Hu P, Zhang K C, Cui J X, Liang W Q, Xi H Q, Sun D C, Lu C R, Chen L
Department of General Surgery, First Medical Center, Chinese PLA General Hospital, Beijing 100853, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2022 May 25;25(5):440-446. doi: 10.3760/cma.j.cn441530-20210812-00327.
To explore the feasibility and preliminary technical experience of the double-tract reconstruction combined with π-shaped esophagojejunal anastomosis after total laparoscopic proximal gastrectomy (TLPG) in the treatment of adenocarcinoma of esophagogastric junction (AEG). A descriptive case series study method was used. Clinical data of 12 AEG patients who underwent the double-tract reconstruction combined with π-shaped esophagojejunal anastomosis after TLPG from January 2021 to June 2021 at the Department of General Surgery, First Medical Center, PLA General Hospital were retrospectively analyzed. Among the 12 patients, the median tumor diameter was 2.0 (1.5-2.9) cm, and the pathological stage was T1-3N0-3aM0. All the patients routinely underwent TLPG and D2 lymph node dissection with double-tract reconstruction combined with π-shaped esophagojejunal anastomosis: (1) Double-tract reconstruction combined with π-shaped esophagojejunal anastomosis: mesentery 25 cm away from the Trevor ligament was treated, and an incision of about 1 cm was made on the mesenteric border of the intestinal wall and the right wall of the esophagus, two arms of the linear cutting closure were inserted, and esophagojejunal side-to-side anastomosis was performed. A linear stapler was used to cut off the lower edge of the anastomosis and close the common opening to complete the esophagojejunal π-shaped anastomosis. (2) Side-to-side gastrojejunostomy anastomosis: an incision of about 1 cm was made at the jejunum to mesenteric border and at the greater curvature of the remnant stomach 15 cm from the esophagojejunostomy, and a linear stapler was inserted to complete the gastrojejunostomy side-to-side anastomosis. (3) Side-to-side jejunojejunal anastomosis: an incision of about 1 cm was made at the proximal and distal jejunum to the mesangial border 40 cm from the esophagojejunostomy, and two arms of the linear stapler were inserted respectively to complete the side-to-side jejunojejunal anastomosis. A midline incision about 4-6 cm in the upper abdomen was conducted to take out the specimen, and an abdominal drainage tube was placed, then layer-by-layer abdominal closure was performed.
(1) adenocarcinoma of esophagogastric junction (Seiwert type II-III) was diagnosed by endoscopy and pathological examination; (2) ability to preserve at least 1/2 of the distal stomach after R0 resection of proximal stomach was evaluated preoperatively.
(1) evaluation indicated distant metastasis of tumor or invasion of other organs; (2) short abdominal esophagus or existence of diaphragmatic hiatal hernia was assessed during the operation; (3) mesentery was too short or the tension was too high; (4) existence of severe comorbidities before surgery; (5) only palliative surgery was required in preoperative evaluation; (6) poor nutritional status.
operation time, intraoperative blood loss, postoperative complications, time to first flatus and time to start liquid diet, postoperative hospital stay, operation cost, etc. Continuous variables that conformed to normal distribution were presented as mean ± standard deviation, and those that did not conform to normal distribution were presented as median (1,3). All the patients successfully completed TLPG with double-tract reconstruction combined with π-shaped esophagojejunal anastomosis, and postoperative pathology showed that no cancer cells were found on the upper incision margin. The operation time was (247.9±62.4) minutes, the median intraoperative blood loss was 100.0 (62.5, 100.0) ml, no intraoperative blood transfusion was required, the incision length was (4.9±1.0) cm, and the operation cost was (55.5±0.7) thousand yuan. The median time to start liquid diet was 1.0 (1.0, 2.0) days, and the mean time to flatus was (3.1±0.9) days. All the patients were discharged uneventfully. Only 1 patient developed postoperative paralytic ileus and infectious pneumonia with Clavien-Dindo classification of grade II. The patient recovered after conservative treatment. There was no surgery-related death. The postoperative hospital stay was (8.3±2.1) days. The double-tract reconstruction combined with π-shaped esophagojejunal anastomosis after TLPG is safe and feasible, which can minimize surgical trauma and accelerate postoperative recovery.
探讨全腹腔镜近端胃切除术（TLPG）联合双通路重建及π形食管空肠吻合术治疗食管胃交界腺癌（AEG）的可行性及初步技术经验。采用描述性病例系列研究方法。回顾性分析2021年1月至2021年6月解放军总医院第一医学中心普通外科12例接受TLPG联合双通路重建及π形食管空肠吻合术的AEG患者的临床资料。12例患者中，肿瘤中位直径为2.0（1.5 - 2.9）cm，病理分期为T1 - 3N0 - 3aM0。所有患者均常规行TLPG及D2淋巴结清扫，并进行双通路重建及π形食管空肠吻合：（1）双通路重建及π形食管空肠吻合：处理距Trevor韧带25 cm处的系膜，在肠壁系膜缘及食管右壁做约1 cm切口，插入线性切割闭合器双臂，行食管空肠侧侧吻合。使用线性吻合器切断吻合口下缘并关闭共同开口，完成食管空肠π形吻合。（2）胃空肠侧侧吻合：在距食管空肠吻合口15 cm处的空肠系膜缘及残胃大弯处各做约1 cm切口，插入线性吻合器完成胃空肠侧侧吻合。（3）空肠空肠侧侧吻合：在距食管空肠吻合口40 cm处的近端和远端空肠系膜缘各做约1 cm切口，分别插入线性吻合器双臂完成空肠空肠侧侧吻合。在上腹部做约4 - 6 cm正中切口取出标本，放置腹腔引流管，然后逐层关闭腹腔。
（1）经内镜及病理检查确诊为食管胃交界腺癌（SeiwertⅡ - Ⅲ型）；（2）术前评估近端胃R0切除后能保留至少1/2远端胃。
（1）评估提示肿瘤远处转移或侵犯其他器官；（2）术中评估食管腹段短或存在膈疝；（3）系膜过短或张力过高；（4）术前存在严重合并症；（5）术前评估仅需姑息手术；（6）营养状况差。
手术时间、术中出血量、术后并发症、首次排气时间、开始进流食时间、术后住院时间、手术费用等。符合正态分布的连续变量以均数±标准差表示，不符合正态分布的以中位数（四分位数间距）表示。所有患者均成功完成TLPG联合双通路重建及π形食管空肠吻合术，术后病理显示吻合口上切缘未见癌细胞。手术时间为（247.9±62.4）分钟，术中出血量中位数为100.0（62.5，100.0）ml，无需术中输血，切口长度为（4.9±1.0）cm，手术费用为（55.5±0.7）千元。开始进流食的中位数时间为1.0（1.0，2.0）天，首次排气平均时间为（3.1±0.9）天。所有患者均顺利出院。仅1例患者发生术后麻痹性肠梗阻及感染性肺炎，Clavien - Dindo分级为Ⅱ级。经保守治疗后康复。无手术相关死亡。术后住院时间为（8.3±2.1）天。TLPG联合双通路重建及π形食管空肠吻合术安全可行，可使手术创伤最小化并加速术后恢复。
