完全腹腔镜全胃切除术近期疗效临床研究

发布时间：2018-03-19 15:04

本文选题：腹腔镜　切入点：胃癌　出处：《浙江大学》2015年硕士论文　论文类型：学位论文

【摘要】：背景和目的胃癌是最常见的消化道恶性肿瘤之一。目前,手术根治切除是治疗胃癌的主要手段。传统开腹手术切口大、疼痛明显,并有切口感染甚至裂开等切口相关并发症。腹腔镜胃癌根治术具有切口小、术后疼痛轻、恢复快、住院时间短等优点,二十多年来在全球范围内迅速发展。由于腹腔内消化道重建技术要求高,尤其是腹腔镜食管空肠吻合,因此目前多数腹腔镜全胃切除术仅在腹腔镜下完成淋巴结清扫,其消化道重建通过上腹部小切口进行,即腹腔镜辅助全胃切除术(Laparoscopy assisted total gastrectomy, LATG)。如能在腹腔镜下完成消化道重建,即完全腹腔镜全胃切除术(Totally laparoscopic total gastrectomy, TLTG),则整个手术过程中视野更清,吻合过程张力小,微创优势更为明显；标本装袋后取出,切口位置可选,也更为美观。本中心于2007年完成首例全腹腔镜全胃切除术,并逐步探索尝试多种腹腔镜食管空肠吻合方法,目前已初步建立一套全腹腔镜全胃切除术操作流程。本研究回顾性分析2007年10月至2015年3月在本中心行腹腔镜全胃切除术患者的临床资料,将TLTG与LATG进行对比,同时比较分析TLTG各种食管空肠吻合方法术中术后指标,总结TLTG I临床经验。对象与方法 1.研究对象选取2007年10月至2015年3月期间于浙江大学医学院附属邵逸夫医院行腹腔镜全胃切除术的病例。同时排除以下情况之一患者：(1)全胃联合其他脏器切除；(2)术前TNM分期Ⅳ期；(3)合并严重心肺脑疾病；(4)术前行新辅助化疗；(5)病灶累及食管下段；(6)中转开腹；(7)手助腹腔镜全胃切除术。 2.手术方式根据日本胃癌指南,采用全胃切除+D2淋巴结清扫术。TLTG食管空肠Roux-en-Y吻合采用以下四种方法：(1)使用圆形吻合器食管空肠端侧吻合(方法A)；(2)使用内镜直线切割闭合器食管空肠侧侧吻合(方法B)；(3)使用内镜直线切割闭合器食管空肠三角吻合(方法C)；(4)腹腔镜直视手工缝合(方法D)。LATG采用经小切口行食管空肠Roux-en-Y吻合。 3.分组根据手术方法分为TLTG组和LATG组。TLTG组根据不同食管空肠吻合方法分为方法A、方法B、方法C、方法D四个亚组。 3.观察指标 ①一般指标：性别、年龄、身高质量指数(body mass index, BMI)、合并症、既往腹部手术史及ASA分级； ②手术相关指标：手术时间、术中出血量、输血情况等； ③肿瘤病理指标：肿瘤大小、分化程度、TNM分期、淋巴结清扫数目、近端切缘距离、切缘情况； ④术后恢复指标：术后肛门排气时间、进流质和半流质时间、术后住院天数、围手术期死亡、术后并发症及其治疗情况； ⑤随访资料：通过门诊或电话随访而获得,包括随访时间、复发转移情况及死亡情况。 4.统计方法计数资料用均数±标准差表示。所有统计分析均使用SPSS18.0完成。p0.05有统计学意义。结果 1.一般情况研究共纳入TLTG,患者103名,其中男性67名,女性36名；平均年龄61.3±10.9岁,平均BMI22.4±3.3kg/m2,43名患者有合并症。术前ASA评级I级53人,Ⅱ级45人,Ⅲ级5人。LATG患者125名,男性75名,女性50名；平均年龄59.7±10.5岁,平均BMI21.7±3.2kg/m2,37名患者有合并症。术前ASA评级I级62人,Ⅱ级57人,Ⅲ级6人。两组在年龄、BMI、术前合并症、ASA评分等指标上无统计学差异。 2.患者术中情况及术后恢复情况 TLTG组患者平均手术时间276.3±51.1min,平均术中出血71.1±45.9m1,平均淋巴结清扫数目34.4±13.9。平均排气时间3.7±1.0天,平均进食流质时间4.3±1.8天,平均进食半流质时间6.9±2.4天,平均住院时间10.1±4.1天。术后并发症发生率13.6%。LATG组患者平均手术时间247.5±66.2min,平均术中出血147.1±84.9m1,平均淋巴结清扫数目35.1±13.2。平均排气时间3.9±1.1天,平均进食流质时间5.1±1.4天,平均进食半流质时间7.9±4.0天,平均住院时间11.3±4.9天。术后并发症发生率19.2%,两组均无围手术期死亡病例。两组之间淋巴结清扫数目、术后并发症等指标差异无统计学意义,TLTG组手术时间更长,术中出血少,术后疼痛轻,术后恢复快。 3.TLTG四种食管空肠吻合方法资料 103例TLTG,患者中,行方法A患者18名,平均吻合时间57.5±18.5min,1例患者出现吻合口狭窄,1例患者出现吻合口漏；行方法B患者22名,平均吻合时间40.0±11.2min,2例患者出现吻合口狭窄,1例患者出现腹腔内出血；行方法C患者10例,平均吻合时间39.0±3.9min；行方法D患者53例,平均吻合时间56.8±19.3min。结论完全腹腔镜全胃切除术是安全可行的。完全腹腔镜全胃切除术有出血少、创伤小、术后恢复快等优点。腹腔内食管空肠吻合各种方式各有其利弊。腹腔镜直视手工缝合法是一种安全、经济、理想的方法。
[Abstract]:Background and purpose
Gastric cancer is one of the most common malignant tumor of digestive tract. At present, the radical resection is the main method for the treatment of gastric cancer. The traditional laparotomy incision, obvious pain, and wound infection and even split incision related complications. Laparoscopic radical resection of gastric cancer with a small incision, less postoperative pain, quicker recovery, shorter hospitalization time etc in more than 20 years, rapid development in the global scope. Due to intra-abdominal digestive reconstruction requirements high, especially with laparoscopic esophageal jejunum, so the majority of laparoscopic total gastrectomy in laparoscopic lymph node dissection, the reconstruction of the digestive tract through abdominal incision, laparoscopy assisted total gastrectomy (Laparoscopy assisted total gastrectomy, LATG). If the completion of digestive tract reconstruction in laparoscopic total laparoscopic total gastrectomy (Totally laparoscopic total gastrectomy, TLTG), the whole operation process is more clear, the tension of the anastomosis process is small and the minimally invasive advantage is more obvious; the specimen is taken out after bag loading, the position of the incision is optional, and it is more beautiful.
The center in 2007 to complete the first laparoscopic total gastrectomy, and gradually explore and try a variety of laparoscopic esophagojejunostomy method, has established a set of totally laparoscopic total gastrectomy procedure. This study retrospectively analyzed the clinical data from October 2007 to March 2015 in the center of laparoscopic total gastrectomy, compared TLTG with LATG, at the same time analysis of various TLTG esophagojejunostomy after index surgery, summarize the clinical experience of TLTG I.
Object and method
1. research objects
During the period from October 2007 to March 2015 in Sir Run Run Shaw Hospital affiliated to the Zhejiang University School of medicine cases underwent laparoscopic total gastrectomy. At the same time out of one of the following conditions: (1) patients with resection of the stomach and other organs; (2) preoperative TNM stage IV; (3) with severe cardiopulmonary cerebral disease; (4) preoperative neoadjuvant chemotherapy; (5) lesions in the lower esophagus (6); Laparotomy; (7) hand assisted laparoscopic total gastrectomy.
2. mode of operation
According to the Japanese gastric cancer guidelines, with total gastrectomy and +D2 lymph node dissection of.TLTG esophagus jejunum Roux-en-Y anastomosis using the following four methods: (1) using circular stapler jejunojejunostomy esophageal (A); (2) the use of endoscopic staplers esophageal jejunum side anastomosis (B); (3) the use of endoscopic staplers esophagojejunal anastomosis triangle (method C); (4) laparoscopic surgery manual suture (method D).LATG used by small incision for esophageal jejunal Roux-en-Y anastomosis.
3. grouping
According to the methods of operation, group TLTG and group LATG.TLTG were divided into A, B, C, and D four subgroups according to the different esophagus jejunostomy methods.
3. observation index
(1) general indicators: sex, age, height mass index (body mass index, BMI), complication, history of previous abdominal surgery and ASA classification;
Surgical related indexes: operation time, intraoperative bleeding, blood transfusion, etc.
Tumor pathological indexes: tumor size, degree of differentiation, TNM staging, number of lymph node dissection, near end margin distance and cutting edge condition;
Postoperative recovery indicators: postoperative anal exhaust time, fluid intake and semi fluid time, postoperative hospitalization days, perioperative mortality, postoperative complications and treatment.
Follow up data: follow up or telephone follow-up, including follow-up time, recurrence and death.
4. statistical methods
The count data were expressed as mean standard deviation. All statistical analyses were statistically significant with the use of SPSS18.0 to complete the.P0.05.
Result
1. general situation
The study included 103 patients with TLTG, 67 males, 36 females; mean age 61.3 + 10.9 years old, the average BMI22.4 + 3.3kg/m2,43 patients had complications. Preoperative ASA rating grade I 53, grade 45, grade 5 in 125.LATG patients, 75 males and 50 females name; average age 59.7 + 10.5 years old, the average BMI21.7 + 3.2kg/m2,37 patients had complications. Preoperative ASA rating grade I 62, grade 57, grade 6. The two groups in age, BMI, preoperative complications, there was no significant difference in ASA score index.
The intraoperative and postoperative recovery of 2. patients
TLTG group of patients with the average operation time was 276.3 51.1min, the average intraoperative bleeding was 71.1 + 45.9m1, the average number of lymph node dissection and 34.4 + 13.9. 3.7 + average exhaust time of 1 days, the average consumption of liquid time 4.3 + 1.8 days, the average semifluid diet time 6.9 + 2.4 days, the average hospitalization time was 10.1 + 4.1 days. The complication rate 13.6%.LATG group of patients with the average operation time was 247.5 + 66.2min after operation, the average bleeding was 147.1 84.9m1, the average number of lymph node dissection and 35.1 + 13.2. 3.9 + average exhaust time of 1.1 days, the average consumption of liquid time 5.1 + 1.4 days, the average semifluid diet time 7.9 + 4 days, the average hospitalization time was 11.3 + 4.9 days. The rate of postoperative complications in 19.2%, the two groups had no perioperative deaths.
There was no significant difference in the number of lymph node dissection and postoperative complications between the two groups. TLTG group had longer operation time, less intraoperative bleeding, less postoperative pain and faster postoperative recovery.
3.TLTG four kinds of esophagus jejunostomy data
103 cases of TLTG patients, 18 patients underwent A, average anastomosis time was 57.5 + 18.5min, 1 cases with anastomotic stenosis, 1 cases of patients with anastomotic leakage; patients with method of B 22, the average anastomosis time was 40 + 11.2min, 2 cases with anastomotic stenosis, 1 cases of patients with the intraperitoneal hemorrhage; 10 cases of patients with C method, the average anastomosis time was 39 + 3.9min; 53 patients were treated with D method, the average time was 56.8 + 19.3min..
conclusion
Totally laparoscopic total gastrectomy is safe and feasible. Totally laparoscopic total gastrectomy with less bleeding, less trauma, quick recovery after operation. Intraperitoneal esophagojejunostomy in various ways have their own advantages and disadvantages. Laparoscopy manual suture is a safe, economical and ideal method.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R735.2

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