| Objective:To explore the feasibility and safety of double channel reconstruction of digestive tract in clinical application.Methods:This paper adopts the method of retrospective cohort study.From January 1,2016 to January 1,2019,23 patients with proximal gastric cancer were enrolled in the gastrointestinal surgery department of the second hospital of Shandong University and some other hospitals.All of the 23 patients completed the reconstruction of the double channel digestive tract under laparoscope.Operation method:the jejunum was severed 15-20cm from the Treitz ligament after the standard proximal gastric cancer resection and lymph node dissection.The distal jejunum was lifted up from the colon,and esophagojejunostomy was performed.Side to side anastomosis of the anterior wall of the remnant stomach and jejunum was performed 10 to 15 cm from the anastomosis.Side to side jejunojejunostomy was performed 25 to 30 cm below the gastrointestinal anastomosis.The main outcome measures included:(1)age,sex,weight,hemoglobin concentration,tumor markers(CEA,CA199),albumin,body mass index(BMI),preoperative pathological results and clinical stages.(2)Intraoperative conditions:operation time,intraoperative bleeding volume,tumor size,location,distance between upper and lower margins of tumor,rapid pathological margin,number of lymph nodes to be cleaned,whether to switch to laparotomy.(3)Postoperative conditions:the time of first anal exhaust,first defecation,first fluid diet,visual pain score,anastomotic leakage,stenosis,obstruction,drainage tube removal time,postoperative hospital stay,postoperative pathology and stage,postoperative chemotherapy.(4)Reexamination and follow-up:body weight,hemoglobin concentration,tumor markers(CEA,CA199),albumin,serum vitamin B12 concentration,visick grade,LA grade of reflux esophagitis,dumping syndrome,gastroscopy and imaging of patients 6 months after operation.Statistical methods:SPSS 20.0 statistical software was used for data analysis.The measurement data are expressed as X±s and analyzed by t test;the counting data are analyzed by 2 test or Fisher exact test.When p<0.05,the difference was statistically significant;when p≥ 0.05,the difference was not statistically significant.Results:All 23 patients successfully completed the operation under laparoscope.The weight(70.2±6.5)kg,hemoglobin concentration(131.7±12.6)g/L,CEA(9.1±2.3)ng/ml,CA199(30.5±6.2)ng/ml,albumin(35.2±3.4)g/L,BMI(21.9±1.9)kg/m2,intraoperative hemorrhage(130±24.6)ml,tumor size(2.8±0.5)cm,swelling(304.4±19.8)min,intraoperative hemorrhage(130±24.6)ml,tumor size(2.8±0.5)cm,and swelling(30±24.6)ml)The distance between the tumor’s incised margin was(6.7±1.0)cm,the number of lymph nodes to be cleaned during the operation was(22.2±3.2),the time of first anal exhaust(3.1±1.1)d,the time of first defecation(4.6±1.0)d,the time of first feeding fluid(4.1±1.1)d,the visual pain score(4.7±1.1),the time of drainage tube removal(6.0±0.8)d,the days of hospitalization(11.7 ± 1.4)d,and the time of postoperative 6 The body weight(67.2±8.1)kg,hemoglobin concentration(101.8 ± 11.9)g/L,CEA(1.5±0.7)ng/ml,CA199(28.6±5.2)ng/ml,albumin(35.5±5.3)g/L,serum vitamin B12(355.5 ±118.1)pg/ml were all in normal distribution.There was no significant difference in body weight,CA199 and albumin between after operation and before operation.(P>0.05).There were significant differences in hemoglobin concentration and CEA between after operation and before operation.(P<0.05).There were 16 patients with well differentiated adenocarcinoma and 7 patients with moderately differentiated adenocarcinoma.The tumors were located at the junction of esophagus and stomach in 16 cases and at the bottom of stomach in 7 cases.All the upper and lower incisional margins were negative.No conversion to laparotomy.No anastomotic leakage,stenosis,obstruction or bleeding occurred in all cases.There were 13 patients with highly differentiated adenocarcinoma,8 patients with moderately differentiated adenocarcinoma and 2 patients with moderately poorly differentiated adenocarcinoma.21 patients were followed up 6 months after operation(2 cases were lost of Union).20 patients were classified as first grade and 1 patient as second grade.Among the 21 patients who were followed up,only one had dumping syndrome,and the rest were normal.Digestive endoscopy reexamination after operation:in one patient who reexamined the gastroscope 20 months after operation,the biopsy of antrum showed that:(antrum)severe chronic inflammation of mucosa with mild intestinal metaplasia,some glandular tubes showed low-level intraepithelial neoplasia,some of them showed high-level intraepithelial neoplasia,and they were treated with mucociliary stripping under gastroscope.Up to now,no tumor metastasis or recurrence has been found.Other patients were normal.Postoperative angiography:most of the contrast agent enters the digestive tract through the esophageal jejunal anastomotic port,and a small part of the contrast agent enters the digestive tract through the residual stomach jejunum pathway,and can stay in the residual stomach for a while without reflux signs.Conclusion:Laparoscopic double channel reconstruction of digestive tract is safe and feasible as a method of radical gastrectomy for proximal gastric cancer.The follow-up shows that there are fewer cases of gastroesophageal reflux disease and dumping syndrome in a short period of time,and the quality of life of the patients is better.This method is an alternative way of radical reconstruction of digestive tract for proximal gastric cancer. |
