| Objective To investigate the ideal digestive tract reconstruction method for distal gastrectomy(DG). To identify the risk factors for esophagojejunal anastomotic leakage(EJAL) and its impact on prognosis for gastric cancer patients after curative total gastrectomy(TG).Methods 1.Clinical and follow-up datas of 862 patients with gastric cancer who underwent DG in Xijing hospital of digestive disease from January 2010 to January 2013 were analyzed retrospectively. According to reconstruction methods, patients were divided into three groups: Billroth I(B I)?Billroth II(B II) + Braun?Roux-en-Y. In order to reduce the differences of clinicopathological characteristics, patients between B I,B II+Braun and Roux-en-Y group were selected using Gmatch methods based on gender, age(±5years), tumor size(±1cm), depth of invasion and number of metastatic lymph node. The perioperative datas, recent(30 days after surgery) complications, gastroscopic results over one year and postoperative survival rate were compared respectively between the three groups. 2. Clinicopathological characteristics of 1254 gastric cancer patients that underwent radical total gastrectomy from January 2012 to May 2015 were recorded. Risk factors of EJAL and prognostic factors of patients after surgery were analysised respectively. In order to reduce the influence of other prognostic factors on survival, patients with and without EJAL group were selected using Gmatch method based on the results of prognostic factors excluding EJAL. Patients survival with or without EJAL was examined before and after matching respectively.Results 1.As compared with B II+Braun and Roux-en-Y groups, the B I group had a significantly shorter operation time than both, an earlier feeding than the former, and a shorter postoperative hospitalization stay than the latter(P<0.05). The incidence of recent complications in B I group was higher than that in the other two groups, however, the difference was not statistically significant(P =0.495). The incidence of reflux gastritis, bile refluxs and reflux esophagitis in Roux-en-Y group were significantly lower than that in B I and B II+Braun groups(P<0.05). There were no significant differences about intraoperative blood loss, blood transfusion, the time of first exhaust and stomach tube extractio, the number of retrieved lymph nodes, the proximal resection margin and the survival rate among the three groups(all P>0.05). 2. Thirty-one patients(2.5%) developed EJAL. Multivariate analysis demonstrated that preoperative low serum albumin(<3.5g/dl)( OR, 5.623; 95%CI, 1.328-19.857; P=0.018), pulmonary insufficiency(OR,7.655;95%CI,1.559-13.472; P=0.006), long duration of operation(?240min)( OR,10.348;95%CI,1.626-7.403; P=0.001) were independent risk factors for EJAL, and EJAL(HR,2.722;95%CI,1.598-4.635;P<0.001) was one of the independent prognostic predictors besides Age, intraoperative blood transfusion, tumor location, depth of invasion(T stage), the number of lymph node metastasis(N stage). Patients with EJAL had a significantly worse over 3-year survival rate than those without(44.3 versus 66.7 percent; P=0.002).Conclusion 1.The three reconstruction methods have the same effect on the tumor eradication. B I has the advantages of more simple operation, faster recovery, less complications and more similar to the physiological structure. Although the operation of Roux-en-Y is relatively complex, but its effect on resisting gastrointestinal reflux is remarkable. There is no obvious advantage of B II+Braun type reconstruction in terms of safety and anti-reflux. Thus, B I and Roux-en-Y should be recommended for digestive tract reconstruction in DG. 2.Esophagojejunal anastomotic leakage(EJAL) after curative total gastrectomy leads to worse survival. Preoperative low serum albumin(<3.5g/dl), pulmonary insufficiency, long duration of operation(?240min)were predictors for EJAL, which should be taken care during perioperative. |
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