Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
J Laparoendosc Adv Surg Tech A. 2021 Jul;31(7):803-807. doi: 10.1089/lap.2020.0569. Epub 2020 Nov 24.
Remnant gastric cancer (RGC) is increasing due to past use of subtotal gastrectomy to treat benign diseases, improvements in the detection of gastric cancer, and increased survival rates after gastrectomy for gastric cancer. Laparoscopic access provides the advantages and benefits of minimally invasive surgery. However, laparoscopic completion total gastrectomy (LCTG) for RGC is technically demanding, even for experienced surgeons. Because of its rarity and heterogeneity, no standard surgical strategy has been established and few surgeons will develop technical expertise to carry out this procedure. To describe our standard technique, giving surgeons a head start in LCTG and report the early experience with this stepwise approach. We detail all the steps involved in the procedure, including trocar placement and surgical description. Between 2009 and 2019, a total of 8 patients with past history of RGC were operated with this technique. All patients had been previously operated by open method, 7 due to peptic ulcer disease and 1 due to gastric cancer. Their mean age at the time of the first surgery was 38.9 years (range 25-56 years) and the mean interval between the first and the second gastrectomy was 32.1 years (range 13.6-49). Billroth II was the previous reconstruction in all cases. A 5-trocar technique was used followed by total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y reconstruction. The mean operation time was 272 minutes (range 180-330) and median blood loss was 247 mL (range 50-500). There was no conversion and no major intraoperative complication. Major postoperative complications occurred in 3 patients. Completion total gastrectomy for RGC is a morbid procedure and laparoscopic access is technically feasible, hopefully carrying the benefits of faster recovery, reduced postoperative pain, and wound complications. By standardizing the approach, the learning curve may be shortened and better results achieved.
残胃癌（RGC）的发病率因过去采用胃次全切除术治疗良性疾病、胃癌检出率提高以及胃癌胃切除术后生存率提高而增加。腹腔镜进入提供了微创外科的优势和益处。然而，对于经验丰富的外科医生来说，腹腔镜完成全胃切除术（LCTG）治疗 RGC 具有很高的技术要求。由于其罕见性和异质性，尚未建立标准的手术策略，很少有外科医生会发展出执行此程序的技术专长。本文旨在描述我们的标准技术，为外科医生开展 LCTG 提供一个起点，并报告这种分步方法的早期经验。我们详细介绍了该手术的所有步骤，包括套管针的放置和手术描述。在 2009 年至 2019 年间，共有 8 例 RGC 病史的患者采用该技术进行手术。所有患者之前均采用开放方法进行手术，7 例因消化性溃疡病，1 例因胃癌。他们第一次手术时的平均年龄为 38.9 岁（25-56 岁），第一次和第二次胃切除手术之间的平均间隔为 32.1 年（13.6-49 岁）。所有病例的先前重建均为 Billroth II 型。采用 5 个套管针技术，然后进行全胃切除术，采用侧侧吻合的腔内食管空肠吻合术和 Roux-en-Y 重建。平均手术时间为 272 分钟（180-330 分钟），中位失血量为 247 毫升（50-500 毫升）。无中转开腹，无术中重大并发症。3 例患者发生严重术后并发症。RGC 的完成性全胃切除术是一种病态手术，腹腔镜进入是可行的，有望带来更快的恢复、减轻术后疼痛和减少伤口并发症的好处。通过标准化方法，学习曲线可能会缩短，结果会更好。
