Yu C, Ji W P, Jiang D J, Chen X L, Liu S, Chen W Z, Ruan X J, Qian J, Lu H, Yan J Y
Department of Gastroenterology, Quzhou Hospital Affiliated to Wenzhou Medical University, Quzhou 324000,China.
Department of Gastroenterology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2025 Aug 25;28(8):922-926. doi: 10.3760/cma.j.cn441530-20241030-00357.
To explore the application value of right-opening single flap valvuloplasty based on tubular stomach in gastrointestinal reconstruction after laparoscopic proximal gastrectomy. Use a linear cutting stapler to make a parallel curve from the angle of the stomach to the junction of the gastric fundus to remove the lesser curvature of the stomach, and detach the gastric body about 5 cm away from the tumor to create a tubular stomach. Use a marker pen to draw a C-shaped seromuscular flap area with a width of 2.5 cm and a height of 3.5 cm 1.5 cm below the residual stomach closure nail, and create a free muscle flap in the gap between the plasma muscle layer and the submucosal layer. Make a transverse incision of 3 cm at the lower edge of the mucosal bed, and intermittently suture the entire lower edge of the gastric wall with 3 stitches. Under laparoscopy, use 4-0 barbed wire to suture the 1 cm wide muscular layer at the top of the tubular stomach and the posterior wall of the esophagus about 5 cm away from the esophageal stump with 3 stitches. Push the upper end of the tubular stomach into the mediastinum, and then tighten the barbed wire to ensure a tight fit between the stomach and the posterior wall of the esophagus. Use an ultrasonic scalpel to remove the esophageal stump, suture the entire posterior wall of the esophagus with the gastric mucosa, and use barbed wire to suture the anterior wall from left to right. The anastomotic site is completely covered with a free muscle flap, and the barbed line is used to continuously suture the muscle flap along the C-shaped line to the gastric pulp muscle layer at the edge of the mucosal bed, embedding the anastomotic site and completing the reconstruction of the digestive tract. Clinical data of 23 patients (18 from the First Affiliated Hospital of Wenzhou Medical University and 5 from the Quzhou Hospital affiliated with Wenzhou Medical University) who underwent laparoscopic proximal gastrectomy, tubular gastroesophageal anastomosis, and pure manual right flap reconstruction surgery for esophagogastric junction adenocarcinoma and proximal gastric cancer from October 2023 to August 2024. There were 15 males and 8 females, with an age of (65.3±7.7) years, the BMI was (22.9±2.8) kg/m. All patients in the group successfully completed the surgery, with a surgery time of (218.5±38.1) minutes, including (73.5±19.2) minutes for anastomosis, intraoperative blood loss of (64.5±15.4) ml, postoperative passage of gas on (3.4±0.5) days, first consumption of liquid food after surgery of (3.9±1.1) days, and postoperative hospital stay of (9.1±0.8) days. One patient developed anastomotic stenosis (grade I) after surgery, presenting with mild swallowing obstruction, which returned to normal after dietary adjustment, and there were no cases of secondary surgery. The median follow-up time for the entire group was 4.0 (0.7-7.0) months, during which there were no deaths or tumor recurrence or metastasis, no complications such as anastomotic stenosis or gastric emptying disorders, and no complaints of acid reflux or heartburn. At one month of postoperative follow-up, the reflux symptom index (RSI) score was (3.1±2.9) points, and at three months, the RSI score was (2.4±1.4) points. The application of right-opening single flap valvuloplasty based on tubular stomach for gastrointestinal reconstruction after laparoscopic proximal gastrectomy is safe,feasible,and has satisfactory short-term efficacy.
探讨基于管状胃的右开单瓣瓣膜成形术在腹腔镜近端胃切除术后消化道重建中的应用价值。使用直线切割吻合器从胃角向胃底交界处做平行曲线,切除胃小弯,将胃体从肿瘤处游离约5cm,制作管状胃。用记号笔在残胃闭合钉下方1.5cm处画出宽2.5cm、高3.5cm的C形浆肌瓣区域,在浆肌层与黏膜下层之间的间隙制作游离肌瓣。在黏膜床下缘做3cm横切口,用3针间断缝合胃壁整个下缘。在腹腔镜下,用4-0倒刺线将管状胃顶端1cm宽的肌层与距食管残端约5cm处的食管后壁缝合3针。将管状胃上端推入纵隔,然后收紧倒刺线,确保胃与食管后壁紧密贴合。用超声刀切除食管残端,将食管全后壁与胃黏膜缝合,再用倒刺线从左至右缝合前壁。吻合口完全被游离肌瓣覆盖,用倒刺线沿C形线将肌瓣连续缝合至黏膜床边缘的胃浆肌层,包埋吻合口,完成消化道重建。收集2023年10月至2024年8月在温州医科大学附属第一医院(18例)和温州医科大学附属衢州医院(5例)接受腹腔镜近端胃切除术、管状胃食管吻合术及单纯手工右瓣重建手术治疗食管胃交界腺癌和近端胃癌的23例患者的临床资料。其中男性15例,女性8例,年龄(65.3±7.7)岁,BMI为(22.9±2.8)kg/m²。该组所有患者均成功完成手术,手术时间为(218.5±38.1)分钟,其中吻合时间为(73.5±19.2)分钟,术中出血量为(64.5±15.4)ml,术后排气时间为(3.4±0.5)天,术后首次进流食时间为(3.9±1.1)天,术后住院时间为(9.1±0.8)天。1例患者术后发生吻合口狭窄(Ⅰ级),表现为轻度吞咽梗阻,经饮食调整后恢复正常,无二次手术病例。全组患者中位随访时间为4.0(0.7 - 7.0)个月,随访期间无死亡、肿瘤复发或转移,无吻合口狭窄、胃排空障碍等并发症,无反酸、烧心等不适主诉。术后1个月随访时反流症状指数(RSI)评分为(3.1±2.9)分,术后3个月时RSI评分为(2.