完全腹腔镜近端胃切除改良双通道吻合法

由于解剖部位的特殊性, 近端胃切除术后失去了食管胃结合部原有的生理结构和功能, 需要进行合适的消化道重建来改善患者术后的反流。传统的双通道吻合方式适用于绝大部分近端胃切除术中的消化道重建, 抗反流效果好, 尤其适用于残胃过小、不适合做食管残胃吻合、糖耐量减低的患者。但是由于手术方式复杂, 吻合口多, 在完全腹腔镜下操作存在较大的难度。我们中心在熟练开展完全腹腔镜近端胃切除双通道吻合法的前提下, 对其进行了改良。本视频就改良双通道吻合法在完全腹腔镜近端胃切除术中的应用进行介绍。     

腹腔镜近端胃切除后抗反流消化道重建术式的临床评价

腹腔镜近端胃切除术的应用越来越多。传统的食管残胃吻合方式会导致患者术后出现严重的反流性食管炎,影响患者生活质量。近年来,多种抗反流的腹腔镜下近端胃切除后消化道重建方式被应用到临床。笔者结合最新的临床研究结果以及自身的临床经验,对腹腔镜近端胃切除后消化道重建方式进行临床评价,重点讨论了食管胃吻合（食管胃后壁吻合、食管胃前...     

早期胃癌行近端胃切除术消化道重建的争议与共识

近端胃切除术是一种保留功能的胃切除手术,近年来在早期胃癌的外科诊疗中的应用逐渐增多。近端胃切除术相较于全胃切除术具有能改善病人术后营养状况等优点,但是由于其破坏了原有的贲门抗反流结构,病人术后出现不同程度的反流性食管炎症状。对于近端胃切除术消化道重建方式的选择,目前尚缺乏公认的理想方法。临床较常用的重建方式包括食管残胃吻合、间置空肠吻合及双通道吻合。同时,各种改良或新型消化道重建方式也在临床应用中不断涌现。各种近端胃切除术消化道重建方式各有利弊,需要开展更多的临床研究进行论证。     

全腹腔镜下近端胃切除间置空肠残胃-空肠双通道吻合一例

对于肿瘤直径<4 cm的早期食管胃结合部癌病例,在保证切缘的情况下,消化道重建可考虑行残胃空肠双通道吻合。因双通道手术吻合口多,操作复杂,在完全腹腔镜下完成比较困难,早年我们团队已开展腹腔镜辅助近端胃切除间置空肠残胃-空肠双通道吻合,近年来,更是将"减钉式"食管空肠吻合引入到全腹腔镜近端胃切除中,形成全腹腔镜下近端胃切...     

食管胃结合部胃肠间质瘤手术方式及消化道重建方法选择

食管胃结合部胃肠间质瘤的主要手术方式有局部切除和近端胃切除,在满足安全手术切缘的前提下,如果齿状线可以完整保留,即可以采取局部切除。近端胃切除术后的主要消化道重建方法有食管-管状残胃吻合,其中食管-管状残胃前壁吻合防反流效果更佳;Kamikawa双浆肌层瓣成型术操作复杂,但是防反流效果可靠;间置空肠重建方法可以有效地防止反流,连续间置空肠简化了手术操作,缩短了手术时间;双通路重建是近年比较常用的方法,可以有效预防术后贫血和维生素B12缺乏。     

腹腔镜近端胃切除术后功能性消化道重建策略

食管胃结合部腺癌发病率逐渐上升, 长径<4 cm的胃上部癌远端淋巴结转移少见, 行近端胃切除术即可满足根治要求。近端胃切除术后反流性食管炎、食物淤滞、吻合口狭窄、营养吸收差, 都是影响患者术后生命质量的重要因素。随着腹腔镜胃癌根治术的不断推广, 腹腔镜下近端胃切除淋巴结清扫术已经标准化, 但是消化道重建方式尚未达成标准共识, 而抗反流成为近年临床关注热点。通过间置空肠达到抗反流效果, 保留或重建抗反流结构的食管残胃吻合, 包括各种抗反流的附加手术, 各有优劣。笔者全面详细介绍各种主流抗反流手术方式及其改良方案, 以期为同道提供参考, 让患者最大化获益。     

腹腔镜胃癌手术的消化道重建

近年来。腹腔镜胃癌手术在中国发展迅速,手术步骤包含足够范围的胃切除、合理的淋巴清扫和消化道重建3部分．其中消化道重建是腹腔镜胃癌手术的关键。腹腔镜远端胃癌根治术常用的消化道重建方式有胃十二指肠吻合（毕Ⅰ式）、胃空肠吻合（毕Ⅱ式）和胃空肠Roux-en-Y吻合：腹腔镜根治性全胃切除术的消化道重建方式首推食管空肠Roux-en-Y吻合：腹腔镜近端胃癌根治术的消化道重建方式主要是食管胃吻合．食管-管状胃吻合能有效降低反流性食管炎的发生率。小切口辅助下消化道重建费用较低、易于掌握、适合国情、值得推荐。     

食管胃结合部癌的消化道重建

近端胃大部切除术后食管残胃吻合是常用的术式,但是由于手术破坏了防反流结构,造成残胃内容物反流至食管内导致反流性食管炎。管状胃消化道重建,采取食管残胃前壁吻合及幽门成型可以在残胃残端形成类似胃底结构,防反流作用明显,基本保持了胃的解剖结构,具备食物的贮存与消化功能。间置空肠可以有效防止反流,连续间置空肠具有操作简便、安全可靠等优点。天津医科大学肿瘤医院对1例食管胃结合部腺癌和1例食管胃结合部间质瘤患者实施近端胃切除术,术后分别采取了管状胃食管吻合和连续间置空肠两种消化道重建方式。患者术后恢复顺利,无相关}肖化道并发症发生。     

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近端胃大部切除仅适于T1N0期食管胃结合部腺癌(AEG),近端胃大部切除后食管-残胃吻合是最常用的术式,但是由于破坏了防反流结构,造成残胃内容物反流至食管内导致反流性食管炎。食管-残胃前壁吻合可以在残胃残端形成类似胃底结构,形成HIS角,防反流作用明显。采取食管与胃黏膜单层套入式吻合也可以达到防止反流的效果。管状胃基本保持了胃的解剖结构,具备食物的贮存与消化功能。间置空肠可以有效防止反流,空肠储袋间置增加了残胃容量。双通路加近口端储袋可以延缓食物进入十二指肠的时间。     

反穿刺技术在腹腔镜食管-残胃(空肠)吻合术中的应用

目的探讨反穿刺技术在腹腔镜食管-残胃(空肠)吻合术中应用的可行性及临床效果。方法回顾性分析2015年1月～2016年6月32例胃食管交界部腺癌行腹腔镜全胃切除或根治性近端胃大部切除术的临床资料。均在腔镜下切开食管前壁,运用反穿刺技术置入抵钉座,完成食管-残胃(空肠)吻合。结果全组均顺利完成手术,手术时间157～245 min(平均186 min),抵钉座置入时间9～16 min(平均13 min),术中出血70～150 ml(平均95 ml),辅助切口长4. 2～5. 1cm(平均4. 7 cm),术后住院时间8～12 d(平均10 d),未发生吻合口漏、狭窄、出血等并发症。结论反穿刺技术在腹腔镜食管-残胃(空肠)吻合术中能简化手术操作,安全可靠,腹壁辅助切口小,值得推广。     

Laparoscopy-assisted Proximal Gastrectomy with Sentinel Node Mapping for Early Gastric Cancer

Background

Laparoscopy-assisted proximal gastrectomy (LAPG) remains a relatively uncommon procedure because of certain technical issues, such as curability, safety, and retention of postoperative patients?? quality of life. The aim of the present study was to evaluate the feasibility of a newly developed LAPG procedure for early-stage proximal gastric cancer.

Methods

We enrolled 37 consecutive patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the upper third of the stomach with the primary tumor diameter less than 4?cm. Laparoscopy-assisted proximal gastrectomy with sentinel node (SN) mapping and esophagogastric anastomosis with a circular stapler and transoral placement of the anvil was attempted.

Results

The LAPG procedure was completed in 36 patients. It was converted to laparoscopy-assisted total gastrectomy in one patient because one SN detected intraoperatively was positive for metastasis by intraoperative pathological diagnosis. There were no severe postoperative complications in any patient. Only one patient (3%) complained of mild reflux symptoms immediately after operation, which were graded endoscopically as B by the Los Angeles Classification of gastroesophageal reflux disease; however, the symptoms were controlled well by a proton-pump inhibitor. Sentinel nodes were detected successfully in 37 (100%) of our patients. The mean number of dissected lymph nodes and identified SNs per case was 29.7 and 5.8, respectively. The sensitivity of prediction of nodal metastasis (including isolated tumor cells) and diagnostic accuracy based on SN status were 100% (3/3) and 100% (37/37), respectively. All patients have been free from recurrence for a median follow-up period of 26?months.

Conclusions

This study reveals that our novel LAPG approach is curative and represents a feasible minimally invasive surgical procedure with minimal morbidity and postoperative reflux esophagitis in patients with upper-third early-stage gastric cancer.     

腹腔镜下近端胃切除术治疗近端早期胃癌

目的:探讨腹腔镜下近端胃切除术治疗近端早期胃癌的可行性与安全性。方法:回顾性分析2007年6月—2010年12月间手术治疗的72例近端早期胃癌患者资料,其中38例行腹腔镜下近端胃切除术(LAPG组),34例行腹腔镜下胃大部切除术(LAG组)。比较两组患者的一般情况、术中与术后各项指标,并用Visick评分比较两组患者术后胃食管反流症状。结果:两组患者年龄、性别、体质量指数、并存疾病、手术时间及术后住院天数差异均无统计学意义(均P>0.05),但LAPG组术中出血量明显少于LAG组(P<0.05)。两组患者术后肛门排气时间、开始进食时间及早、晚期并发症发生率差异均无统计学意义(均P>0.05),但LAPG组术后Visick评分明显高于LAG组(P<0.05)。两组患者术后病理指标、手术前后的营养学指标变化、术后生存率差异均无统计学意义(均P>0.05)。结论:腹腔镜下近端胃切除术能够安全的应用于近端早期胃癌的治疗,但应警惕术后胃食管反流症状的发生。     

Function-Preserving Gastrectomy for Early Gastric Cancer

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures. Applications of function-preserving gastric cancer surgery may therefore also be increasing because of its low incidence of lymph node metastasis, excellent survival rates, and the possibility of less-invasive procedures such as laparoscopic gastrectomy being used in combination. Pylorus-preserving gastrectomy (PPG) with radical lymph node dissection is one such function-preserving procedure that has been applied for EGC, with the indications, limitations, and survival benefits of PPG already reported in several retrospective studies. Laparoscopy-assisted proximal gastrectomy has also been applied for EGC of the upper third of the stomach, although this procedure can be associated with the 2 major problems of reflux esophagitis and carcinoma arising in the gastric stump. In the patient with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved very small stomach may provide a better quality of life for the patients and fewer postoperative complications. Finally, the laparoscopy endoscopy cooperative surgery procedure combines endoscopic submucosal dissection with laparoscopic gastric wall resection, which prevents excessive resection and deformation of the stomach after surgery and was recently applied for EGC cases without possibility of lymph node metastasis. Function-preserving laparoscopic gastrectomy is recommended for the treatment of EGC if the indication followed by accurate diagnosis is strictly confirmed. Preservation of remnant stomach sometimes causes severe postoperative dysfunctions such as delayed gastric retention in PPG, esophageal reflux in PG, and gastric stump carcinoma in the remnant stomach. Moreover, these techniques present technical difficulties to the surgeon. Although many retrospective studies showed the functional benefit or oncological safety of function-preserving gastrectomy, further prospective studies using large case series are necessary.     

Current status of laparoscopic proximal gastrectomy in proximal gastric cancer: Technical details and oncologic outcomes

The incidence of proximal gastric cancer has been increasing continuously. This status has prevailed despite the application of laparoscopic proximal gastrectomy as a surgical treatment for early proximal gastric cancer. The widespread adoption and standardization of this surgical procedure as the primary treatment for the abovementioned cancer has been hampered by the lack of consensus on the optimal reconstruction method after proximal gastrectomy. In addition, the oncological safety of proximal gastrectomy for advanced gastric disease remains unclear. We reviewed the English-language literature to clarify the current status of laparoscopic proximal gastrectomy in proximal gastric cancer. Japanese gastric cancer guidelines have suggested three types of reconstructions for proximal gastrectomy, namely, esophagogastrostomy, double-tract reconstruction, and jejunal interposition. Optimal reconstruction methods remain to be determined because of the lack of adequately performed and well-designed randomized controlled trials. The technical complexity and challenging implementation of reconstruction procedures have resulted in several complications with anastomoses. Multicenter randomized controlled trials are necessary to evaluate the various reconstruction methods and the oncological safety of laparoscopic proximal gastrectomy for advanced gastric disease.     

Effects of duodenogastric bile reflux on gastric mucosal hexosamine concentrations after selective proximal vagotomy or extended distal gastrectomy for duodenal ulcer

Effects of duodenogastric reflux (DGR) of bile on hexosamine concentrations in gastric mucosa were studied in 17 healthy controls and 133 patients with duodenal ulcer patients before and after surgery. Total bile acid concentration in gastric juice was measured using enzyme method to estimate DGR. Mucosal hexosamine concentration of the biopsy specimens taken from the gastric corpus and antrum was measured according to Boas's method. The operative procedures included selective proximal vagotomy (SPV) with or without pyloroplasty, and extended distal gastrectomy with Billroth I(BI) or II(BII) anastomosis. The rate of DGR were significantly higher in cases after gastrectomy, especially in BII cases than in cases after SPV. In the early postoperative period after SPV with or without pyloroplasty, DGR was increased significantly. However, the reflux rate was decreased gradually to the preoperative level thereafter, suggesting that normal function of gastric emptying might be recovered with time. The hexosamine concentration of the antral mucosa showed clearly an inverse relationship to the changes in DGR rate. These results suggested that SPV could be the more physiological procedure than gastrectomy from the point of DGR.     

保留幽门回盲肠代胃在近端胃癌根治术中的应用

目的:为减少近端胃癌根治术后返流性食管炎的发生及增加胃切除术后的残胃容量,提高胃癌术后的总体生存质量。方法:在近端胃癌根治术后,将带血供的回盲肠移植于残胃与食道之间,结果:14例中,术后第10天恢复正常饮食的11例;食道回肠吻合口漏及狭窄各1例;死亡1例。生存的13例中随诊6～12个月,均无返流性食道炎症状,恢复术前饮食量。结论:保留幽门回盲肠代胃可有效防止近端胃癌根治术后的反流性食道炎及增加饮食量,提高生存质量。     

Pylorus-preserving procedure in partial and total gastrectomy

Summary 1. The operative technique and the postoperative results of the original pylorus-preserving gastrectomy (PPG) and those of the Maki procedure as applied to cases of total gastrectomy are reported briefly.2. The essence of these operations is to retain the pyloric cuff of 1.0–1.5 cm in length in order to preserve sphincteric function without the use of the drainage procedure. Ingested food was seen to empty gradually and rhythmically through the pyloric ring into the duodenum thereby avoiding dumping syndrome and reflux esophagitis.3. As gastric acidity is reduced sufficiently by PPG, this method is to be recommended for treatment of intractable gastric ulcer cases and other benign lesions in which the foci are located in the distal half of the stomach. Though the method seems to be also useful in selected cases of duodenal ulcer, stenosis at the level of the pylorus and duodenum may preclude the application of the method.4. The Maki procedure with jejunal interposition following nearly-total proximal gastrectomy is recommended in patients whose pylorus and its surroundings have remained free of tumor.