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Title: [Safety and feasibility of laparoscopic double-flap technique in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction tumors larger than 5 cm].
Author: Zhu XF, Xiong WW, Zheng YS, Luo LJ, Li J, Huang HP, Fan ZS, Xue YL, Luo SJ, Xu YT, Wan J, Wang W.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2021 Feb 25; 24(2):167-172. PubMed ID: 33508923.
Abstract:
Objective: To investigate the safety and feasibility of laparoscopic double-flap technique (Kamikawa) in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction (EGJ) leiomyoma and gastrointestinal stromal tumor (GIST) with the maximum diameter >5 cm. Methods: A descriptive case-series study was used to retrospectively analyze the data of patients with EGJ leiomyoma and GIST undergoing laparoscopic-assisted proximal gastrectomy and double-flap technique (Kamikawa) at the Department of Gastrointestinal Surgery, Guangdong Hospital of Traditional Chinese Medicine from September 2017 to March 2019. All the tumors invaded the cardia dentate line, and the maximum diameter was >5 cm. After the exclusion of patients requiring emergency surgery and complicating with severe cardiopulmonary diseases, a total of 4 patients, including 3 males and 1 female with age of 29-49 years, were included in this study. After laparoscopic-assisted proximal gastrectomy, the residual stomach was pulled out of the abdominal cavity and marked with methylene blue at the proximal end 3~4 cm from the anterior wall of the residual stomach in the shape of "H". The gastric wall plasma muscular layer was cut along the "H" shape, and the space between the submucosa and the muscular layer was separated to both sides along the longitudinal incision line to make the seromuscular flap. The residual stomach was put back into the abdominal cavity. Under laparoscopy, 4 stitches were intermittently sutured at the upside of "H" shape and 4-5 cm from the posterior wall of the esophageal stump. The stump of the esophagus was cut open, and the submucosa and mucosa were cut under the "H" shape to enter the gastric cavity. The posterior wall of the esophageal stump was sutured continuously with the gastric stump mucosa and submucosa under laparoscopy. The anterior wall of the esophageal stump was sutured continuously with the whole layer of the residual stomach. The anterior wall of the stomach was sutured to cover the esophagus. The anterior gastric muscle flap was sutured and embedded in the esophagus to complete the reconstruction of digestive tract. The morbidity of intraoperative complications and postoperative reflux esophagitis and anastomosis-related complications were observed. Results: All the 4 patients completed the operation successfully, and there was no conversion to laparotomy. The median operative time was 239 (192-261) minutes, the median Kamikawa anastomosis time was 149 (102-163) minutes, and the median intraoperative blood loss was 35 (20-200) ml. The abdominal drainage tube and gastric tube were removed, and the fluid diet was resumed on the first day after surgery in all the 4 patients. The median postoperative hospitalization time was 6 (6-8) days. Postoperative pathology revealed 3 leiomyomas and 1 GIST. There were no postoperative complications such as anastomotic leakage or stenosis, and no reflux symptoms were observed. The median follow-up time was 22 (11-29) months after the operation, and no reflux esophagitis occurred in any of the 4 patients by gastroscopy. Conclusion: For >5 cm EGJ leiomyoma or GIST, double-flap technique (Kamikawa) used for digestive tract reconstruction after proximal gastrectomy is safe and feasible. 目的： 探讨腹腔镜辅助食管胃吻合肌瓣成形术（Kamikawa吻合）在治疗肿瘤最大径>5 cm的食管胃结合部（EGJ）平滑肌瘤或胃肠间质瘤近端胃切除术后消化道重建的安全性及可行性。 方法： 采用描述性病例系列研究方法，回顾性分析广东省中医院胃肠外科2017年9月至2019年3月期间，收治并施行腹腔镜辅助近端胃切除术和Kamikawa吻合的EGJ平滑肌瘤和胃肠间质瘤病例资料。肿瘤均侵犯贲门齿状线，且最大径>5 cm；排除需急诊手术和合并有严重心肺疾病患者后，共4例患者纳入本研究，男性3例，女性1例，年龄29~49岁。患者接受腹腔镜辅助近端胃切除术后，把残胃提出腹腔外，距残胃前壁近端3~4 cm处亚甲蓝标记"H"形，并沿"H"形切开胃壁浆肌层，沿纵行切开线向两侧分离黏膜下层和肌层之间的间隙，制作浆肌瓣；将残胃放回腹腔，腹腔镜下将"H"形上边与食管后壁距断端4~5 cm处间断缝合4针；切开食管残端，在"H"形的下边切开黏膜下层和黏膜层，进入胃腔；腹腔镜下将食管断端后壁与残胃黏膜层和黏膜下层连续缝合，食管断端前壁与残胃全层连续缝合，将胃前壁浆肌瓣缝合包埋食管，完成消化道重建。观察患者术中并发症和术后反流性食管炎和吻合口相关并发症的发生率。 结果： 4例患者均顺利完成手术，无中转开腹。手术中位时间为239（192~261）min，Kamikawa吻合中位时间为149（102~163）min，术中中位出血量为35（20~200）ml。4例患者均术后第1天拔除腹腔引流管和胃管，并恢复流质饮食，术后住院中位时间为6（6~8）d。术后病理提示，3例平滑肌瘤，1例胃肠间质瘤。术后无吻合口漏及狭窄等并发症，未观察到反流症状。术后中位随访时间22（11~29）个月，4例患者复查胃镜均未见反流性食管炎。 结论： 对于>5 cm的EGJ平滑肌瘤或胃肠间质瘤，近端胃切除术后应用腹腔镜辅助Kamikawa吻合进行消化道重建，安全可行。.

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