进展期胃癌全胃切除"围巾式"食管-空肠吻合术(附121例报告)

目的 介绍“围巾式”食管-空肠吻合术预防术后吻合口瘘的临床经验。方法 分析1997年1月至2005年12月连续121例进展期胃癌全胃切除“围巾式”食管-空肠吻合术的临床结果。结果 手术死亡率1．65％（2／121）。存活的119例中，术后均未发生吻合口瘘和反流性食管炎。2000年12月以前，有4例（3．36％）术后发生吻合口狭窄，经胃镜下扩张治愈；改进技术后再无吻合口狭窄发生。结论 “围巾式”食管-空肠吻合术可减少进展期胃癌全胃切除术后吻合口并发症，安全、有效。     

Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer

Background  To facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing. Methods  From September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors’ institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45° counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed. Results  Laparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred. Conclusions  Using the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.     

胃癌切除术切端癌残留临床分析

目的探讨胃癌切除术切端癌残留的原因及预防手段,减少癌残留的发生。方法回顾性分析我院１９８８年１月至１９９３年４月胃癌切除术切端癌残留３２例。结果胃癌切除术切端癌残留率７．４７％。上切端癌残留１１例,下切端癌残留１７例,上下端均有癌残留４例。根治性胃癌切除术癌残留率５．５％,姑息性胃癌切除术癌残留率１２．６１％,二者经统计学检验有显著差异。远、近端胃切除术切端癌残留率分别为５．８６％及１３．０％,统计学检验二者有显著性差异。癌残留与癌肿的大体类型、大小、分化程度及浸润深度有关（Ｐ＜０．０５）。结论浅表广泛型早癌,弥漫浸润型进展癌,癌肿直径＞５ｃｍ,分化程度低或不良,癌肿侵破浆膜者,易发生癌残留。术中切端冰冻活检,有助于减少胃癌切除术切端癌残留的发生率。     

全腹腔镜根治性全胃切除术后食管空肠吻合口漏相关因素分析及吻合方式选择经验探讨

目的探讨全腹腔镜根治性全胃切除术（TLTG）后食管空肠吻合口漏的相关危险因素及吻合方式的选择。 方法回顾性分析2016年1月至2020年12月行TLTG的150例胃癌患者临床资料。采用SPSS 22.0完成数据统计处理,TNM分期及分化程度等级计数资料行秩和检验,其他单因素分析的计数资料行χ²检验,多因素分析行Logistic回归分析。P<0.05为差异有统计学意义。 结果150例TLTG的胃癌患者中,术后发生食管空肠吻合口漏14例（9.3%）。单因素分析结果显示,患者年龄、肺功能不全、术前血清白蛋白（ALB）、术中失血量、术中输血情况及吻合方式是TLTG后食管空肠吻合口漏发生的危险因素（P<0.05）。多因素结果显示,患者年龄≥60岁、肺功能不全、术中输血及圆型吻合器吻合是TLTG后食管空肠吻合口漏发生的独立危险因素（P<0.05）。 结论患者年龄≥60岁、肺功能不全、术中输血及圆型吻合器吻合与TLTG后食管空肠吻合口漏的发生密切相关。因此TLTG术前应积极控制相关危险因素,术中操作严谨细致、选择合适吻合方式,以降低胃癌患者术后吻合口漏的发生。     

全胃切除手法改良空肠P袢代胃术的临床应用

目的：评价全胃切除术后手法改良空肠P袢代胃术的临床效果。方法：依据胃癌生物学特性及根治的要求，对72例胃癌患施行全胃切除术后实施手法改良空肠P袢代胃术重建消化道，并对其并发症的发生及术后生活质量，生存期进行分析。结果：本组术后发生并发症仅10例，发生率为13．9％，患饮食次数为每天4－5次，无饱胀，食欲不振等症状，无倾倒综合征，有56例术后体重增加，5年生存率为38．9％，结论：改良空肠P袢代胃术术式简单易行，能较为有效地防止术后并发症的发生，同时能改善胃癌患术后的生活质量，提高生存率。     

A modified method of laparoscopic side-to-side esophagojejunal anastomosis: report of 14 cases

Background  Alimentary tract reconstruction after laparoscopic total gastrectomy is a technical challenge. Although feasible, reconstruction through a small incision has several drawbacks. The authors therefore report a modified method of laparoscopic side-to-side esophagojejunal anastomosis developed at their hospital. Methods  The side to side esophagojejunal anastomosis was completed with a endo-GIA firing, followed by transection of the jejunum and esophagus with another firing of endo-GIA. Results  This modified procedure was performed successfully for 14 patients with gastric cancer. The mean operation time for this procedure was 42.5 ± 10.2 min. No postoperative death, fistula, or hemorrhage occurred. All the patients were followed up for a mean period of 14.5 months with no cancer recurrence at the anastomosis or anastomotic stricture. All the patients had a barium swallow test 6–2 months after the operation. The mean maximum diameter of the anastomosis was 3.8 cm (range, 3.0–4.2 cm). Four patients experienced temporary symptoms of dumping syndrome or dysphagia, which disappeared 6 months postoperatively. Conclusion  The authors consider this modified laparoscopic side-to-side esophagojejunal anastomosis to be safe, less challenging, and more economical, providing an alternative for alimentary tract reconstruction after laparoscopic total gastrectomy.     

腹腔镜根治性全胃或近端胃切除后食管抵钉座置入新技术

目的 探讨腹腔镜根治性全胃切除或根治性近端胃大部切除后,牵引法放置食管抵钉座行食管残胃或食管空肠吻合新技术的临床价值.方法 回顾性分析2010年3月至2011年2月我中心应用牵引法将吻合器抵钉座置入食管完成腹腔镜根治性全胃切除食管空肠吻合或根治性近端胃大部食管残胃吻合的21例胃癌患者的临床资料.手术采用五孔法,在完成胃周淋巴结清扫和食管游离后,先在超过肿瘤上方3 cm处切开食管,将带牵引线抵钉座完全置入食管近端,保留牵引线在食管切口外,然后切割缝合器横断食管,借助牵引线将抵钉座定位杆拉出,最后在腹腔镜下完成吻合.结果 21例患者均在腹腔镜下顺利完成手术,无中转开腹.15例行腹腔镜根治性全胃切除,6例行根治性近端胃大部切除.平均手术时间为(257±38) min,术中平均出血量为(119±32) ml,术后平均下床活动时间为92.5±0.5)d,术后肛门平均排气时间为(3.7±0.8)d,术后平均住院时间为(7.5±2.6)d.本组患者术后无围手术期死亡,无吻合口出血、吻合口瘘等;但3例患者术后出现并发症,其中1例为肺部感染合并胸腔积液,经积极保守治疗后痊愈;1例为吻合口狭窄,经胃镜气囊扩张治疗后症状缓解;另有1例为切口感染,经积极切开引流换药后痊愈.术后病理检查:所有患者吻合圈和标本切缘未见癌细胞.组织学类型:高分化腺癌4例,中分化腺癌8例,低分化或黏液腺癌9例.UICC分期:Ⅰ期5例,Ⅱ期10例,Ⅲ期6例.21例患者平均随访时间为(11±4)个月96～17个月),无肿瘤复发、转移.结论 牵引法放置食管抵钉座行食管残胃或食管空肠吻合安全可靠,操作简单容易掌握,为腹腔镜下消化道重建提供了一种新的技术选择.     

腹腔镜残胃癌根治术

残胃癌一般是指胃或十二指肠溃疡等行胃大部切除术后5年以上,或胃癌根治术后10年以上残胃发生的原位癌。因腹腔镜残胃癌根治术切除率低故操作仍困难。虽然腹腔镜胃癌根治术技术趋于成熟,但关于腹腔镜残胃癌的报道仍较少。2009年1月至2012年6月兰州军区兰州总医院在完成700余例腹腔镜胃癌根治术的基础上成功施行腹腔镜残胃癌切除术18例,其结果显示：腹腔镜残胃癌切除术技术上安全可行并有满意的近期效果,已掌握腹腔镜胃癌D2根治术的外科医师可实施腹腔镜残胃癌切除术。     

胃癌切除胃肠袢Roux—en—Y瓣式吻合术183例临床观察

目的 胃肠短袢Roux-en-Y瓣式吻合术的抗反流效果,探讨Roux淤积综合征的防治方法。方法 随访986年10月至1997年6月胃癌切除胃空肠短袢Roux-en-Y瓣式吻合术183例,通过症状调查,按改良Visick标准评级,有症状借助消化道钡餐、胃镜并活检、B超、CT检查排除吻合口狭窄、残胃溃疡和肿瘤复发后,确定短袢Roux-en-Y瓣式吻合术的抗反流效果及Roux淤积综合征的发病率。结果 172例（94．0％）获随访结果,5例不满2年因肿瘤复发死亡,3例术后胃瘫,2例因粘连性肠梗阻接受粘连松解术,2例因腹膜广泛种植转移癌致肠梗阻。可进行改良Visick评级165例,Ⅲ、Ⅳ级12例皆为肿瘤复发,未发现有明显症状的反流性胃炎,无倾倒综合症和Roux淤积综合征。结论 扩大胃的切除范围,同时缩短Roux袢的长度,可防治Roux淤积综合征,对空肠空肠吻合口进行抗反渡加工,短袢Roux-en-Y吻合抗反流效果满意。     

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BackgroundThere remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.MethodAll surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).ResultsFrom a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.ConclusionThis study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.     

经腹经纵隔全胃或次全胃切除47例分析

目的 探讨胃肿瘤行全胃或次全胃切除的路径及合理的消化道重建方式。方法 1997—2005年对47例胃上部厦贲门肿瘤行经腹经纵隔全胃或次全胃切除、结肠段消化道重建术，对其手术方法、手术并发症、术后消化道症状进行观察。结果 术后发生食管横结肠吻合口漏1例，余46例无吻合口漏及术后消化道等并发症。与经胸腹手术相比，具有创伤小，并发症少，恢复快等特点。结论 经腹经纵隔全胃或次全胃切除、结肠段消化道重建是一种安全、实用、疗效满意的手术方法，术后加强营齐支持治疗，可明显提高病人的生存质量．、     

腹腔镜下胃癌全胃切除术79例的体会

目的 探讨腹腔镜下胃癌行全胃切除术的可行性及效果.方法 对2004年6月至2006年12月共行腹腔镜下根治性全胃切除术79例,其中行D1及D1+淋巴结清扫12例,D2/D2+淋巴结清扫67例.肿瘤位于胃近端者19例,位于胃体者41例,皮革胃2例,位于胃窦并浸润至胃小弯中上部者17例进行分析.结果 79例中77例成功进行腹腔镜手术,2例中转开腹,中转率为2.5%.平均手术时间(275.8±20.8) min,平均出血量(163.3±48.6) ml,平均每例清扫淋巴结(34.7±12.2) 枚,肿瘤近残端(3.8±1.2) cm,远残端(6.9±2.8) cm.术后肛门排气时间(3.6±0.9) d,下床活动时间(2.5±0.4) d.无术后死亡,无吻合口漏,术后发生并发症7例均经内科治疗痊愈.术后随访9～39个月,平均25.6个月,15例患者因肿瘤复发死亡,余64例仍生存.结论 腹腔镜下全胃切除联合胃癌标准根治术是安全可行的,能达到开腹手术的淋巴结清扫范围,且具有创伤小、出血少、恢复快、并发症率低等优点.     

全腹腔镜全胃切除＋D2淋巴结清扫＋Orvil辅助食管空肠Roux－en－Y吻合术

食管空肠吻合采用OrVil腔内行食管空肠Roux－en－Y吻合,巡回护士将OrVil装置经口放入,引导胃管缓慢送到食道下端并到达食道切缘,主刀用超声刀锐性切开食道切缘正中暴露OrVil的引导胃管,用肠钳将OrVil引导胃管从食道残端的小孔内拉出,直到食道切缘的小孔卡住钉砧头,然后剪断OrVil与引导胃管之间的连接线,确定屈氏韧带,远端25 cm处直线切割闭合器离断空肠,残端包埋,结肠前上提远端。取上腹正中切口,长约4 cm,放置切口保护器,外套装7号手套,于手套拇指剪切口进管状吻合器,重新建立气腹行腹腔镜下食管空场吻合。     

腹腔镜下胃切除术后消化道重建的操作技巧和注意事项

胃的恶性和良性疾病是我国常见病．多发病．腹腔镜手术治疗这类疾病,是当代胃外科的一个显著标志．腹腔镜辅助胃癌根治术是其典型代表,也已被人们广泛认可和接受。腹腔镜下完成胃切除、淋巴清扫和消化道吻合重建的完全腹腔镜胃癌根治术。是对腹腔镜辅助胃癌根治手术的继承和发展,但因腹腔镜下消化道吻合的技术难度和风险,人们对其还有争论,完全腹腔镜胃癌根治术在中国和亚洲尚未得到广泛的发展。本文就腹腔镜下消化道吻合重建的历史与现状、技术和风险等相关问题,进行论述和讨论。     

经口抵钉座置入系统在胃癌腹腔镜全胃切除术消化道重建中的临床价值

目的 探讨应用经口抵钉座置入系统( OrVilTM)在胃癌腹腔镜全胃切除术消化道重建中的临床价值.方法 回顾性分析2011年1月至2012年2月南方医科大学南方医院收治的8例晚期胃癌患者的临床资料.患者先在腹腔镜下完成全胃切除+ D2淋巴结清扫术,辅助切口取出全胃标本后,应用OrVilTM完成食管空肠吻合.分析患者术中、术后和预后情况.结果 所有患者顺利完成腹腔镜全胃切除+小切口辅助Roux-en-Y食管空肠吻合术,无术中并发症发生,在吻合时无需延长辅助切口.平均手术时间为(203±38)min,平均抵钉座放置时间为(10±4) min,术中平均出血量为(106±18)ml.术后病理检查证实切缘均为阴性.术后平均肛门排气时间、平均恢复流质饮食时间、平均恢复半流质饮食时间、平均住院时间分别为(3.5±1.3)d、(5.5±2.9)d、(7.5±3.2)d、(11.5±3.5)d.8例患者中位随访时间为10个月(1 ～14个月),无术后近、远期吻合口相关并发症(瘘、狭窄、出血)发生.结论 OrVilTM在胃癌腹腔镜全胃切除+小切口辅助Roux-en-Y食管空肠吻合术中的应用安全可行.     

胃癌全胃切除术后消化道重建方式的选择

目的：探讨全胃切除术后较理想的消化道重建方式。方法：对近6年来122例施行全胃切除术患者的临床资料进行回顾性分析。全胃切除后消化道重建分别采用全胃切除术后消化道重建Orr式Roux-en-Y食管空肠吻合术、P型空肠袢食管空肠Roux-en-Y吻合术和远端空肠反口贮袋的Roux-en-Y食管空肠吻合术。结果：3种术式在食后烧灼感、进食量、进食次数、体重下降、倾倒综合征、血红蛋白、白蛋白等指标的比较，无明显差异（均P>0.05）。P型空肠袢食管空肠Roux-en-Y吻合术组所用手术时间显著多于Orr组及反口组（P<0.05）。反口组的贮袋大小及半排空时间显著优于Orr组及P袢组（P<0.05）。结论：远端空肠反口贮袋的Roux-en-Y吻合术是一种值得推荐的新型全胃切除术后消化道重建方法。     

完全腹腔镜与腹腔镜辅助胃癌根治术的比较

目的 研究缝合重建完全腹腔镜下胃癌根治术与腹腔镜辅助下胃癌根治术的优缺点,探讨在完全腹腔镜下缝合重建吻合方式的安全性与可行性.方法 回顾性分析2009年7月至2010年7月在第四军医大学西京消化病医院完全腹腔镜下缝合重建胃癌D2根治术与腹腔镜辅助胃癌D2根治术49例患者的临床资料,手术均由同一位经验丰富的普通外科医师完成.结果 完全腹腔镜胃癌根治21例中行远端胃切除15例,全胃切除6例,均采用镜下手工缝合胃肠吻合和空肠-空肠吻合,应用25mm管型吻合器完成食管空肠吻合;腹腔镜辅助胃癌根治28例中行远端胃切除21例,全胃切除7例.完全腹腔镜组与腹腔镜辅助组平均手术时间分别为(279±65)min、(232±40)min(P＜0.05),平均肿瘤下切缘为(3.1±0.9)cm、(2.9±0.9)cm(P＞0.05),平均上切缘为(5.7±1.5)cm、(5.1±1.4)cm(P＞0.05),两组切缘均无癌残留.完全腹腔镜组术后无需用镇痛药,腹腔镜辅助组平均使用镇痛药1.8 d;完全腹腔镜组术后通气时间为3 d,腹腔镜辅助组为4.8 d;完全腹腔镜组术后发生早期并发症2例,其中1例腹腔感染,1例肺部感染.腹腔镜辅助组2例,其中1例切口感染,1例肺部感染.术后中位随访时间4个月,两组均无吻合口瘘与狭窄发生.结论 完全腹腔镜下缝合重建的胃癌D2根治术具有可以接受的手术时间和早期并发症的发生率,可在有选择的患者中由经验丰富的外科医师应用.

Abstract：

Objectives To compare total laparoscopic gastrectomy with intracorporeal hand-sewn Gl reconstruction and laparoscopy-assisted gastrectomy for gastric cancer. Methods Between July 2009 and July 2010, 21 patients of gastric cancer underwent total laparoscopic D2 radical gastrectomy with intracorporeal hand-sewn reconstruction and 28 did laparoscopy-assisted D2 radical gastrectomy in Xijing Hospital of Digestive Diseases. All patients were operated on by an experienced surgeon. Patient demographics, TNM stage, location of tumor, the intraoperative and postoperative details of the two groups were compared. Results In the 21 patients undergoing total laparoscopic gastrectomy, there were 15 of distal gastrectomy and 6 of total gastrectomy, compared with 21 and 7 in laparoscopy-assisted group. In total laparoscopic group, intracorporeal hand-sewn technique was used for gastro-jejunal and jejuno-jejunal (J-J)anastomosis, and 25 mm circular stapler was used for esophago-jejunal anastomosis. The operation time was significant longer in total laparoscopic group than in laparoscopy-assisted group of (279 ± 65 ) min vs.(232 ±40) min (P ＜ 0.05 ). No significant difference was observed between the two groups in proximal margin [(5.7 ± 1.5 )cm vs. (5.1 ± 1.4) cm, P ＞ 0.05] and distal margin [( 3.1 ± 0.9 )cm vs. ( 2.9 ±0.9) cm,P ＞0.05]. The iv narcotic use in laparoscopy-assisted group was 1.8 d but it was not used in total laparoscopic group. The first passing flatus was on day 3 in total laparoscopic group compared with 4.8 d in laparoscopy-assisted group. Both groups had 2 postoperative early complications, one intra-abdominal infection and one lung infection in total laparoscopic group compared with one wound infection and one lung infection in laparoscopy-assisted group. There was no anastomosis-related complications after 4 months of follow-up. Conclusions The operation time and postoperative early complication was acceptable for selected patients treated by total laparoscopic D2 radical gastrectomy with intracorporeal hand-sewn GI tract reconstruction in hands of experienced laparoscopic surgeon.     

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目的 总结和分析残胃癌的临床诊治特点。方法 回顾性分析1996年2月至2003年11月收治的14例残胃癌病人。结果 手术切除率为78．6％,根治切除率57．1％,5年生存率21．4％;根治性切除者的2年生存率达87．5％。结论 根治性外科治疗及病期是决定残胃癌预后的关键。