查看更多>>摘要：目的 探讨改良反穿刺法食管空肠吻合在全腹腔镜根治性全胃切除术中的应用价值。 方法 采用描述性病例系列分析方法，回顾性收集2022年6月至2023年1月期间，福建省立医院胃肠外科收治的35例行全腹腔镜下根治性全胃切除改良反穿刺法食管空肠吻合的胃癌患者的临床及病理资料。全组患者年龄（64.9±8.0）岁，男性22例（62.9%），体质指数（23.2±2.4）kg/m2，肿瘤位于胃上中部24例（68.6%），位于食管胃结合部11例（31.4%）。改良反穿刺法技术要点：（1）食管切开位置：于右侧壁切开食管置入抵钉座，然后利用右中腹部操作孔置入直线切割闭合器离断食管；（2）抵钉座置入方式：在钉砧座杆尖端穿丝线固定，抵钉座置入食管腔内后仅留丝线显露在外，直线切割闭合器紧贴丝线横行闭合切断食管，后通过丝线牵出钉砧座杆并拉紧固定；（3）空肠捆绑：先用丝线于空肠残端处绑紧套入吻合器中心杆上的空肠环，后用纱布条带再将空肠环与输出袢空肠捆绑固定。分析患者手术完成、术后恢复及术后病理情况。 结果 。 35例患者均顺利完成手术，无中转开腹，无围手术期死亡。手术时间为（232.7±34.4）min，抵钉座置入时间为（8.5±1.4）min，消化道重建时间为（40.5±4.8）min，术中出血量100（20~250）ml，手术切口长度为（5.3±0.9）cm。所有患者肿瘤上切缘均为阴性，距离为（3.5±1.2）cm，清扫淋巴结数目（33.9±7.1）枚。术后首次下床、首次肛门排气、恢复流质饮食及术后住院时间分别为（3.2±1.1）d、（3.7±1.5）d、（4.6±2.3）d及（9.8±3.2）d。术后5例（14.3%）患者出现并发症，其中食管空肠吻合口漏1例、食管空肠吻合口狭窄2例，肺部感染、不完全性肠梗阻各1例，均予保守治疗后痊愈 结论 在全腹腔镜根治性全胃切除术中采用改良反穿刺法行食管空肠吻合安全可行，可以获得更高的食管上切缘，且手术切口小，近期疗效良好，值得推广。 Objective To evaluate the value of implementing a modified reverse puncture procedure for esophagojejunostomy during totally laparoscopic total gastrectomy. Methods This was a descriptive case series. Relevant clinical data, including the operative procedure, recovery, and pathological findings of 35 patients with gastric cancer who had undergone esophagojejunostomy with a modified reverse puncture technique during totally laparoscopic total gastrectomy in the Department of Gastrointestinal Surgery, Fujian Provincial Hospital, from June 2022 to January 2023, were prospectively collected and retrospectively analyzed. The age of all patients in the group was (64.9±8.0) years old, with 22 males (62.9%) and a body mass index of (23.2±2.4) kg/m2. The tumors were located in the upper and middle parts of the stomach in 24 cases (68.6%) and in the junction of the esophagus and stomach in 11 cases (31.4%). Important technical aspects of the modified reverse puncture procedure are as follows. (1) Site of the esophageal incision: a transverse incision is made across the right lateral wall of the esophagus at the expected site of esophageal disjunction. (2) Technique for inserting an anvil: after threading a silk thread through the tip of anvil, the end of the thread is knotted and fixed as the traction thread, after which an anvil is inserted into the esophagus through the esophageal incision, leaving the end of the traction line exposed. Next, a 60-mm linear cutter is placed through the right midclavicular trocar to straighten the opened esophagus vertically, after which the rod of the anvil is pulled out of a small incision that has been made in the esophagus by pulling the traction thread, thus completing anvil placement. (3) Jejunal binding: the jejunum on the central bar of the stapler is fastened with silk thread to the stump of the jejunum, and then tied to the output loop of the jejunum with a gauze strip. Results All 35 surgeries were successful, with no mortality or conversion to laparotomy. The operation time, anvil insertion time, and digestive tract reconstruction time were (232.7±34.4), (8.5±1.4), and (40.5±4.8) minutes, respectively. The intraoperative blood loss was 100 (20–250) mL and the incision was (5.3±0.9) cm long. The upper surgical margin was negative in all patients and the mean distance between the upper and tumor margins was (3.5±1.2) cm. The mean number of lymph nodes dissected per patient was 33.9±7.1. The times to initial ambulation, initial passage of flatus , postoperative fluid intake, and length of postoperative hospital stay were (3.2±1.1), (3.7±1.5), (4.6±2.3), and (9.8±3.2) days, respectively. Postoperative complications occurred in five patients: one case of anastomotic leak, two of anastomotic stenosis, one of pulmonary infection, and one of incomplete intestinal obstruction, all of which were successfully managed conservatively. Conclusion Esophagojejunostomy using a modified reverse puncture technique during totally laparoscopic total gastrectomy is safe and feasible for gastric cancer, requiring only a small incision and achieving higher upper esophageal resection margins and good postoperative recovery, and therefore warrants further implementation.
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