【作者】 王亚农； 徐宇； 朱蕙燕； 莫善兢； 蔡宏； 吴江宏； 曹学冬；

【Author】 Wang Ya-Nong Xu Yu Zhu Yui-Yan Mo Shan-Jing Cai Hong Wu Jiang-Hong Cao Xue-Dong

【机构】 复旦大学附属肿瘤医院腹部外科；

【摘要】 目的:管状吻合器已经在我院开展的各项消化道肿瘤手术中被广泛应用。随着器械自身的更新和外科医生经验的积累,我们对运用管状吻合器,进行胃大部切除术后消化道重建的技术,进行了一定的改进。现将这种新技术,及在过去3年中享受了这一技术的病例的统计结果呈现给大家。方法:研究包括了2003年到2005年间,采用这种新方法来实现消化道重建的所有胃大部切除病例。共150例,其中男性95 例,女性55例,平均年龄57岁,肿瘤分布于贲门28例、胃底11例、胃体上部2例、胃体下部15例和胃窦85例,另有 9例巨大病灶跨越多个解剖结构,最终病理诊断包括胃癌140 例、胃淋巴瘤5例、胃间质瘤2例、胃平滑肌肉瘤2例、胃神经鞘瘤I例,术后分期I期41例,II期24例,III期54例, IV期21例。所有的数据由SPSS 13．0进行录入和分析。改进的方法可以运用在各种胃大部切除中。所有根治性手术均严格要求拥有D2及以上的淋巴结清扫范围、病理阴性的十二指肠或食道切缘及5cm以上的胃体切缘(除间质瘤和平滑肌肉瘤病例)。与以往的端侧吻合方法不同的是,既往我们将吻合口置于残胃的胃体后壁,而现在吻合器将直接在胃残端上作端端吻合。以毕I式吻合为例作介绍:(1)按切缘要求断离十二指肠,在十二指肠残端置入吻合器底座, (2)确定胃体切除线,用关闭器沿切除线从大弯侧关闭胃体,断离标本,留胃体残端的靠小弯侧约3cm开放,(3)将吻合器机头从残端小弯侧的开放口处轻轻塞入,将头部小心扭向十二指肠残端,将吻合器机头正中的吻合针,从刚才的关闭线和原胃大弯线的交汇点处穿出,(4)将针头和底座相扣后,逐步合拢十二指肠残端和胃体残端,注意在完全契合前,保证a．胃体残端在吻合器头部保持恰当张力以避免胃壁残端发生破裂或皱褶, b．刚才的关闭线——即整个胃体的断离线,与大小弯处于同一平面,以保证吻合口的前后对称性, (5)合拢两残端并激发,退出吻合器,检查吻合圈的完整性。关闭器关闭刚才的开放口,以使其成为新胃小弯的一部分,(6)丝线加固关闭口的浆肌层,视情况加固吻合口,吻合口周线和关闭线交汇点必须作荷包包埋。端端吻合结束。毕II式远端胃大部切除和近端胃大部切除的方法类似。结果:3年来,我们的手术小组用这种方法,成功完成了150例胃大部切除手术:根治性131 例,姑息性19例,近端胃大部切除41例,毕I式远端胃大部切除53例,毕II式远端胃大部切除56例。平均手术时间为 146±32(90—225)分,平均术后住院天数为13±6(6—55) 天,平均住院总费用(不包括进口吻合器费用)为21714．92 元。平均恢复经口进食为术后第9天。术后短期的吻合口并发症包括吻合口出血2例、吻合口狭窄3例、可疑的吻合口漏导致吻合口周围积液2例,远期的吻合口并发症主要是吻合口轻度狭窄7例,进食哽噎感持续存在5—7个月。所有并发症均经保守治疗后好转。无发生手术死亡。结论:我们对于管状吻合器使用的新应用,不但能够顺利地完成胃大部切除术后的消化道重建,理论上保证了重建后胃肠道的良好连续性和对称性、节约了胃体,从而降低了吻合口的张力,且临床上不增加手术的复杂性和并发症的发生率,是一种可行、安全、实用的新技术。更多还原

【Abstract】 Objective: The circular stapler has been widely employed in virtually various surgeries for gastrointestinal tumors in our hospital nowadays. With the accumulative experience of the surgeon and the improvement of the appliance itself, our team have succeeded to performed a little modification during the anastomosis by utilize the circular stapler after partial gastrectomy. Here we represent you this novel technique and the results of the cases who enjoyed it. Methods: From 2003 to 2005, 150 patients with gastric tumor underwent the partial gastrectomy by the staple technique with the new technique in our surgical group. Among these participants, there were 95 males and 55 females with mean age of 57 years. The neoplasm can be located in cardia of 28 cases, fundus of 11, upper body of 2, lower body of 15, antrum of 85. And 9 big lesion passed through more than one part of the stomach. The final diagnosis of the patients, according to the postoperative pathological analysis, were as follows: carinoma 140 cases, lymphoma 5 cases, GI stromal tumor 2 cases, leiomyosarcoma 2 cases, nerve sheath tumor 1 cases. Among the cancer patients, the distribution of the stage (AJCC 1998) shows 41 for Stage 1,24 for Stage II, 54 for Stage III and 21 for Stage IV. All the relevant data was collected from the medical records and processed by SPSS 13.0. The modified anastomosis technique can be applied in all kinds of partial gastrectomes. All the surgical procedure for radical purpose should gain a severe D2 or more extended lymphadenectomy, a pathological proved negative cutting edge of duodenum or esophagus as well as a 5-cm distal-to-tumor margin of the gastric remnant, except for the GI stromal tumor and leiomyosarcoma. Compared with the previous side-to-end way, the end-to-end anastomosis is constructed on the stump edge instead of the posterior wall of the gastric remnant Below prescribe the Billroth I program: Transect the duodenum with the adequate margin and place the anvil of the stapler into the stump. Deciding the transection line on the stomach, close and resect the stomach body along the line from the side of greater curvature with a linear stapler. Remove the specimen with about 3 cm edge of the line open near the lesser curvature. Insert the stapler into the lumen through the remaining edge. Turn the cartridge towards the anvil fixed in the duodenal stump carefully. Release the centre rod with a trochar inside the cartridge and pierce the gastric wall right at the junction point of the close line of the gastric stump and the original midline of the greater curvature. Bring the cartridge in gastric and the anvil in duodenum together slowly. And Before fixing them, make sure that (a) hold the gastric stump on the cartridge with a proper tension to avoid any disruption or folds of the stump, and (b)set the previous close line as well as the transaction line of the stomach in the same plane with the greater and lesser curvatures to ensure the a更多还原