摘要
目的比较远端胃癌根治术应用毕Ⅰ式与毕Ⅱ式吻合实施消化道重建的手术安全性及短期胃镜随访情况。方法采用回顾性队列研究方法,收集2013年1月至2017年7月期间,北京大学肿瘤医院胃肠肿瘤中心四病区收治的接受根治性远端胃大部切除术的胃腺癌患者资料,排除Ⅳ期胃癌、行急诊手术、术前化疗、行联合脏器切除以及合并有其他恶性肿瘤病史者,共277例胃腺癌患者纳入本研究。根据消化道重建方法的不同,分为毕Ⅰ式吻合组(143例)和毕Ⅱ式吻合组(134例)。比较两组患者术中情况、术后早期恢复情况、术后并发症发生情况以及术后1年胃镜随访情况。正态分布变量采用t检验,非正态分布变量用Mann Whitney U检验,分类变量用χ2检验或Fisher精确概率法进行组间比较。结果毕Ⅰ式吻合组年龄(58.1±10.9)岁,男性93例(65.0%),体质指数(23.3±3.2)kg/m2;毕Ⅱ式吻合组年龄(58.3±9.5)岁,男性94例(70.1%),体质指数(23.7±2.9)kg/m2。两组患者基线资料的差异无统计学意义(P>0.05)。与毕Ⅰ式吻合组比较,毕Ⅱ式吻合组手术时间较长[(230.7±44.6)min比(210.3±41.4)min,t=3.935,P<0.001],但术后首次进食时间(中位数:7.0 d比8.0 d,Z=3.376,P=0.001)、首次拔除腹腔引流管时间(中位数:8.0 d比8.0 d,Z=2.176,P=0.030)及术后住院时间(中位数:9.0 d比10.0 d,Z=3.616,P<0.001)均更短,差异均有统计学意义(均P<0.05)。而两组患者的手术方式、术中出血量、淋巴结清扫数目以及术后首次排气时间的差异均无统计学意义(均P>0.05)。毕Ⅰ式吻合组术后发生吻合口出血1例、吻合口漏3例、胃排空障碍和腹腔感染各4例,均经保守治愈;毕Ⅱ式吻合组术后发生吻合口出血及腹腔内出血各1例、胃排空障碍和腹腔感染各3例,均经保守治愈,术后十二指肠残端漏1例行二次手术;两组患者术后并发症发生率分别为8.4%(12/143)和6.7%(9/134),差异无统计学意义(χ^2=0.277,P=0.599)。毕Ⅰ式吻合组和毕Ⅱ式吻合组分别有78例和57例接受术后1年胃镜检查。两组患者食物潴留[21.8%(17/78)比33.3%(19/57),χ^2=2.242,P=0.134]、残胃炎[48.7%(38/78)比47.4%(27/57),χ^2=0.024,P=0.877]和胆汁反流发生率[12.8%(10/78)比10.5%(6/57),χ^2=0.166,P=0.684]的差异均无统计学意义(均P>0.05)。结论在远端胃癌根治术的消化道重建中,毕Ⅰ式吻合操作更简便,毕Ⅱ式吻合患者术后恢复更快。两种吻合方式的术后并发症发生率及短期胃镜随访结果相当。
Objective To compare the safety of Billroth Ⅰand Billroth Ⅱ reconstruction in distal gastrectomy for gastric cancer and short-term endoscopic findings. Methods A retrospective cohort study was carried out. Clinical data of gastric adenocarcinoma patients who received distal subtotal gastrectomy with Billroth Ⅰ or Billroth Ⅱ reconstruction at Department 4 of Gastrointestinal Surgery, Peking University Cancer Hospital from January 2013 to July 2017 were collected retrospectively. Patients with stage Ⅳ gastric cancer, emergent operation, preoperative chemotherapy, combined organ resection and other malignancies were excluded. A total of 277 patients were enrolled in the study with 143 patients in the Billroth Ⅰ group and 134 patients in the Billroth Ⅱ group. The intra-operative conditions, postoperative early recovery, postoperative complications, and postoperative 1-year endoscopic findings were compared between the two groups. The normal distribution variables were analyzed by t test;the non-normal distribution variables were analyzed by Mann-Whitney U test;sort variables were compared between groups using the χ^2 test or Fisher's exact test. Results In the Billroth I group, 93 (65.0%) cases were male, mean age was (58.1±10.9) years and body mass index was (23.3±3.2) kg/m2. In the Billroth II group, 94 (70.1%) cases were male, mean age was (58.3±9.5) years and body mass index was (23.7±2.9) kg/m2. There were no significant differences in baseline data between in the two groups (all P>0.05). As compared to the Billroth I group, the Billroth II group had significantly longer operation time [mean (230.7±44.6) minutes vs.(210.3±41.4) minutes, t=3.935, P<0.001], significantly shorter time to first diet (median 7.0 vs. 8.0 days, Z=3.376, P=0.001), to first abdominal drainage tube removing (median 8.0 vs. 8.0 days, Z=2.176, P=0.030) and significantly shorter postoperative hospital stay (median 9.0 vs. 10.0 days, Z=3.616, P<0.001). There were no significant differences between two groups in proportion of laparoscopic surgery, intra-operative blood loss, number of harvested lymph nodes and the first flatus time (all P>0.05). In the Billroth I group, 1 case developed anastomotic bleeding, 3 cases anastomotic leakage, 4 cases emptying disorder, 4 cases peritoneal cavity infection, and all of them healed after conservative treatment. In the Billroth II group, 1 case developed anastomotic bleeding, 1 case peritoneal cavity bleeding, 3 cases emptying disorder, 3 cases peritoneal cavity infection, and all of them healed after conservative treatment, while 1 case developed postoperative duodenal stump leakage and underwent a second operation. Morbidity of postoperative complication was 8.4%(12/143) and 6.7%(9/134) in the Billroth I group and Billroth II group respectively (χ^2=0.277, P=0.599) without statistically significant difference. Postoperative one-year endoscopy was performed in 78 cases of the Billroth I group and 57 cases of the Billroth II group. Endoscopic findings revealed that ratio of food retention [21.8%(17/78) vs. 33.3%(19/57),χ^2= 2.242, P=0.134], ratio of residual gastritis [48.7%(38/78) vs. 47.4%(27/57),χ^2=0.024, P=0.877] and incidence of bile reflux [12.8%(10/78) vs. 10.5%(6/57),χ^2=0.166, P=0.684] were not significantly different between two groups. Conclusions For distal gastrectomy, Billroth Ⅰ reconstruction is easier to operate, while BillrothⅡreconstruction presents faster recovery of gastrointestinal function and shorter hospital stay. The morbidity of postoperative complication and short-term endoscopic findings between two groups are comparable.
作者
张楠
徐凯
苏向前
Zhang Nan;Xu Kai;Su Xiangqian(Department 4 of Gastrointestinal Surgery,Key Laboratory of Carcinogenesis and Translational Research(Min istry of Education),Peking University Cancer Hospital&Institute,Beijing 100142,China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2019年第3期273-278,共6页
Chinese Journal of Gastrointestinal Surgery
基金
国家自然科学基金项目(81672439、81272766、81450028)
北京市自然科学基金(7162039)
首都卫生发展科研专项(CFH2018-2-2153)
北京市医院管理局临床医学发展专项(XM201309、ZYLX201701).
