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  • Title: [Preliminary study on implementation of modified tubular gastric side-overlap anastomosis in laparoscopic proximal gastrectomy].
    Author: Wu CY, Lin JA, Ye K.
    Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2024 Feb 25; 27(2):175-181. PubMed ID: 38413086.
    Abstract:
    Objective: To investigate the feasibility and safety of implementing modified tubular gastric side-overlap anastomosis in laparoscopic proximal gastrectomy. Methods: In this retrospective, descriptive case series, we analyzed clinical data of seven patients who had undergone laparoscopic proximal gastrectomy and gastrointestinal reconstruction with modified tubular gastric side-overlap anastomosis from October 2022 to March 2023 in the Second Affiliated Hospital of Fujian Medical University. The study patients comprised five men and two women aged 57-72 years and of body mass index 18.5-25.7 kg/m2. All seven patients had preoperative gastroscopic and pathological evidence of esophagogastric junction cancer and all were found by preoperative enhanced computed tomography and/or endoscopic ultrasonography to have stage CT1-2N0M0 tumors. The main steps in the reconstruction of a modified tubular gastric side-overlap anastomosis are as follows: (1) mobilizing the lower esophagus and opening the left pleura to expand the space; (2) severing the esophagus with a linear cutter stapler; (3) creating a 3-cm-wide tubular stomach along the greater curvature; (4) creating a 5-cm guide line on the lesser curvature of the anterior wall of the tubular stomach and a small opening below the guide line; (5) rotating the esophageal stump 90° counterclockwise and making a small opening on the right posterior wall of the esophageal stump, along with using a 45-mm linear cutter stapler for esophagogastric side-to-side anastomosis under the guidance of the gastric tube and guide line ; (6) closing the common opening using barbed sutures; (7) embedding the cut edge of the esophageal stump such as to closely oppose it to the esophagus; (8) using barbed sutures to continuously suture the lower esophagus bilaterally to the anterior wall of the tubular stomach; and (9) closing the opened esophageal hiatus and pleura. The main outcome measures were intraoperative (operation time, digestive tract reconstruction time, closing the common opening time, intraoperative blood loss, and number of dissected lymph nodes), postoperative (time to passage of flatus , time to liquid diet, time to ambulation, length of postoperative hospital stay, and postoperative complications), pathological (maximum diameter of the tumor and pathological stage) and findings on follow-up. Results: Laparoscopic proximal gastrectomy with reconstruction of a modified tubular gastric side-overlap anastomosis was successfully completed in all seven patients; no conversion to laparotomy was required and there were no postoperative complications. The operation time, digestive tract reconstruction time, and closing of common opening time were 187-229, 61-79, and 7-9 minutes, respectively. Intraoperative blood loss was 15-23 ml and the number of dissected lymph nodes was 14-46 per case. Time to passage of flatus, time to liquid diet, time to ambulation, and postoperative hospital stay were 1-2, 2-3, 3-4, and 6-7 days, respectively. Postoperative pathological examination showed that the maximum tumor diameters were 1.6-3.3 cm in four patients with stage IA disease and three patients with stage IB. The seven patients were followed up for 6-11 months, during which none required routine use of proton pump inhibitors or gastric mucosal protective agents and there were no deaths or tumor recurrence/metastasis. No patients had anemia or hypoproteinemia 3 and 6 months after surgery. Six months after surgery, NRS2002 and GERDQ scores were 1-2 and 2-3, respectively. Gastroscopy showed narrow anastomoses in 6 patients with Los Angeles grade A and one patient with grade B disease. No evidence of significant bile reflux was found and no anastomotic stenosis or reflux was detected on upper gastrointestinal angiography. Conclusion: It is safe and feasible to implement modified tubular gastric side-overlap anastomosis for digestive tract reconstruction in laparoscopic proximal gastrectomy. 目的： 探讨改良管型胃Side-overlap吻合法在腹腔镜近端胃切除术中应用的可行性和安全性。 方法： 采用描述性病例系列研究方法，回顾性分析由福建医科大学附属第二医院2022年10月至2023年3月期间，对7例行腹腔镜近端胃切除并采用改良管型胃Side-overlap吻合法进行消化道重建患者的临床资料。其中男性5例，女性2例；年龄57~72岁；体质指数为18.5~25.7 kg/m2。7例患者术前胃镜及病理学检查结果均提示为食管胃结合部癌，术前CT增强扫描和（或）超声内镜检查，均提示为cT1~2N0M0期肿瘤。改良管型胃Side-overlap吻合法的主要重建步骤：（1）游离食管下段，打开左侧胸膜以拓展空间；（2）使用直线切割闭合器离断食管；（3）沿胃大弯制作3 cm宽的管型胃；（4）在管型胃前壁偏小弯侧作一5 cm的指引线，并在指引线下方开一小口；（5）逆时针旋转食管残端90°，在食管残端右后壁开一小口，在胃管和指引线的引导下使用45 mm直线切割闭合器进行食管胃侧侧吻合；（6）使用倒刺线关闭共同开口；（7）包埋食管残端切缘，使食管与残胃紧密贴合；（8）使用倒刺线将食管下段双侧与管型胃前壁连续缝合包埋；（9）关闭打开的食管裂孔和胸膜。主要观察指标为患者术中（手术时间、消化道重建时间、共同开口关闭时间、术中出血量和淋巴结清扫数）和术后（术后首次排气时间、首次进食流食时间、首次下床活动时间、住院天数及术后并发症发生情况）情况、术后病理学检查（肿瘤最大径和病理分期）及随访结果。 结果： 7例患者均顺利完成腹腔镜近端胃切除术改良管型胃Side-overlap吻合消化道重建，均未出现中转开腹及术后并发症。手术时间为187~229 min，消化道重建时间为61~79 min，共同开口关闭时间为7~9 min，术中出血量为15~23 ml，淋巴结清扫数目为14~46枚/例；术后排气时间为1~2 d，术后进流食时间为2~3 d，术后下床活动时间为3~4 d，术后住院时间为6~7 d。术后病理学检查提示，肿瘤最大径为1.6~3.3 cm，ⅠA期4例，ⅠB期3例。7例患者获得6~11个月随访，随访期间未常规使用质子泵抑制剂及胃黏膜保护剂，无死亡或肿瘤复发转移。术后3和6个月均未发生贫血或低蛋白血症。术后6个月时，NRS2002评分及GERDQ评分为1~2分及2~3分；胃镜检查可见一狭长形的吻合口，Los-Angeles分级A级6例，B级1例，未见明显胆汁反流；上消化道造影均未见吻合口狭窄和反流。 结论： 改良管型胃Side-overlap吻合法可以作为腹腔镜近端胃切除术中安全可行的消化道重建方式。.
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