全腹腔镜下食管-空肠π吻合在贲门癌根治术中的近期安全性研究

张晨嵩; 潘成武; 王庆康; 王远鹏; 吴晗; 马家驰

doi:10.16766/j.cnki.issn.1674-4152.003543

全腹腔镜下食管-空肠π吻合在贲门癌根治术中的近期安全性研究

doi: 10.16766/j.cnki.issn.1674-4152.003543

1.
蚌埠医科大学第一附属医院肿瘤外科，安徽蚌埠 233004
2.
蚌埠医科大学第二附属医院普通外科，安徽蚌埠 233000

基金项目:

安徽省自然科学基金面上项目 2208085MH242

安徽省高等学校自然科学重点项目 2023AH051990

蚌埠市科学技术指导类项目 20220130

蚌埠医学院第一附属医院高新技术领先项目 2023032

详细信息

通讯作者:
马家驰，E-mail：tsmjc2013@163.com

中图分类号: R735.2 R730.56
计量
- 文章访问数: 407
- HTML全文浏览量: 198
- PDF下载量: 8
- 被引次数: 0
出版历程
- 收稿日期: 2023-12-04
- 网络出版日期: 2024-07-22

Short term safety research of total laparoscopic π-shaped esophagojejunal anastomosis in radical surgery for adenocarcinoma of esophagogastric junction

1.
Department of Oncology Surgery, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui 233004, China

摘要

摘要: 目的比较全腹腔镜下食管-空肠π式吻合与腹腔镜辅助食管-空肠Roux-en-Y吻合在贲门癌全胃切除术的近期临床疗效及安全性。方法分析2020年6月—2022年7月在蚌埠医科大学第一附属医院治疗的72例食管胃结合部腺癌患者的临床及病理资料。所有患者均行腹腔镜全胃切除+D2淋巴结清扫术，其中38例患者行全腹腔镜下贲门癌根治术+食管-空肠π吻合(全腹腔镜组)，34例患者采用腹腔镜辅助贲门癌根治术+食管-空肠Roux-en-Y吻合(腹腔镜辅助组)，分析不同术式的安全性及对应激反应的影响。结果全腹腔镜组手术时间长于腹腔镜辅助组且手术切口长度显著短于腹腔镜辅助组(P＜0.001)。全腹腔镜组术中出血量[(130.26±23.54)mL]明显低于腹腔镜组[(167.21±28.53)mL, t=6.017，P＜0.001]。全腹腔镜组术后首次排气时间明显短于腹腔镜辅助组(P=0.003)。2组术后拔除引流管时间、术后住院时间、术后并发症发生情况及手术清扫淋巴结个数比较，差异均无统计学意义(P>0.05)。术后第1天和第5天全腹腔镜组患者血清CRP水平显著低于腹腔镜辅助组(P＜0.05)。结论全腹腔镜下贲门癌根治+食管-空肠π吻合的手术方式是安全的，能够减少术中出血，缩短患者恢复时间，缓解术后疼痛，减少术后并发症的发生，且对机体创伤性应激反应的影响较小。
- 贲门癌 /
- 完全腹腔镜 /
- 全胃切除术 /
- π吻合 /
- 创伤应激
Abstract: Objective To analyze the short-term clinical efficacy and safety of total laparoscopic π-shaped esophageal jejunostomy and laparoscopic assisted Roux-en-Y esophago-jejunostomy for adenocarcinoma of the esophagogastric junction. Methods The clinical and pathological data of 72 patients with adenocarcinoma of the esophagogastric junction treated in the First Affiliated Hospital of Bengbu Medical University from June 2020 to July 2022 were collected. All patients underwent laparoscopic total gastrectomy + D2 lymphadenectomy, in whom 38 patients underwent total laparoscopic radical resection of cardiac cancer + π-shaped esophageal jejunostomy and 34 patients underwent laparoscopic-assisted radical resection of cardiac cancer + Roux-en-Y esophago-jejunostomy. The safety and effects on stress response indicators of different surgical methods were analyzed. Results The mean operation time of the total endoscopy group was longer than that of the laparoscopic-assisted group and the length of the incision was significantly shorter than that in the laparoscopic-assisted group (P < 0.001). In terms of intraoperative bleeding, the amount of intraoperative bleeding in the total endoscopy group (130.26±23.54) mL was significantly lower than that in the laparoscopic group [(167.21±28.53) mL, t=6.017, P < 0.001]. The first postoperative exhaust time in the total endoscopy group was significantly lower than that in the laparoscopic-assisted group (P=0.003). There were no significant differences in extubation time, postoperative hospitalization days, postoperative complications, and number of surgically removed lymph nodes between the two groups (P>0.05). The serum level of CRP in the total endoscopy group was significantly lower than that in the laparoscopic-assisted group on the first and fifth day after surgery (P < 0.05). Conclusion Total laparoscopic radical resection of cardiac cancer + π esophagojejunostomy is safe, which can reduce intraoperative bleeding, shorten the recovery time of patients, relieve postoperative pain, greatly reduce the occurrence of postoperative complications, and has little effect on the body's traumatic stress response.
- Adenocarcinoma of esophagogastric junction /
- Total laparoscopic surgery /
- Total gastrectomy /
- π-shaped esophagojejunal /
- Traumatic stress

HTML全文

图 1 食管-空肠术中π吻合图片

注：A为离断十二指肠；B为向左下方牵拉，充分显露食管，使用超声刀在食管右侧壁开孔；C为食管-空肠侧侧吻合；D为经共同开口，观察食管-空肠吻合口情况；E为关闭食管-空肠共同开口；F为倒刺线加固缝合吻合口。

Figure 1. Intraoperative images of π-shaped esophagojejunostomy

下载: 全尺寸图片幻灯片

表 1 2组贲门癌手术患者的基本资料比较

Table 1. Basic data of two groups of patients undergoing surgery for adenocarcinoma of esophagogastric junction

项目	全腹腔镜组(n=38)	腹腔镜辅助组(n=34)	统计量	P值
年龄(x±s，岁)	68.66±15.33	62.91±14.68	1.621^a	0.110
性别[例(%)]			0.686^b	0.471
男性	32(84.21)	26(76.47)
女性	6(15.79)	8(23.53)
BMI(x±s)	23.71±3.72	22.37±2.67	1.738^a	0.087
合并症[例(%)]
心律失常	3(7.89)	4(11.76)	0.024^b	0.877
高血压	18(47.37)	9(26.47)	3.344^b	0.067
糖尿病	2(5.26)	2(5.88)	0.161^b	0.687
冠心病	4(10.53)	4(11.76)	0.084^b	0.772
陈旧性脑梗死	7(18.42)	6(17.65)	0.007^b	0.933
ASA分级[例(%)]			0.227^c	0.054
Ⅰ	11(28.95)	18(52.94)
Ⅱ	25(65.79)	16(47.06)
Ⅲ	2(5.26)	0
既往腹部手术史[例(%)]	5(13.16)	3(8.82)	0.044^b	0.835
Siewert分型[例(%)]			0.028^b	0.867
Siewert Ⅱ型	13(34.21)	11(32.35)
Siewert Ⅲ型	25(65.79)	23(67.65)
注：^a为t值，^b为χ²值，^c为Z值。

下载: 导出CSV

表 2 2组贲门癌手术患者术中指标比较(x±s)

Table 2. Comparison of two groups of patients undergoing surgery for adenocarcinoma of esophagogastric junction(x±s)

组别	例数	手术时间[M(P₂₅, P₇₅), min]	术中出血量(x±s, mL)	术中输血患者人数[例(%)]	手术切口长度(x±s, cm)
全腹腔镜组	38	195.5(185.5, 216.0)	130.26±23.54	2(5.26)	4.58±0.69
腹腔镜辅助组	34	168.5(160.0, 185.0)	167.21±28.53	4(11.76)	10.42±0.90
统计量		5.888^a	6.017^b	0.334^c	31.035^b
P值		＜0.001	＜0.001	0.569	＜0.001
注：^a为Z值，^b为t值，^c为χ²值。

下载: 导出CSV

表 3 术后2组贲门癌手术患者病理学指标比较

Table 3. Comparison of pathological data of patients with adenocarcinoma of esophagogastric junction after operation between two groups

项目	全腹腔镜组(n=38)	腹腔镜辅助组(n=34)	统计量	P值
肿瘤长径(x±s，cm)	4.17±1.68	4.49±1.99	0.740^a	0.462
分化程度[例(%)]			0.003^b	0.956
G1~G2	21(55.26)	19 (55.88)
G3~G4	17(44.74)	15 (44.12)
Borrmann分型[例(%)]			0.487^b	0.626
Borrmann Ⅰ型	3(7.89)	2(5.88)
Borrmann Ⅱ型	18(47.37)	16(47.06)
Borrmann Ⅲ型	13(34.21)	10(29.41)
Borrmann Ⅳ型	4(10.53)	6(17.65)
Lauren分型[例(%)]			0.536^b	0.765
肠型	23(60.53)	20(58.82)
弥漫型	10(26.32)	11(32.35)
混合型	5(13.15)	3(8.82)
T分期[例(%)]			0.285^c	0.776
T1	4(10.53)	6(17.65)
T2	5(13.16)	1(2.94)
T3	2(5.26)	1(2.94)
T4a	27(71.05)	26(76.47)
N分期[例(%)]			0.060^c	0.952
N0	19(50.00)	14(41.18)
N1	3(7.89)	9(26.47)
N2	5(13.15)	3(8.82)
N3a/N3b	11(28.96)	8(23.53)
病理学分期[例(%)]			0.556^c	0.578
Ⅰ	8(21.05)	7(20.59)
Ⅱ	12(31.58)	8(23.53)
Ⅲ	18(47.37)	19(55.88)
手术清扫淋巴结个数(x±s，个)	30.84±9.34	34.76±8.52	1.854^a	0.068
注：^a为t值，^b为χ²值，^c为Z值。

下载: 导出CSV

表 4 2组贲门癌手术患者术后情况及相关并发症情况比较

Table 4. Comparison of postoperative conditions and related complications of patients with adenocarcinoma of esophagogastric junction in two groups

项目	全腹腔镜组(n=38)	腹腔镜辅助组(n=34)	统计量	P值
首次排气时间(x±s，d)	3.79±1.20	5.03±2.00	3.130^a	0.003
拔除引流管时间(x±s，d)	6.08±1.57	6.63±1.04	1.731^a	0.088
首次进食半流质时间(x±s，d)	6.20±2.80	7.10±1.90	1.577^a	0.119
术后住院时间(x±s，d)	7.00±1.60	7.40±1.50	1.081^a	0.283
术后并发症[例(%)]
吻合口出血	1(2.63)	2(5.88)	0.010^b	0.923
吻合口瘘	2(5.26)	0		0.495^c
吻合口狭窄	1(2.63)	2(5.88)	0.010^b	0.922
乳糜漏	1(2.63)	1(2.94)		＜0.999^c
切口感染	4(10.53)	5(14.71)	0.032^b	0.858
呼吸衰竭	0	1(2.94)		0.472^c
心力衰竭	1(2.63)	0		＜0.999^c
肠梗阻	0	0
注：^a为t值，^b为χ²值, ^c为使用Fisher精确检验。

下载: 导出CSV

表 5 2组贲门癌手术患者术后炎症指标比较(x±s)

Table 5. Comparison of postoperative inflammation indexes in two groups of patients undergoing adenocarcinoma of esophagogastric junction surgery(x±s)

组别	例数	白细胞计数(×10⁹/L)			C-反应蛋白浓度(mg/L)
组别	例数	术前	术后第1天	术后第5天	术前	术后第1天	术后第5天
全腹腔镜组	38	5.6±1.1	10.8±0.7	6.7±1.7	3.1±0.6	65.5±12.8	24.9±3.8
腹腔镜辅助组	34	5.7±1.3	10.7±1.9	6.8±1.6	3.2±0.4	90.5±10.8	30.2±5.9
F值		-0.155	0.127	-0.667	-0.822	-4.941	-3.041
P值		0.877	0.899	0.507	0.414	＜0.001	0.003
注：白细胞计数3个时间点比较，F_时间=33.212，P_时间=0.311；F_组间=5.756，P=0.855；F_交互=11.552，P=0.089。C-反应蛋白浓度3个时间点比较，F_时间=9.864，P_时间=0.700；F_组间=14.532，P=0.097；F_交互=132.513，P=0.154。

下载: 导出CSV

参考文献(24)

[1]	郭爱军, 鲁明典, 周波. 手助腹腔镜在胃癌根治术中的应用[J]. 中华全科医学, 2021, 19(7): 1099-1102. doi: 10.16766/j.cnki.issn.1674-4152.001994 GUO A J, LU M D, ZHOU B. The application of hand-assisted laparoscopic D2 radical gastrectomy[J]. Chinese Journal of General Practice, 2021, 19(7): 1099-1102. doi: 10.16766/j.cnki.issn.1674-4152.001994
[2]	JUNG K W, WON Y J, KONG H J, et al. Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2016[J]. Cancer Res Treat, 2019, 51(2): 417-430. doi: 10.4143/crt.2019.138
[3]	KAKEJI Y, ISHIKAWA T, SUZUKI S, et al. A retrospective 5-year survival analysis of surgically resected gastric cancer cases from the Japanese Gastric Cancer Association nationwide registry (2001-2013)[J]. Gastric Cancer, 2022, 25(6): 1082-1093. doi: 10.1007/s10120-022-01317-6
[4]	SHI Y, XU X H, ZHAO Y L, et al. Long-term oncologic outcomes of a randomized controlled trial comparing laparoscopic versus open gastrectomy with D2 lymph node dissection for advanced gastric cancer[J]. Surgery, 2019, 165(6): 1211-1216. doi: 10.1016/j.surg.2019.01.003
[5]	卓恩挺, 王连臣, 符国宏, 等. 腹腔镜下腹会阴直肠癌手术中腹膜外造口与腹膜内造口的疗效比较[J]. 中国普通外科杂志, 2021, 30(2): 241-246. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ202102020.htm ZHUO E T, WANG L C, FU G H, et al. Efficacy comparison of extraperitoneal and intraperitoneal colostomy in laparoscopic abdominoperineal resection for rectal cancer[J]. Chinese Journal of General Surgery, 2021, 30(2): 241-246. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ202102020.htm
[6]	姚远, 方可, 张正君, 等. 食管空肠π吻合在全腹腔镜根治性全胃切除术中的应用[J]. 中国普通外科杂志, 2020, 29(10): 1204-1211. doi: 10.7659/j.issn.1005-6947.2020.10.007 YAO Y, FANG K, ZHANG Z J, et al. Application of π -shaped esophagojejunostomy in laparoscopic radical total gastrectomy[J]. Chinese Journal of General Surgery, 2020, 29(10): 1204-1211. doi: 10.7659/j.issn.1005-6947.2020.10.007
[7]	KANG S H, CHO Y S, MIN S H, et al. Intracorporeal esophagojejunostomy using a circular or a linear stapler in totally laparoscopic total gastrectomy: a propensity-matched analysis[J]. J Gastric Cancer, 2019, 19(2): 193-201. doi: 10.5230/jgc.2019.19.e17
[8]	MURAKAMI K, OBAMA K, TSUNODA S, et al. Linear or circular stapler A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy[J]. Surg Endosc, 2020, 34(12): 5265-5273. doi: 10.1007/s00464-019-07313-9
[9]	XING J, XU K, LIU M, et al. Modified π-shaped esophagojejunostomy in totally laparoscopic total gastrectomy: a report of 40 consecutive cases from a single center[J]. J Int Med Res, 2022, 50(8): 3000605221116328. DOI: 10.1177/03000605221116328.
[10]	郭建, 孙康, 瞿建国, 等. 加速康复外科路径下腹腔镜全胃切除术后完全腹腔镜食管-空肠π吻合的临床疗效[J]. 中国普通外科杂志, 2022, 31(8): 1080-1088. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ202208011.htm GUO J, SUN K, QU J G, et al. Clinical efficacy of totally laparoscopic π-shaped esophagojejunostomy following laparoscopic gastrectomy under the enhanced recovery after surgery pathway[J]. Chinese Journal of General Surgery, 2022, 31(8): 1080-1088. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ202208011.htm
[11]	中华医学会外科学分会腹腔镜与内镜外科学组, 中国研究型医院学会机器人与腹腔镜外科专业委员会. 腹腔镜胃癌手术操作指南(2016版)[J]. 中华消化外科杂志, 2016, 15(9): 851-857. doi: 10.3760/cma.j.issn.1673-9752.2016.09.001 Section of Laparoscopic & Endoscopic Surgery, Branch of Surgery, Chinese Medical Association; Robotic and Laparoscopic Surgery Committee of Chines Research Hospital Association. Guideline for laparoscopic gastrectomy for gastric cancer(2016 edition)[J]. Chinese Journal of Digestive Surgery, 2016, 15(9): 851-857. doi: 10.3760/cma.j.issn.1673-9752.2016.09.001
[12]	季刚, 卫江鹏, 李世森, 等. 腹腔镜胃癌手术中高位食管空肠吻合重点与难点[J]. 中国实用外科杂志, 2023, 43(9): 997-1001. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK202309006.htm JI G, WEI J P, LI S S, et al. Key points and difficulties of high esophagojejunal anastomosis in laparoscopic gastrectomy for gastric cancer[J]. Chinese Journal of Practical Surgery, 2023, 43(9): 997-1001. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK202309006.htm
[13]	严东羿, 张顺, 袁彪, 等. 完全腹腔镜与腔镜辅助根治性全胃切除术的短期疗效对比[J]. 中国肿瘤外科杂志, 2021, 13(3): 261-266. doi: 10.3969/j.issn.1674-4136.2021.03.013 YAN D Y, ZHANG S, YUAN B, et al. Comparison of short-term efficacy between 3D totally laparoscopic and laparoscopy-assisted radical total gastrectomy[J]. Chinese Journal of Surgical Oncology, 2021, 13(3): 261-266. doi: 10.3969/j.issn.1674-4136.2021.03.013
[14]	冯志刚, 杨雨民. 胃癌患者微创全胃切除的手术效果研究[J]. 中国内镜杂志, 2018, 24(7): 51-55. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGNJ201807011.htm FENG Z G, YANG Y M. Effect of laparoscopic total gastrectomy in patients with gastric cancer[J]. China Journal of Endoscopy, 2018, 24(7): 51-55. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGNJ201807011.htm
[15]	黄昌明, 郑朝辉, 陆俊. 完全腹腔镜胃癌手术消化道重建专家共识及手术操作指南(2018版)[J]. 中国实用外科杂志, 2018, 38(8): 833-839. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201808001.htm HUANG C M, ZHENG C H, LU J. Expert consensus and surgical guidelines for digestive tract reconstruction in complete laparoscopic surgery for gastric cancer (2018 edition)[J]. Chinese Journal of Practical Surgery, 2018, 38(8): 833-839. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201808001.htm
[16]	汪兵, 夏亚斌, 张义胜, 等. 全腹腔镜全胃切除术食管空肠吻合术反穿刺法与Overlap法的比较[J]. 中国微创外科杂志, 2020, 20(7): 590-594. doi: 10.3969/j.issn.1009-6604.2020.07.004 WANG B, XIA Y B, ZHANG Y S, et al. Comparative analysis of reverse puncture device and overlap methods of esophagojejunostomy in totally laparoscopic total gastrectomy[J]. Chinese Journal of Minimally Invasive Surgery, 2020, 20(7): 590-594. doi: 10.3969/j.issn.1009-6604.2020.07.004
[17]	李胜, 杨文光, 樊林. 捆绑式反穿刺法食管空肠吻合技术在腹腔镜胃癌根治术中的应用[J]. 中国普通外科杂志, 2019, 28(10): 1197-1204. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ201910007.htm LI S, YANG W G, FAN L. Application of tied reverse puncture esophagojejunostomy in laparoscopic radical gastrectomy for gastric cancer[J]. Chinese Journal of General Surgery, 2019, 28(10): 1197-1204. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ201910007.htm
[18]	何子锐, 臧潞. 食管胃结合部腺癌腹腔镜手术消化道重建方式的进展[J]. 中国普通外科杂志, 2021, 30(10): 1127-1132. doi: 10.7659/j.issn.1005-6947.2021.10.001 HE Z R, ZANG L. Advances in laparoscopic digestive tract reconstruction for adenocarcinoma of the esophagogastric junction[J]. Chinese Journal of General Surgery, 2021, 30(10): 1127-1132. doi: 10.7659/j.issn.1005-6947.2021.10.001
[19]	JEONG O, JUNG M R, KANG J H, et al. Reduced anastomotic complications with intracorporeal esophagojejunostomy using endo-scopic linear staplers (overlap method) in laparoscopic totalgastrectomy for gastric carcinoma[J]. Surg Endosc, 2020, 34(5): 2313-2320. doi: 10.1007/s00464-019-07362-0
[20]	龚帅, 张蓬波, 张冲, 等. 食管空肠π形吻合在完全腹腔镜全胃切除术中的应用[J]. 中国普外基础与临床杂志, 2021, 28(9): 1188-1192. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWL202109008.htm GONG S, ZHANG P B, ZHANG C, et al. Application of π-shaped esophagojejunal anastomosis in totally laparoscopic total gastrectomy[J]. Chinese Journal of Bases and Clinics in General Surgery, 2021, 28(9): 1188-1192. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWL202109008.htm
[21]	ZHANG S, KHALIQ J, LI D, et al. Robotic total gastrectomy with π-shaped esophagojejunostomy using a linear stapler as a novel technique[J]. World J Surg Oncol, 2018, 16(1): 238. DOI: 10.1186/s12957-018-1542-z.
[22]	韦明光, 王楠, 吴涛, 等. 食管空肠overlap与π形吻合术后短期疗效及患者生活质量的对比研究[J]. 中国普通外科杂志, 2019, 28(4): 407-416. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ201904006.htm WEI M G, WANG N, WU T, et al. Overlap versus π-shaped esophagojejunostomy: a comparative study of short-term results and patients' quality of life[J]. Chinese Journal of General Surgery, 2019, 28(4): 407-416. https://www.cnki.com.cn/Article/CJFDTOTAL-ZPWZ201904006.htm
[23]	龚佑红, 吴艳烈. 食管空肠π形吻合术在完全3D腹腔镜下根治性全胃切除术中的应用[J]. 临床外科杂志, 2022, 30(7): 649-652. doi: 10.3969/j.issn.1005-6483.2022.07.015 GONG Y H, WU Y L. Application of complete 3D laparoscopic modified π-shaped esophagojejunostomy in radical total gastrectomy[J]. Journal of Clinical Surgery, 2022, 30(7): 649-652. doi: 10.3969/j.issn.1005-6483.2022.07.015
[24]	WANG Y, LIU Z, SHAN F, et al. Short-term outcomes after totally laparoscopic total gastrectomy with esophagojejunostomy constructed by π-shaped method versus overlap method[J]. J Surg Oncol, 2021, 124(8): 1329-1337. doi: 10.1002/jso.26642