| BackgroundAt present,gastric cancer is a common malignant tumor of the digestive system.Its incidence is the second highest among malignant tumors in China,and it is the most common cause of cancer death in the world.In recent years,with the adjustment of people’s dietary structure and the effective control of Helicobacter pylori,Worldwide,the incidence and death rates of gastric cancer are declining.However,the morbidity and mortality of adenocarcinoma of esophagogastric junction(AEG),a special type of gastric cancer,were increasing year by year.Over the past two decades,The results of a single-center large sample study published by West China Hospital of Sichuan University showed that the proportion of AEG in the incidence of all gastric adenocarcinomas risen from 22.3 percent to 35.7 percent in the1990s,.Among them,due to the significant increase in the incidence of SiewertⅡandⅢAEG,and most of the preoperative clinical stages of the patients are in the middle and late stage,the operation difficulty coefficient is high,and the overall prognosis is poor,so it has become the focus of international and domestic experts.Surgical treatment of Siewert typeⅡand typeⅢAEG,is the most important and effective treatment in many treatment strategies.Since Kitano first reported on laparoscopic-assisted distal gastrectomy,laparoscopy has been used in the treatment of gastric cancer and achieved satisfactory short and long-term results.Prospective randomized controlled trials in South Korea,Japan and China have also confirmed that Compared with traditional open surgery,laparoscopic radical gastrectomy has great short-term and long-term benefits.Therefore,as laparoscopic technology matured,more and more surgeons began to try laparoscopy to treatment of Siewert typeⅡandⅢAEG and complete total gastrectomy,and report the related research results:less bleeding,less pain,rapid recovery of gastrointestinal function,reduce hospital stay and so on.With the wide development of SiewertⅡandⅢAEG laparoscopic total gastrectomy,it is particularly important to choose an appropriate way to reconstruct the digestive tract..The reconstruction of tract is difficultlys in gastric cancer surgery,And in which the reconstruction of esophagus and jejunum by total gastrectomy is particularly difficult,and it is also a hot and difficult topic for surgeons to discuss.According to different anastomosis methods,esophagojejunostomy can be divided into tubular anastomosis and linear anastomosis.At present,the commonly used tubular anastomosis is end-to-side esophagojejunostomy,and the commonly used linear anastomosis is Overlap esophagojejunostomy.The innovative semi-end-to-end esophagojejunostomy(semi-end-to-end anastomosis,SEEA)developed by our center in 2013 has achieved good clinical effects in the application of esophagojejunostomy,which has the advantages of short reconstruction time of digestive tract and low incidence of complications of esophagojejunostomy.Therefore,the clinical effects of SiewertⅡandⅢAEG laparoscopic total gastrectomy with SEEA anastomosis and Overlap anastomosis were compared and analyzed.To evaluate the clinical value of SiewertⅡandⅢAEG laparoscopic total gastrectomy with SEEA esophagojejunostomy and Overlap anastomosis.ObjectiveIn this study,we retrospectively analyzed the short-term clinical effects of SiewertⅡandⅢAEG laparoscopic total gastrectomy with SEEA anastomosis and Overlap anastomosis,and to explore the clinical value of SEEA and Overlap anastomosis in SiewertⅡandⅢAEG laparoscopic total gastrectomy.UniversityMethodThis study is a retrospective cohort study.The clinicopathological data and postoperative follow-up data of 85 patients with locally advanced SiewertⅡandⅢAEG treated in the Department of General surgery of the Hospital of Army Medical University from January 1,2016 to January 1,2019 were collected and statistically analyzed.Among them,46 patients underwent laparoscopic total gastrectomy with SEEA esophagojejunostomy(SEEA group),and 39 patients underwent laparoscopic total gastrectomy with Overlap anastomosis(Overlap group),the data of the patients in the two groups were collected:1.the operation situation(Operation time,blood loss,number of lymph nodes dissected,number of positive lymph nodes,tumor distance near cutting edge,time of esophagojejunostomy,length of auxiliary incision,complications related to intraoperative esophagojejunal anastomosis:anastomotic stricture and anastomotic bleeding).2.Postoperative recovery(postoperative anal exhaust time,postoperative water intake time,postoperative feeding time,postoperative extubation time,postoperative hospital stay,postoperative esophagojejunal anastomosis related complications:anastomotic bleeding and anastomotic fistula,postoperative non-esophagojejunal anastomotic complications:duodenal stump fistula,pulmonary infection,abdominal infection and incision infection)3,Short-term postoperative follow-up(survival,anastomotic stenosis,tumor recurrence and metastasis within 1 year after operation).SPSS23.0 Statistical software was used.Measurement data meeting to normal distribution were showed as x±s,and t test was used for comparison between groups.The counting data were showed as absolute number or percentage,andχ~2test or Fisher exact probability method was used for comparison between groups.data were compared by non-parametric rank or sum test.0.05 indicates that the difference is statistically significantResult1.Comparison of characteristics between SEEA group and Overlap group.A total of 85 patients with locally advanced Siewert typeⅡandⅢAEG were included in the study,including 46 patients in SEEA group and 39 patients in Overlap group.There was no significant difference in basic data,sex,age,body mass index,Siewert classification,maximum tumor diameter,pathological type and p TNM stage between the two groups(p>0.05).2.Operation situationIn SEEA group and Overlap group,laparoscopic total gastrectomy and esophagojejunostomy were completed successfully.There was no case of splenectomy,no conversion to laparotomy and no intraoperative death.Compared with Overlap group,the distance of tumor proximal margin in SEEA group was higher[(2.3±0.9)cm and(1.6±1.0)cm,p<0.05],the time of esophagojejunostomy was shorter[(32±3)min and(42±5)min,p<0.05],and the length of auxiliary incision was longer[(7.5±1.6)cm and(4.8±1.2)cm].And there was no significant difference in number of lymph node dissection and positive lymph nodes and complications related to intraoperative esophagojejunostomy between SEEA group and Overlap group(p>0.05).One patient in Overlap group underwent esophagojejunostomy during esophagojejunostomy,the anastomotic jejunum was punctured distally by linear cutting stapler,and the ruptured jejunum was resected during operation,and then Overlap esophagojejunostomy was performed with free jejunum.3.Postoperative recoveryPatients in SEEA group and OVERLAPS group recovered well after operation.There was 1 case of esophageal and jejunal anastomotic bleeding in the two groups,and the difference between the Overlap group and SEEA group was statistically significant(χ2=4.449,P<0.05).All patients with postoperative bleeding from esophagojejunostomy were improved by medical conservative treatment such as blood transfusion,endoscopic hemostasis and hemostasis drug infusion.There were no significant differences between the two groups in the time of the first exhaust,the time of the first drinking water,the time of the first feeding,the time of extubation,and the complications of non-esophagojejunostomy and other aspects(P>0.05).One case of esophagojejunostomy fistula occurred in the overlap group,which was cured by conservative treatment such as abdominal puncture and drainage,anti-infection,fasting and so on..Two patients with postoperative duodenal residual fistula in Overlap group were cured by anti-infection,puncture and drainage,nutritional support and other treatments;Five patients in SEEA group and three patients in Overlap group were cured by anti-infection,atomization and expectant treatment.Two patients in SEEA group and one patient in Overlap group were cured of postoperative abdominal infection by anti-infection and abdominal puncture drainage.In the SEEA group,One case of wound infection was cured by dressing change and anti-infection therapy.4.Follow upAll 85 patients in the SEEA group and the Overlap group were followed up for 1 year after surgery.During the follow-up,3 patients in the SEEA group and 2 patients in the Overlap group died,0 patients in the esophagojejunal anastomosis and Two patients in the Overlapgroup died without recurrence of esophagojejunostomy.ConclusionCompared with advanced SiewertⅡandⅢAEG laparoscopic total gastrectomy and Overlap anastomosis,SEEA anastomosis is a safe and convenient method,not only the distance near the cutting edge of the tumor is higher,the time of esophagojejunostomy is shortened,but the incidence of postoperative esophagojejunostomy bleeding is lower,but the length of the auxiliary incision of Overlap anastomosis is shorter. |
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