Capella J F, Capella R F
Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.
Obes Surg. 1999 Feb;9(1):22-7; discussion 28. doi: 10.1381/096089299765553674.
Gastro-gastric fistulas and marginal ulcers are frequent and serious complications of gastric compartmentalization procedures for obesity.
The authors analyzed 810 patients after 911 operations for gastro-gastric fistulas and marginal ulcers over an 8-year period. All patients underwent a form of gastric bypass, in which a pouch is constructed along the lesser curvature of the stomach. The outlet of the pouch was restricted with a prosthetic band. In the first 189 patients (Group I), the pouch and stomach were stapled in continuity or partially divided. In the next 222 patients (Group II), segments were stapled and separated by transection. In the remaining 492 cases (Group III), in addition to transection of the stomach, a limb of jejunum was interposed between the pouch and excluded stomach. Stapled anastomoses were done in Group I and II patients and a portion of Group III patients. The remaining patients underwent hand-sewn anastomosis.
Gastro-gastric fistulas occurred in 49% of the patients in Group I, 2.6% of those in Group II, and 0% of those in Group III. In stapled anastomosis, the incidence of marginal ulceration in Groups I, II, and III were 8.5%, 5.4%, and 5.1%, respectively. In a subset of Group III patients, in whom a two-layer, hand-sewn anastomosis was done, the incidence was 1.6% when the outer layer was not absorbable and 0% when both layers were absorbable.
Gastro-gastric fistulas and marginal ulcerations are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. Transection of gastric segments with interposition of jejunum prevents gastro-gastric fistula formation. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Our early data suggest that the use of absorbable sutures at the gastrojejunostomy significantly decreases the incidence of marginal ulceration.
胃-胃瘘和边缘溃疡是肥胖症胃分隔手术常见且严重的并发症。
作者分析了8年间911例接受胃-胃瘘和边缘溃疡手术的810例患者。所有患者均接受了某种形式的胃旁路手术，即沿胃小弯构建一个胃袋。胃袋出口用人工束带限制。在最初的189例患者（第一组）中，胃袋与胃连续缝合或部分分开。在接下来的222例患者（第二组）中，各段进行缝合并通过横断分开。在其余492例病例（第三组）中，除了胃横断外，在胃袋与旷置胃之间插入一段空肠。第一组和第二组患者以及部分第三组患者进行吻合器吻合。其余患者进行手工缝合吻合。
第一组49%的患者发生胃-胃瘘，第二组为2.6%，第三组为0%。在吻合器吻合中，第一组、第二组和第三组边缘溃疡的发生率分别为8.5%、5.4%和5.1%。在第三组的一个亚组中，进行了两层手工缝合吻合，当外层不可吸收时发生率为1.6%，当两层均为可吸收时发生率为0%。
胃-胃瘘和边缘溃疡可能是由于吻合钉移位和其他异物导致黏膜破损的结果。胃黏膜完整性的缺乏促进了胃消化过程的作用。胃段横断并插入空肠可防止胃-胃瘘的形成。完整的浆膜似乎可阻止胃酶对肠壁的消化。我们的早期数据表明，在胃空肠吻合术中使用可吸收缝线可显著降低边缘溃疡的发生率。
