中国实用外科杂志

中国实用外科杂志

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腹腔镜辅助保留幽门胃切除术改善早期胃癌术后胆汁反流性胃炎前瞻性随机对照研究

夏    翔a，沈艳莹b，朱纯超a，吕恒宇a，黄    晨a，曹    晖a，赵    刚a，张子臻a   

  1. 上海交通大学医学院附属仁济医院 a.胃肠外科  b.病理科，上海200127
  • 出版日期:2020-05-01 发布日期:2020-05-15

  • Online:2020-05-01 Published:2020-05-15

摘要： 目的  比较腹腔镜辅助保留幽门胃切除术（LAPPG）与腹腔镜辅助远端胃大部切除术（LADG）（Billroth Ⅰ式吻合）对胃体中部早期胃癌病人术后继发性胆汁反流性胃炎（BRG）的影响。方法  自2018年2月至2018年12月，对上海交通大学医学院附属仁济医院胃肠外科收治的69例早期胃体中部癌（cT1N0M0）病人进行1∶1前瞻性随机化入组，其中LAPPG组（行LAPPG）34例，LADG组（行LADG，BillrothⅠ式吻合）35例，进行6个月随访，比较两组术前、术中、术后及随访结果。  结果 两组病人在年龄、性别、BMI、术前合并症及术后病理诊断的基线水平差异无统计学意义（P>0.05）。 两组淋巴结清扫数目、手术时间、术中出血量、术后首次排气时间、胃管拔除时间、Ⅱ级以上并发症差异无统计学意义（P>0.05）。术后6个月随访结果显示，BRG临床表现无特异性，在两组中差异无统计学意义（P>0.05）；但内镜下诊断BRG比例LAPPG组显著低于LADG组，差异有统计学意义［3例（8.8%） vs. 16例（45.7%），χ2=11.763，P=0.001］；LAPPG组中Kellosalofen分级Ⅱ度以上BRG的比例显著低于LADG）组，差异有统计学意义［2例（5.7%) vs. 9例（25.7%），χ2=5.062，P=0.024］；组织学活检发现LADG组胃小凹增生1例、腺体萎缩伴肠化3例，LAPPG组未观察到上述病理组织学异常，但两组差异无统计学意义（P>0.05）。  结论   LAPPG治疗早期胃体中部癌安全可行，该术式较LADG可改善术后BRG的发生率及严重程度。 其对病人术后长期疗效及残胃癌发生率的影响仍有待大样本RCT研究的长期随访证实。

关键词: 早期胃癌, 腹腔镜辅助保留幽门胃切除术, 腹腔镜辅助远端胃大部切除术, 胆汁反流性胃炎

Abstract: Laparoscopic assisted pylorus-preserving gastrectomy reducing postoperative bile reflux gastritis：A single center prospective randomized controlled study        XIA Xiang*, SHEN Yan-ying, ZHU Chun-chao, et al. *Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
Corresponding author：ZHANG Zi-zhen，E-mail：zzzhang16@hotmail.com
Abstract    Objective    To evaluate the effects of laparoscopic assisted pylorus-preserving gastrectomy (LAPPG) and laparoscopic assisted distal gastrectomy (LADG) with Billroth I anastomosis on bile reflux gastritis (BRG) in patients with middle-third early gastric cancer.  Methods    From February 2018 to December 2018, 69 patients with middle-third early gastric cancer (cT1N0M0) admitted to the Department of Gastrointestinal Surgery，Renji Hospital，Shanghai Jiao Tong University School of Medicine were randomly divided into LAPPG and LADG groups (1:1), and then were followed up for 6 months. There were 34 patients in LAPPG groups who underwent LAPPG, and 35 patients in LADG groups who underwent LADG with Billroth I anastomosis. The results of preoperative, intraoperative, postoperative and follow-up were compared between the two groups. Results There was no significant difference in age, gender, BMI, preoperative complications, tumor size and low differentiation proportion between the two groups (P>0.05). There was no significant difference in the number of lymph node examination, operation time, intraoperative bleeding, the time of the first postoperative exhaust, the time of gastric tube extraction and postoperative complications above level Ⅱ between the two groups (P>0.05). Six months follow-up results showed that there was no significant difference in BRG related clinical symptom and BMI changes between the two groups. The proportion of BRG diagnosed by endoscopy in LAPPG (3 cases,8.8%) was significantly lower than that in LADG group (16 cases, 45.7%) (χ2=11.763，P=0.001). Among them, there were 2 cases (5.7%) above BRG Ⅱ degree in LAPPG which was significantly lower than LADG (9 cases, 25.7%) (χ2=5.062，P=0.024). Histologic biopsy showed 1 case of gastric fovea hyperplasia and 3 cases of glandular atrophy with intestinal metaplasia in LADG group, but there was no significant difference between the two groups (P>0.05). Conclusion    LAPPG is safe and feasible procedure for patients with middle-third early gastric cancer. Compared with LADG, LAPPG can improve the incidence and severity of BRG. The long-term follow-up of large sample RCT study is still needed to confirm its effect on postoperative long-term efficacy and incidence of gastric stump cancer.

Key words: early gastric cancer, laparoscopic assisted pylorus-preserving gastrectomy, laparoscopic assisted distal gastrectomy, bile reflux gastritis