎发生率分别为4．3％（2／46）、7．7％（3／39）和5．6％（2／36），差异无统计学意义（P〉0．05）；Roux潴留综合征发生率分别为2．2％（2／46）、17．9％（7／39）和19．4％（7／36），A组明显低于B、C组（P〈0．01）。术后6个月和12个月，A组体重和进食量的恢复均优于B、C组（P〈0．05）。与术前相比，术后6个月3组PNI均下降（P〈0．05）；12个月时，A组PNI与术前比较差异已无统计学意义（P〉0．05），而B、C组的差异仍有统计学意义（P〈0．05）。A组术后6个月和12个月时的Visick分级指数Ⅰ～Ⅱ级均优于B、C组（P〈0．05）。结论非离断式Roux-en—Y空肠储袋术是全胃切除术后理想的消化道重建术式。     

Management of jejunal pouch dysfunction following total gastrectomy and Roux-en-Y reconstruction for gastric cancer: a case report

INTRODUCTION

Total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction is a well recognised procedure for patients undergoing curative resections for gastric malignancy. The formation of a jejunai pouch is thought by some to create a reservoir that, when compared with straight oesophagojejunal anastomosis, reduces the incidence of postoperative dumping.

CASE HISTORY

A patient presented two years after a total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction for a T3N2M0 adenocarcinoma of the stomach, with postprandial vomiting and dysphagia resulting in massive weight loss and malnutrition. Recurrent cancer and stricturing was ruled out by gastroscopy and computed tomography, and distal obstruction was ruled out by an oral contrast study. The diagnosis of a functional jejunai pouch disorder was made by exclusion.Balloon dilatation of the pouch and the oesophagojejunal anastomosis found little symptomatic improvement. The patient''s deteriorating nutritional status prompted us to urgently perform revisionai surgery. A re-laparotomy and pouch-jejunal bypass procedure was performed. Post-operatively, the patient made a full symptomatic recovery and began gaining weight

CONCLUSIONS

A pouch-enteric bypass is a suitable treatment option for patients with functional jejunai pouch dysmotility following a total gastrectomy and jejunai pouch formation in the absence of distal obstruction and recurrent disease.     

Simple versus double jejunal pouch for reconstruction after total gastrectomy

BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.     

全胃切除消化道重建术中空肠储袋的临床研究进展

全胃切除术是常见的胃癌根治术之一。尽管消化道重建的方式繁多,但何种最好尚无定论。经检索近年来有关全胃切除后的消化道重建临床研究报道,主要介绍不同空肠肠袋、Roux-en-Y重建术式的优劣。结果表明,空肠肠袋、Roux—en—Y重建术式并不显著增加手术病死率和并发症发生率,能够改善术后早期食物摄入和体重增加。多数报道认为有利于提高术后生活质量。肠袋重建并未增加手术的风险,而且在早期能改善食物摄入,增加体重,有利于患者术后恢复,一定程度上提高患者生活质量。而患者术后长期效果,由于其影响因素涉及范围广,如地区差异和经济条件等,故要得出一精确结论还有待于进一步的探索。现就非十二指肠径路的主要方式及效果作一简述。     

胃切除术后非离断式Roux-en-Y消化道重建的临床研究

目的探讨胃大部切除术后非离断式Roux-en-Y消化道重建方式的临床效果。方法对1994年5月至2002年4月的152例胃大部切除术后的患者施行非离断式Roux-en-Y吻合术(A组)53例,Roux-en-Y吻合术(B组)37例,BillrothⅡ吻合术(C组)62例。非离断式Roux-en-Y吻合术是在传统的BillrothⅡ术式基础上,在空肠输入袢与输出袢之间加作空肠-空肠Braun吻合,同时对靠近胃肠吻合口的输入袢用10号丝线束扎阻断。将3种吻合术后近期和远期并发症发生情况进行对照研究。结果全组术后随访均在6个月以上,术后近期内并发症发生率A、B、C组分别为9.4%、13.5%和16.1%,3组比较差异无显著性意义;碱性反流性胃炎的发生率分别为1.9%、5.4%和33.9%,A、B组均明显低于C组(P<0.01);Roux潴留综合征A组无1例发生,B组发生率为24.3%,两组差异有显著性意义(P<0.01)。3组总的术后并发症发生率分别为11.3%、43.2%和50.0%,A组显著低于B、C组(P<0.01)。同时发现,术后体重下降者在C组较A组更为常见(P<0.01)。结论非离断式Roux术在保留传统Roux术式抗反流优点的同时,克服了传统术式易发生Roux潴留综合征的弊病,是胃大部切除术后理想的消化道重建术式。     

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目的评估全胃切除术后,间置空肠代胃术(jejunalpouchreconstruction,JIP)和RouxenY吻合法消化道重建对病人生存质量的影响,以选择最佳的重建方法。方法回顾性分析1990年1月至2002年10月168例病人行全胃切除术后,分别行JIP和RouxenY吻合消化道重建病人术后1年的进食量、体重、血浆营养参数变化、代胃肠管的储存及排空功能、食管下段胆酸及pH值等术后生存质量指标。结果JIP组间置空肠扩张,术后营养状态及生存质量优于RouxenY吻合组,且消化道不良症状及胆汁反流发生率明显低于后者。结论全胃切除后,采用间置空肠消化道重建简单易行,并可明显提高病人术后的生活质量。     

全胃切除术后Roux-en-Y和储袋吻合的近期疗效

目的探讨全胃切除术中采用Roux-en-Y＋储袋吻合进行消化道重建的近期疗效。方法回顾性分析2013年7月至2013年11月四川大学华西医院收治的7例食管胃结合部腺癌、3例胃体癌患者的临床资料。患者采用全胃切除＋D：淋巴结清扫术,消化道重建采用横结肠前Roux-ell-Y十储袋吻合。采用门诊或电话进行随访,了解患者术后恢复情况,随访时间截至2013年11月。分析患者手术时间、术中出血量、术后住院时间、术后并发症发生率及病死率等手术疗效指标。结果10例患者中,5例采用经腹路径,5例采用经食管裂孔路径。手术时间为（266±23）rain,出血量为（143±40）mL,术后住院时间为（9．3±0．5）d。1例患者术后发生腹腔感染、弥漫性腹膜炎（非吻合口漏导致）,经腹腔冲洗引流治疗后痊愈。无吻合口漏、吻合口出血、腹腔出血等手术并发症发生,无手术死亡。所有患者达到Rn切除,淋巴结清扫数目为（45±18）枚（26～90枚）,阳性淋巴结数目为0～72枚。10例患者获得随访,短期内无明显烧心症状,进食量及进餐数均自觉满意。结论全胃切除术后采用Roux-elq-Y＋储袋吻合进行消化道重建安全可行,近期疗效满意。     

Improved quality of life with jejunal pouch reconstruction after total gastrectomy

BACKGROUND: There is increasing evidence that the effect of jejunal pouch reconstruction is satisfactory for reservoir function in several randomized control studies. However, these studies were performed in patients with advanced gastric cancer, where significant numbers of the patients died of disease recurrence. In order to exclude the influence of disease recurrence, we performed jejunal pouch reconstruction after total gastrectomy in patients with early gastric cancer in a randomized controlled study and investigated whether or not an improved quality of life (QOL) was observed with jejunal pouch reconstruction. METHODS: Fifty consecutive patients receiving total gastrectomy for early gastric cancer were prospectively divided into the Roux-en-Y reconstruction group without pouch (RY group) or the jejunal pouch reconstruction group (pouch group). Body weight, eating capacity, QOL assessment by gastrointestinal symptom rating scale (GSRS), nutritional parameters, endoscopical examination, 24-hour pH monitoring and Bilitec monitoring were evaluated at 3, 12, and 48 months after surgery. RESULTS: Jejunal pouch reconstruction provided the better QOL than Roux-en-Y reconstruction without pouch both at short-term and long-term periods in a randomized control study. Moreover, as a new finding, pouch reconstruction provided less bile reflux into the esophagus compared with Roux-en-Y reconstruction. CONCLUSIONS: Jejunal pouch reconstruction provided improvement of QOL in patients receiving total gastrectomy.     

Laparoscopically assisted total gastrectomy with jejunal pouch interposition

Background Jejunal pouch interposition (JPI) is known as a useful gastric replacement procedure after total gastrectomy. The JPI procedure, however, has not been applicable to laparoscopically assisted total gastrectomy (LATG) because of its technical complexity and difficulty. This study aimed to describe our modified LATG/JPI technique, and to evaluate its feasibility, safety, and early postoperative functional outcome. Methods Between September 2002 and August 2003, LATG/JPI was attempted for five patients (3 men and 2 women) with early gastric cancers in the upper portion of the stomach. The mean age of the patients was 57 years, and their BMI was 21 kg/m². Using a 5-port technique, the gastric arteries were laparoscopically clipped and divided with adequate lymphatic dissection. After completion of gastric resection, the anvil of a circular stapling device was placed in the esophageal stump. An 8-cm minilaparotomy then was performed, and the 12-cm pouch was created extracorporeally in the “reverse U” fashion. The stapled pouch-esophagostomy was performed under laparoscopic monitoring. The remainder of the procedure was accomplished under direct vision. Results All cases were managed laparoscopically without any complications. The mean operating time was 407 min, and the blood loss was 279 ml. All the patients showed rapid and uneventful recovery. Postoperative studies, including dual scintigraphy, showed that all jejunal pouches were satisfactorily functioning. Conclusions This study showed LATG/JPI to be feasible and safe. With technical modifications, LATG/JPI can become a potentially effective option for improving patients’ quality of life after total gastrectomy.     

非离断式Roux—en—Y吻合在远端胃癌根治术后消化道重建中的应用

目的评价非离断式Roux-en-Y吻合用于远端胃癌根治术后消化道重建的临床效果。方法回顾性分析2005年3月至2008年3月间天津医科大学肿瘤医院行远端胃癌根治术且有完整随访资料的419例患者．根据其不同的消化道重建方式分为：UncutRY组（非离断式Roux-en-Y吻合）127例,BI组（BillrothI式）138例,M—BⅡ组（改良BillrothII式）108例,RY组（Roux—en-Y吻合）46例。结果UncutRY组患者手术时间[（132．6±19．2）min]和术后住院时间[（10．4±1．2）d]较RY组[（142．5±11．7）min和（12．1±3．7）d]缩短（P〈0．05）;术后反流性胃炎发生率（3．2％,4／127）较BI组（24．6％,34／138,P〈0．05）和M．BII组（25．9％,28／108,P〈0．05）下降;吻合口溃疡发生率（0／127）较M—BⅡ组（4．6％,5／108,P〈0．05）下降;Roux-en-Y潴留综合征（RSS）发生率（0／127）较RY组（17．4％,8／46,P〈0．05）下降。结论非离断式Roux．en．Y在保留传统Roux—en—Y术式减少碱性反流优点的同时．克服了RSS的弊病,是胃大部切除术后理想的消化道重建术式。     

非离断式Roux—en—Y吻合在腹腔镜全胃切除术消化道重建中的应用

目的：探讨非离断式Roux—en—Y吻合术匝用于腹腔镜全胃切除术消化道重建中的临床效果。方法：将102例胃癌患者按全胃切除后消化道重建方式不同分为非离断式Roux—en—Y吻合术（A组,30例）和Orr式空肠食管Roux—en—Y吻合术（B组,72例）。比较2组患者消化道重建的时间、术后并发症发生情况、进食后症状、单餐进食量、体质量和相关营养代谢指标。结果：消化道重建时间A组（38．1±3．1）mlnjB组（44．7±2．9）min,差异有统计学意义（P〈0．05）。反流性食管炎及倾倒综合征发生率2组差异无统计学意义（P〉0.05）;Roux—en—Y滞留综合征（RSS）发生率A组3．3％,明显低于B组（22．2％,P〈0．05）。术后12个月Visick分级指数I～Ⅱ级者A组优于B组（P-0．034）。术后6个月,除血红蛋白外,体质量、白蛋白下降程度及预后营养指数（PNI）A组优于B组,差异有统计学意义（P〈0．05）。术后12个月,相关营养代谢指标2组差异无统计学意义（P〉0．05）。结论：非离断式Roux—en—Y术发挥了保持肠道连续性和手术相对简单的优势,减少术后RSS并发症,改善患者营养状况,是临床上值得推广的一种消化道重建方式。     

全胃切除改良功能空肠间置法胃肠道重建

全胃切除术后并发的反流性食管炎、倾倒综合征、食欲减退、摄食不足、消化不良、体重下降及贫血等无胃综合征,严重影响患者生活质量,故应寻找一种合理的消化道重建方式。郝希山等[1]创用功能性空肠间置代胃术(functional je-junal interposition,FJI,1999年),我们认为更符合生理,并在此基础上进一步加以改良,报告如下。1资料与方法1.1一般资料2004年7月至2005年1月,术前通过胃镜病理确诊,全胃切除术后有完整病历资料的10例。男7例,女3例,年龄45~68岁。均为胃上、中部癌,贲门癌3例,胃体小弯侧5例,大弯侧1例,累及整个小弯1例。BorrmannⅢ型9…     

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目的介绍一种全胃切除术改良双贮袋Roux-en-Y吻合消化道重建方式,并与传统袢式吻合和Roux-en-Y吻合的中短期效果进行对比研究。方法 2008年5月至2010年3月河南省肿瘤医院普外科将106例因胃癌行根治性全胃切除术病人,随机分为3组分别接受改良双贮袋Roux-en-Y吻合、袢式吻合和Roux-en-Y吻合3种空肠代胃手术方式。比较3组病人的手术时间、术后并发症、住院总费用和住院时间。并于术后1、6、12个月分别进行胃癌病人生活质量调查问卷(QLQ-STO22)评分。结果改良双贮袋Roux-en-Y吻合在手术时间、术后并发症、住院总费用、住院时间等方面与其他两组比较差异无统计学意义。但生活质量评估(吞咽困难、疼痛、呃逆和饮食受限)明显优于其他两组。结论改良双贮袋Roux-en-Y吻合具有安全、术后生活质量高等优点。     

Comparing reconstruction with ileocecal graft to jejunal interposition pouch after total gastrectomy in rats.

After total gastrectomy, the ileocecal graft may act as a reservoir and protect against reflux but give rise to transposition of the ileum and cause possible changes in bile acid metabolism and nutrition. This study compared the ileocecal graft and jejunal pouch. Male Wistar rats weighing 265 +/- 22 g were submitted to sham operation (S), ileocecal interposition graft (IIG), and jejunal pouch interposition graft (JP) after total gastrectomy. Eight weeks later, the esophagus was examined for evidence of esophagitis. Nutritional biochemistry and weight profile were documented preoperatively and 8 weeks after surgery. The oral glucose tolerance test was performed. Thirty-three rats were operated on and 30 survived for 8 weeks. Esophagitis occurred in seven JP rats. Body weight was significantly higher in IIG than in JP rats (p < .05). Normal glucose tolerance to intragastric glucose load was observed in sham and operated rats. JP rats had a significant decrease in serum albumin, glucose, transferrin, hemoglobin, iron, folate, and calcium, compared to sham (p < .05). Cobalamine was significantly lower in IIG rats than in JP rats (p < .05). In the IIG and JP groups, serum/hepatic total bile acid did not differ significantly from preoperative and sham values. In conclusion, the IIG interposition graft in rats prevented esophagitis, preserved nutrition, and did not interfere with enterohepatic total bile acid circulation.     

Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Internal herniation is a well-described complication after a gastric bypass, particularly when performed laparoscopically, although it is rarely described following a total gastrectomy. A 55-year-old lady presented with a 24-hour history of vomiting and rigors 10 months after a radical total gastrectomy with Roux-en-Y reconstruction for a gastric adenocarcinoma. Computed tomography (CT) showed a complete small bowel obstruction and a mesenteric swirl sign, indicating a possible internal hernia. The entire small bowel was found at laparotomy to have migrated through the mesenteric defect adjacent to the site of the previous jejunojejunostomy and was dark purple and aperistaltic. The small bowel was reduced through the defect. At a second laparotomy, the small bowel looked healthy and the defect was repaired. Postoperative recovery was unremarkable. Of numerous signs described, the mesenteric swirl sign is considered the best indicator on CT of an internal hernia following Roux-en-Y reconstruction in gastric bypass surgery. A swirl sign on CT in a patient with abdominal pain should always raise the suspicion of an internal hernia.     

全胃切除术后保留幽门环间置空肠消化道重建与食管空肠Roux-en-Y吻合的应用价值

目的评价全胃切除术后保留幽门环间置空肠消化道重建与食管空肠Roux-en-Y吻合两种消化道重建方式的临床应用价值。方法总结30年来全胃切除术后采用保留幽门环间置空肠消化道重建术与食管空肠Roux-en-Y吻合术治疗54例胃底贲门癌和胃体癌(Ⅰ期)患者的临床资料。结果间置空肠消化道重建术27例,无手术死亡;其中1例术后5d出现间置空肠排空障碍,经治疗3周恢复正常;27例均治愈出院;术后6个月～1年,全组均进食量增加,每餐可达200～300g,每日3～5餐;检查见间置空肠代偿性扩张,最大直径达6cm。食管空肠Roux-en-Y吻合术27例,无手术死亡;25例治愈出院;2例吻合口瘘,经治疗3周后瘘口愈合;术后6个月仍有3例发生倾倒综合征,5例出现轻度胆汁反流性食管炎。结论保留幽门环间置空肠消化道重建术是简单可行而有效的方法。食管空肠Roux-en-Y吻合术更为简单,适用于年老、重症或姑息性全胃切除的患者,但部分患者可出现倾倒综合征和反流性食管炎是其缺点。     

非离断式Roux－en－Y吻合在全腹腔镜根治性全胃切除术消化道重建中的可行性研究

目的探究非离断式Roux－en－Y吻合在全腹腔镜根治性全胃切除术消化道重建中的安全性及可行性。 方法回顾性分析2015年6月至2017年5月接受全腹腔镜根治性全胃切除术的75例胃癌患者临床资料,根据术中消化道重建术式不同进行分组,非离断组37例,行非离断式Roux－en－Y吻合,传统组38例行传统Roux－en－Y吻合。采用统计软件SPSS 20.0进行数据分析,围手术指标、血清营养指标等计量资料采用( ±s)表示,行独立t检验;近远期并发症等行χ²检验或Fisher检验,P<0.05差异有统计学意义。 结果非离断组在手术总时间、消化道重建时间、术中出血量、恢复排气时间、首次进食时间、住院时间方面明显优于传统组(P<0.05),两组术中均无中转开腹。传统组近、远期并发症总发生率(13.2%、21.1%)明显高于非离断组(2.7%、5.4%),差异有统计学意义(P<0.05)。非离断组患者术后短期疗效及胆汁反流情况均优于传统组(P<0.05)。术后3个月两组血清营养指标逐渐恢复,非离断组高于传统组(P<0.05)。 结论非离断式Roux－en－Y吻合应用于全腹腔镜根治性全胃切除术消化道重建中安全可行,值得临床推广使用。     

Usefulness of reconstruction with jejunal pouch in total gastrectomy for gastric cancer in early improvement of nutritional condition

BACKGROUND: Roux-en-Y reconstruction with a jejunal pouch is a modified standard procedure in total gastrectomy for gastric cancer. The aim of the current study was to evaluate the usefulness of the reconstruction using a jejunal pouch in subsequent improvement of the nutritional condition of patients with gastric cancer after total gastrectomy. METHODS: Sixteen patients with gastric cancer treated by total gastrectomy and reconstruction with simple Roux-en-Y from January 1993 to December 1996 and 14 patients treated by total gastrectomy and reconstruction with Roux-en-Y and jejunal pouch from January 1997 to December 1998 were investigated in regard to postoperative heartburn, changes in the body weight, and prognostic nutritional index. RESULTS: Postoperative heartburn occurred in 1 patient (7.1%) among patients treated with Roux-en-Y and jejunal pouch and 3 (18.8%) among patients treated with simple Roux-en-Y. The body weight ratio at 1 year after operation in patients treated with Roux-en-Y and jejunal pouch (88.2% +/- 4.2%) was significantly higher than that in patients treated with simple Roux-en-Y (80.0% +/- 4.6%; P <0.01). The prognostic nutritional index ratios for patients treated with Roux-en-Y and jejunal pouch at 1 and 3 months after operation were 93.9% +/- 9.1% and 101.7% +/- 11.0%, respectively, and were significantly higher than that in patients treated with simple Roux-en-Y (86.2% +/- 8.8% and 88.1% +/- 8.2%, P <0.05 and P <0.01, respectively). CONCLUSIONS: Reconstruction using a jejunal pouch in total gastrectomy is useful for an early improvement of the nutritional condition of patients with gastric cancer.