【作者】 薛英威； 王宽； 韩继广；

【Author】 Xue Ying-Wei Wang Kuan Han Ji-Guang 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:无论吻合方式如何,全胃切除术术后或多或少伴有烧心、返酸等消化液返流的症状,大部分病人的症状通过保守疗法能够缓解,少数病人症状顽固,造成严重的心理和生理负担,影响生存质量。我们认为,以术中病理为保障,在不影响根治手术效果的前提下,保留食管-为括约肌的解剖生理结构,从而维持了贲门上方的相对于胃内的高压区,理论上应该可以杜绝这一并发症的出现,故作如下的临床病例比较。方法:生理学上,在食管与胃贲门连接处以上, 有一段长约4—6厘米的高压区,其内压力一般高出胃内5～ 10mmHg,因此是正常情况下阻止胃内容物逆流入食管的屏障。传统意义上的全胃切除术上切断线要求的范围是贲门上方2—3厘米,如有必要可继续向上延长1-2厘米,甚至开胸。那么这一生理结构必定被破坏。我们把2004年-2005年的拟行全胃切除手术的病人前瞻性随机分为两组,年龄介于40-70 岁,手术切除成功者为合格样本,对照组30例行传统全胃切除,实验组30例行保留贲门的全胃切除术,两组吻合术式均采用我们认为最熟练的并发症最少的Lawrence-P式吻合术式(图详见原文), 两组均保留迷走神经腹腔分支及肝胆分支,两组均进行上切端组织术中病理检查以保证根治手术质量。进行比较的指标包括:术后吻合口瘘几率、平均肠道恢复时间、住院时间、术后半年时随访营养状况(以出院体重为基数增加标记为+,减少标记为-)及返流情况。结果:实验组／对照组:吻合口瘘0／0,肠道恢复时间4．3／4．7,住院时间:12．1／10．2(P>0．05),半年后随访时营养状况比较实验组明显优于对照组(差数秩和检验,P<0．05), 返流情况明显少于对照组(P<0．05)。讨论:如何提高病人生活质量是当前外科工作中面临的主题之一。全胃切除术消化道重建方式不下十数种,随着临床上术式的改进,患者术后消化液返流症状逐渐减轻,但仍未达到令人满意的程度。在慎重的解剖学上研究及动物实验的基础上,我们将传统上切断线下移至贲门下2—3cm,术中冰冻病理证实切端无癌残留。通过本研究发现,保留贲门的术式有效的减少了术后消化液返流,使病人术后营养状况得到改善,是值得推荐的术式。更多还原

【Abstract】 Objective: Patients who underwent traditional total gastrectomy usually suffered from the abnormal gastric motility, such as nausea, vomiting, reflux, etc. Most of symptoms could be settled down, whereas in small percentage of them were intractable, which make a lot of burden physiologically or psychologically. In our opinion, at the basis of same therapeutic effect, reserving the esophagus-cardia structure-- a relative high- pressure area, which can, at least in theory, prevent this kind of complication. From this point of view, we design and practice the following contrast. Methods: Physiologically, just upper the esophagus-cardia adjuvant, about 4-6cm, there is a high-pressure area, in which the pressure is higher than that in stomach, ensuring the food emptying smoothly from up to down. In traditional proximal gastrectomy, this physiological structure will be destoried for the cutting curve locating at 2-3cm upper than cardia. We have collected 60 patients underwent total gastrectomy from 2004 to 2005. All of them must follow the rules: ageing between 40 to 70, receiving successful lesion resection, in A group, performing traditional total gastrectomy, in B group, performing cardia receiving operation, in both groups, conducting Lawrence-P reconstruction that we think as lowest complications with, in both groups, the vagus nerve divisions were reserved, no cancer cells were detect by pathological testing in the upper cutting curve tissue. The postoperative effects of A and B group will be contrasted in many aspects. Results: A group vs B group: anastomose fistula 0/0, resuming of gastrointestinal function 4.3/ 4.7(day), average time in hospital postoperatively 12.1/10. 2(day), the nutritional status is obviously better than that in B group half year postoperatively (P<0.05), reflux status is significant different between the two groups (P<0. 05). Conclusion: How to improve the quality of life is the main motif in present-day surgical practice. Although, the reconstructions following the total gastrectomy are keeping improved, as the result, the symptoms of reflux are counteracting, in overall, the reflux status is not satisfied. From this study, we approved that the new way, reserving the cardia in total gastrectomy is an effective method to reduce the occurrence of reflux and improve the nutrition status greatly. So, this is a potential and rec-ommendable operation.更多还原