近端胃切除术后消化道重建的术式及应用

<正>对于胃上部及食管胃结合部的肿瘤,大多数专家主张首选腹腔镜全胃切除术(laparoscopic-assisted total gastrectomy,LTG)联合开放吻合术、使用辅助切口吻合口或完全腹腔镜吻合术(Overlap吻合和π形吻合术),其优势在于可以根治性切除潜在转移的淋巴结并且避免近端胃切除术(proximal gastrectomy,PG)后发生严重的反流性食管炎^[1]。对于接受全胃切除术(total gastrectomy,TG)的患者来说,Roux-en-Y吻合术为常见术式,但因其改变消化道连续性,易引起营养吸收障碍、贫血和其他并发症,导致术后体重减轻、生活质量差等问题^[2]。     

管状胃-食管吻合对近侧胃切除术后胃食管反流的影响

目的探讨管状胃-食管吻合对食管胃交界部腺癌近侧胃切除术后胃食管反流的影响。方法对54例采用开腹手术,行传统残胃-食管吻合术;83例采用腹腔镜辅助手术,行管状胃-食管吻合术的患者进行回顾性分析。结果两组均无围手术期死亡、吻合口瘘、吻合口狭窄及胃排空障碍的发生;两组患者术后1个月、3个月时体重较术前均有下降,但两组间差异无统计学意义（P〉0.05）;管状胃-食管吻合术组术后1个月、3个月时反流性疾病问卷评分低于残胃组[（9.99±4.69）vs.（15.09±7.98）,P〈0.01]、[（9.39±4.58）vs.（14.30±7.87）,P〈0.01],管状胃组术后1个月、3个月时胃食管反流病的发生率低于残胃组[（13.25%vs.53.70%）,P〈0.01]、[（10.84%vs.48.15%）,P〈0.01]。两组间差异均有统计学意义。结论腹腔镜辅助近侧胃切除术管状胃-食管吻合安全,可靠,可降低术后胃食管反流,提高患者生活质量。     

近端胃切除术后消化道重建

传统的近端胃切除术难以控制反流,术后反酸、烧灼感等消化液反流症状给病人带来持久的痛苦,饮食受限,发生营养不良甚至衰竭。我科开展了保留贲门的近端胃切除术和环状襻式单通道间置空肠近端胃切除术已6年余,截至2010年9月,已完成保留贲门的近端胃切除术40例,环状襻式单通道间置空肠近端胃切除术102例,基本上消除了传统近端胃切除术后的反流等问题,同时极大地减少了全胃切除的概率,远端残胃得以保留,改善了营养状态。通过核素检测发现,术后6     

近端胃切除术后的消化道重建

随着胃癌诊断技术的进步,位于胃上部的早期胃癌检出率不断提高。根据日本胃癌学会2002年《日本胃癌治疗指南》,位于胃上部的Ⅰa期及直径<2 cm的Ⅰb期早期胃癌可作为行近端胃切除术的适应证。全胃切除术曾因其良好的安全性及根治性被广泛接受,但全胃切除使胃泌素、胃酸和胃蛋白酶等分泌功能消失,影响消化功能,导致病人长期营养不良。近期的一系列研究表明,早期胃癌病人行近     

腹腔镜近端胃切除后抗反流消化道重建术式的临床评价

腹腔镜近端胃切除术的应用越来越多。传统的食管残胃吻合方式会导致患者术后出现严重的反流性食管炎,影响患者生活质量。近年来,多种抗反流的腹腔镜下近端胃切除后消化道重建方式被应用到临床。笔者结合最新的临床研究结果以及自身的临床经验,对腹腔镜近端胃切除后消化道重建方式进行临床评价,重点讨论了食管胃吻合（食管胃后壁吻合、食管胃前...     

全胃切除术后三种消化道重建术式的比较研究

目的 探讨全胃切除术后合理的消化道重建方式。方法对189例胃癌患者全胃切除术后分别采用了Orr式Roux-en-Y空肠食管吻合术、P形空肠袢空肠食管Roux-en-Y吻合术和Moynihan式吻合术进行消化道重建，对其手术时间、手术并发症、术后1、3年饮食状况和消化道症状及营养指标进行对比观察。结果3种术式的患者手术死亡率、术后1年和3年的饮食状况、腹泻和倾倒综合征的发生率比较，均P〉0．05；差异无统计学意义。术后1、3、5年的累计生存率比较，P〉0．05，差异也元统计学意义。Orr式空肠食管Roux-en-Y吻合术和P形空肠袢空肠食管Roux-en-Y吻合术后均能有效地防止反流性食管炎，明显优于Moynihan式吻合术（P〈0．01）。Orr式空肠食管Roux-en-Y吻合术较P形空肠袢空肠食管Roux-en-Y吻合术操作简单、手术时间短、手术并发症也较少。结论Orr式空肠食管Roux-en-Y吻合术是胃癌全胃切除后消化道重建较为合适的术式。     

全胃切除术后消化道重建术式的再探讨

近年来,全胃切除术在胃癌治疗中的应用日益增多,而全胃切除术后消化道重建始终是胃肠外科医生关注和难以割舍的话题,有关的纷争也一直未曾停息。迄今,文献报告的全胃切除术后消化道重建方式多达70余种,不同术式各有其优缺点,即便如此目前仍未获得一种真正理想的消化道重建术式。争论的核心是如何在保证手术根治效果和安全性的同时,提高患者术后生活质量;而其焦点主要围绕以下三个方面：（1）维持十二指肠生理通道是否必要;（2）是否需要构建食物贮袋;（3）哪种贮袋最为理想。要使这些争议获得较为明确的结论,我们应该正确运用循证医学的研究方法,以严谨的态度,增大研究的样本量,开展多中心前瞻性随机对照研究。     

完全腹腔镜全胃切除术后消化道重建的难点与技巧

随着腹腔镜技术近年来的规范与推广,腹腔镜根治性全胃切除术得到越来越多的开展,其主要的难点问题仍集中于全胃切除后的消化道重建。完全腹腔镜下的重建方式首选食管空肠Roux-en-Y吻合,其吻合方式主要有两种,即应用圆形吻合器行食管空肠端侧吻合和应用直线切割吻合器行食管空肠侧侧吻合,两种方法各有利弊,后者吻合口径更大。完全腹腔镜全胃切除术后消化道重建的优势在于,吻合全程在腹腔镜直视下进行,视野更好,安全性更高,手术创伤更小,是一种较为安全、简便、有效的吻合方法。     

腹腔镜袖状胃切除术对胃食管反流病的影响

胃食管反流病在肥胖患者中的发病率较高,而代谢减重手术是重度肥胖患者的重要治疗手段。其中腹腔镜袖状胃切除术作为现阶段最流行的减重手术,其对胃食管反流病的影响也受到越来越多的关注。由于袖状胃手术对胃食管反流病的影响争议较大,本文现总结胃食管反流病的病理生理基础、袖状胃手术对胃食管反流病影响的相关文献及袖状胃术后胃食管反流病的治疗方案,以期为临床实践提供帮助。     

胃癌全胃切除术后3种消化道重建方式的比较研究

目的：探讨胃癌全胃切除术后理想的消化道重建方式。方法：对191例胃癌患者按全胃切除术后消化道重建方式的不同,分为Roux-en-Y空肠食管吻合术组（R组）、袢式Braun吻合术组（B组）和袢式空肠代胃改良Ⅰ式吻合术组（L组）,比较3种术式患者的手术死亡率、术后并发症发生率、进食量、营养指标及存活率。结果：3种术式的患者手术死亡率、术后并发症发生率、3年累积存活率比较差异无统计学意义（P〉0.05）;与其他2组比较,L组术后6、12个月时单餐进食量明显占优（P〈0.05）;L组术后1年的平均体重、血清学营养指标及预后营养指数均优于R组和B组,差异有统计学意义（P〈0.05）。结论：袢式空肠代胃改良Ⅰ式吻合术能明显改善患者的生活质量,是胃癌行全胃切除消化道重建较理想的术式。     

Value of tests for evaluation of gastroesophageal reflux in children

The accuracy of five tests for the diagnosis of gastroesophageal reflux in children was performed in 93 symptomatic children with gastroesophageal reflux and 16 nonreflux patients. These tests include the barium esophagram, the Tuttle test, extended esophageal pH monitoring, esophagoscopy, and esophageal biopsy. Esophagoscopy was less sensitive in detecting reflux in patients than any other test (P = less than 0.001), and biopsy was more likely to identify reflux patients than the barium swallow (P = less than 0.02), but there was no test superior to others. The severity of esophagitis noted at endoscopy or the presence of eosinophils or neutrophils in the mucosa was not associated with a decreased possibility that one other test would be normal or that surgical repair of the reflux would be performed. Patients with extended esophageal pH test scores markedly elevated were less likely to have another negative test (P = less than 0.01) and more likely to have surgical repair of gastroesophageal reflux (P = less than 0.001). Obtaining two tests of esophageal function that agree increases the certainty of diagnosis, and use of several tests are indicated if the results of a single test do not support the clinical impression.     

腹腔镜下或胃镜下胃食管反流手术的疗效观察

目的探讨腹腔镜下或胃镜下胃食管反流(gastroesophageal reflux d isease,GERD)手术的疗效、手术方法及适应证。方法总结2005年8月~2006年1月施行腹腔镜下N issen手术52例和胃镜下胃壁折叠术28例的一般资料、手术结果,以及术后1、3个月的随访资料。结果两组的症状指数及反流时间均明显下降。腹腔镜组灼心感指数和反流指数分别从72.2±7.3和1.80±0.45下降至14.5±4.8和0.26±0.15(P均<0.05);胃镜组该两指数分别从70.6±9.4和1.80±0.32下降至28.2±7.6和0.30±0.12(P均<0.05)。腹腔镜组食管下段反流时间百分比从11.2%±6.2%下降至2.5%±0.4%(P<0.05);胃镜组从10.2%±5.7%下降至7.6%±1.2%(P<0.05)。腹腔镜手术中1例中转开腹手术,近期并发症3例,远期并发症2例,术后完全缓解率93.9%(46/49)。胃镜手术近期并发症3例,无远期并发症,术后完全缓解率58.3%(14/24)。结论腹腔镜下N issen手术是治疗严重GERD的理想术式,胃镜下胃折叠术则适用于治疗病情轻的GERD以减少其对药物的依赖,但疗效尚待进一步提高。     

腹腔镜治疗胃食管反流性疾病的临床研究

目的:探讨腹腔镜治疗胃食管反流性疾病的安全性和疗效。方法:回顾分析2004年至2009年为83例患者行腹腔镜手术的临床资料。结果:83例手术均获成功,手术时间30~60min,平均45min,出血5~20ml,术后24h进流质饮食,临床症状消失,术后无并发症发生,住院3~8d,平均5d。随访6个月~5年无复发。结论:应用腹腔镜治疗胃食管反流性疾病安全、可靠,具有广阔的应用前景。     

腹腔镜胃底折叠术治疗胃食管反流病372例

目的 探讨腹腔镜胃底折叠术治疗胃食管反流病(GERD)的可行性和临床应用价值.方法 2005年9月至2010年8月,对372例GERD病人实施腹腔镜胃底折叠术,其中Nissen胃底折叠术146例,Toupet胃底折叠术79例,前180°胃底折叠术147例,记录围手术期相关指标,随访观察治疗效果.结果 372例均完成腹腔镜手术,无中转开腹者.手术时间50～210 min,平均85 min;术中出血40～150 ml,平均86 ml.术后住院3～21天,平均4.3天.术后临床症状均得到缓解,无严重并发症及死亡病例.术后3个月复查胃镜、上消化道造影、食管测压和24 h食管pH检测均恢复正常.350例随访～63个月,平均27.3个月,对手术效果满意率92.57%,19例有进固体食物时轻度梗噎感,6例反酸症状复发,使用抑酸药物可控制,1例食管裂孔疝复发.结论 腹腔镜胃底折叠术治疗中、重度GERD充分体现了微创手术创伤小、恢复快、安全可行、疗效可靠的特点;3种胃底折叠方式根据病人具体情况应用,能够最大限度地保证手术效果、降低操作难度,减少术后并发症.

Abstract：

Objective To investigate the feasibility and clinical value of laparoscopic surgery in treating patients with gastroesophageal reflux disease. Methods From September 2001 to August 2009, 372 patients with gastroesophageal reflux disease undertwent laparoscopic fundoplication, including 146 cases of Nissen fundoplication, 79 Toupet fundoplication, and 147 anterior 180 degrees partial fundoplication. Para-operative clinical parameters were recorded. All patients were routinely followed up. Clinical outcomes were collected and analyzed. Results Laparoscopic surgery was successfully performed in all patients, and no conversions were required. The operating time was 50 -210 minutes (mean, 85 minutes), the operative blood loss was 40 - 150 ml( mean, 86 ml) ,the postoperative hospital stay was 3 - 21 days( mean, 4.3 days ). The symptoms in most cases were adequately relieved after operation. There were no severe postoperative morbidity and mortality. Endoscopy, radiology, esophageal manometry and 24-hour pH monitoring were repeated 3 months after surgery. After the follow-up period of 3 -63 months ( mean, 27.3 months), the satisfaction rate of operation was 92.57%. 19 cases had mild dysphagia when eating solid food. Symptoms recurrence of acid reflux occurred in 6 cases, which were controlled by antacid medications. Hiatal hernia recurrence occurred in 1 case. Conclusions Laparoscopic operation should be the method of choice to treat the moderate to severe gastroesophageal reflux disease, with the advantages of minimized trauma,quick recovery, safety,feasibility and reliable effect. According to individual condition of patients, appropriate fundoplication procedure should be employed carefully to ensure results of operations, reduce operating difficulties and the rate of postoperative complications.     

食管癌贲门癌术后酸反流与十二指肠胃食管反流

目的 探讨食管癌和贲门癌术后酸反流和十二指肠胃食管反流(DGER)的相互关系、反流特征以及对食管黏膜的损伤作用.方法 对32例食管癌和贲门癌术后病人进行烧心、反酸症状调查,应用电子胃镜检查、24 h食管pH和胆红素同步监测.结果 (1)胃食管反流症状的发生率65.6%,反流性食管炎的发生率为75.0%,其中2例发生Barrett食管,发生率为6.25%.(2)24 h食管pH和胆红素监测结果显示,28.1%的病人仅存在酸反流,15.6%仪存在DGER,53.1%同时有酸反流和DGER.DeMeeste评分与abs>0.14的时间百分比无明显的相关性(P=0.3109).平卧位pH<4.00的时间百分比和abs>0.14的时问百分比明显高于直立位(P<0.05).(3)通过比较在不同pH区间内胆红素的吸收率,显示在pH 3～6的区间内,胆红素abs>0.14的时间百分比明显高于其他区间(P<0.05).(4)DeMeester评分和胆红素abs>0.14的时间百分比与反流症状评分无明显的相关(P>0.05),与反流性食管炎评分呈正相关(P<0.05).结论 食管癌和贲门癌术后存在广泛的酸反流和DGER,反流形式以混合性反流为主(同时出现酸反流和DGER),混合性反流对食管黏膜的损伤作用更严重.酸反流和DGER均受体位影响.24 h食管pH和胆红素同步监测有助于揭示反流特征及反流物对食管黏膜的损伤作用.     

胃食管反流病1014例住院患者的诊治分析

目的探讨胃食管反流病(GERD)流行病学特点、临床症状及诊治方法。方法收集解放军第二炮兵总医院胃食管反流病中心从2006年10月至2009年11月入院诊治的1014例GERD患者临床资料,对患者性别、年龄、地域分布、临床症状及诊治进行分析。结果本组1014例GERD患者中,临床典型症状248例(24.5%),主要表现为反酸、反食、烧心等症状;非典型性症状766例(75.5%),以喘息、憋气最多,其次分别为咳嗽、咳痰、咽部异物感、咽痛、胸痛等。入院前741例患者(73.1%)被误诊,分别诊断为哮喘、支气管炎、慢性咽炎、冠心病等,确诊GERD后472例患者采用Stretta射频治疗,378例患者采用腹腔镜Nissen胃底折叠术治疗,164例患者采用药物治疗。结论胃食管反流病的表现复杂多样,涉及多个系统、器官,加强该病的全面认识,做到早期诊断及治疗,避免误诊误治,从而改善预后,提高患者生活质量。     

Gastrectomy as a Remedial Operation for Failed Fundoplication

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997–2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients’ overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty. Presented at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006.     

Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results

BackgroundBile reflux is a factor in the appearance of severe esophagitis and Barrett’s esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients.ObjectivesTo evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms.SettingUniversity hospital.MethodsProspective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux.ResultsErosive esophagitis was observed in 11 patients and Barrett’s esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms.ConclusionDGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.