【作者】 王宽； 韩继广； 薛英威；

【Author】 Wang Kuan Han Ji-Guang Xue Ying-Wei Department of abdominal surgery, The tumor hospital of Harbin Medical University

【机构】 哈尔滨医科大学附属肿瘤医院腹外科；

【摘要】 目的:越来越多的学者们发现,胃癌根治术后患者出现的胆道结石、习惯性腹泻及术后胃肠功能障碍等情况很可能与迷走神经的损伤有关。我们的目标是通过严格的前瞻性的临床研究,来判断这种学说正确与否。若确实如此,将为今后临床一线术式的转变奠定基础,探讨其适应症。方法:自2003 年1月份至2004年12月份期间,前瞻性的选择远端胃癌60例, 研究范围的规定:年龄40-70岁,病灶位于幽门管、胃窦或体窦交界, 术中探查迷走神经主干、肝胆分支及腹腔支均未受到原发灶及转移淋巴结的侵犯,均切除远端约60%-70％的胃体,均采用BillrothⅡ式吻合方式加行Brown式输入输出段侧侧吻合,均达到根治标准(标准D2根治方式),术前超声诊断均未发现胆石和胰腺异常的存在。随机分为2组。每组男女比例1:1,A组仔细解剖并保留迷走神经肝胆支、腹腔支, B组不作保留。结果:术后短期效果的观察,A组胃肠功能障碍者0例,B组2例,两组住院期间均未有明显腹泻症状。术后平均进食时间差别不显著。远期效果的比较,术后1年,胆石症的诊断率,A:B=1:9,P<0．05,测量空腹和油脂饮食后,超声测量胆囊最大纵切面后应用电子尺测量面积及胆总管内径的变化,胆囊最大径面积及胆总管内径的变化两组差别显著(P<0．05),自述腹泻症状大干每月5次为阳性,A:B=6:8, P>0．05。结论:保留迷走神经肝胆支组较传统胃癌根治术组胆囊功能明显改善,胆囊结石形成数量明显减少。而腹泻的发生,似乎与腹腔神经分支的保留关系不大,更可能与幽门括约肌结构的消失有关。本研究中以远端胃癌根治术的患者群为对象,目的是便于比较,这种保留神经的术式可以推广到近端胃癌根治术和根治性全胃切除术中。更多还原

【Abstract】 Objective: More and more experts feel that it seems possible-among the patients underwent radical gastrectomy, the symptoms, such as gall stone, habitual diarrhea and physiologic derangement should be related with the extent destroy on vagus nerve. Our aim is justify the theory right or not though the strict prospective clinical study. If the data support the theory, we should take the new operation in place of traditional radical gastrectomy. Methods: We have collected 60 cases distal gastric cancer from Jan, 2003 to Dec, 2004. All of them must follow the rules: ageing between 40 to 70, lesion locates in distal stomach, no vagus of the divisions were suffered from the primary cancer or metastasis lymph nodes, resection parts between 60% to 70%, Billroth II and Brown reconstruction, degree of lymph nodes cleaning were D2, gall stone and pancreas disease are not detected by the preoperative ultrasound testing. All the cases are divided into 2 groups (A and B). In each of them, male and female are echo. Reserving vagus nerve was performed in A group, whereas, it was not be in B group. Results: Shortly after operations, the complication of physiologic derangement was observed zero and 2 cases in A and B group respectively. No diarrhea was observed in overall cases. And, no difference was in the time starting eating. At the point of one year from the operation, the following data were collected and analyzed, the cases of gall stone were detected--A/B=1/9, P<0.05, By ultra sound, the changing of the biggest tansect areas of cholecyst and bile duct were measured at two points, emptying and 2 hours following lipidic diet The result shows the significant difference between the 2 groups. But, the diarrhea occurrence ratio is same. Conclusion: Preserving hepatocystic vagus in radical gastrectomy can obviously improve the cystic function and decrease the occurrence of cholecystitis. As to the postoperative diarrhea, it seems be more related to rather the disappear of pylori sphincter than the reserving of celiac divisions. In this study, for better contrast, all cases are distal gastric cancers, so, the reserving way could also be conducted in proximal and total gastrectomy in the same way.更多还原