初期100回連続自己吸引術と後期切開型食道結腸切開術の安全性を評価した

[Safety evaluation on initial 100 consecutive procedures of self-pulling and latter transected esophagojejunostomy].

• Hankun Hao
• Jun Hong
• Yaping Wang
• Jian Wang
• Yibing Bei
• Luchun Hua

抄録

目的:

腹腔鏡下胃全摘術(TLTG)におけるself-pulling術と後期切開食道結腸術(SPLT)の有用性と短期安全性を評価した。

OBJECTIVE: To evaluate the feasibility and the short-term safety of self-pulling and latter transected esophagojejunostomy(SPLT) in totally laparoscopic total gastrectomy (TLTG).

方法:

2014年6月から2017年1月までに復旦大学華山病院総合外科にて胃癌患者100名がTLTG-SPLTを受けた（SPLT群）。2013年10月～2015年12月にTLTG＋オーバーラップまたは機能的エンドツーエンド吻合を受けた従来群と比較し、臨床病理学的特徴、手術成績、術後成績をレトロスペクティブに収集した。D2リンパ節郭清は全例で定期的に実施した。SPLT群では、最初のステープラーで十二指腸を断裂した後、食道を「自己引きずり」を維持するために滅菌した麻縄を握って結紮・引きずり下ろし、後縦隔の剥離を可能にした。その後、食道の右後壁にリガチャーロープの上から2～3cmの穴をあけた。腸間膜の張力を確認すると、Treitzの靭帯から20cm離れた空腸の反腸間膜境界に別の穴を開けた。続いて、食道の右後壁と空腸の反腸縁との間に第二線状ホッチキスを用いて「側方食道結腸切開術（E-J）」を行い、入口孔を形成した。後者の切開」は、食道と求心性ループ空腸を同時にエントリーホールのレベル以上に切開しやすくするために、助手のトロカールから挿入した第３のステープラーで行った。その後、E-Jより40cm下の求心ループ切片とRoux肢の間に別の2本のステープラーを用いたサイド・ツー・サイド空腸切開術（J-J）を行い、E-Jの入口穴がステープラーの入口としても機能するようにした。したがって、TLTG-SPLTは完了し、標本は臍のトロカール部位から切開して除去された。

METHODS: One hundred patients with gastric cancer received TLTG-SPLT at General Surgery Department of Huashan Hospital (Fudan University) from June 2014 to January 2017(SPLT group). The clinicopathologic characteristics, surgical and postoperative outcomes were collected retrospectively and compared with the conventional group undergoing TLTG plus overlap or functional end-to-end anastomosis from October 2013 to December 2015. D2 lymph node dissection was regularly performed for all the patients. In SPLT group, a sterile hemp rope was held to ligate and drag down the esophagus to maintain "self-pulling" after the duodenum was transected by the first stapler, allowing the detachment of the posterior mediastinum. Then a hole 2-3 cm above the ligature rope was made on the right-posterior wall of the esophagus. When the mesenteric tension was checked, another hole was made at the anti-mesenteric border of the jejunum 20 cm distal to the ligament of Treitz. A side-to-side esophagojejunostomy (E-J) was then performed between the right-posterior wall of esophagus and the anti-mesenteric wall of the jejunum with the second linear stapler, forming an entry hole. The "latter transection" was applied with the third stapler inserted from the assistant's Trocar, which facilitated the esophagus and the afferent loop jejunum to be simultaneously transected above the level of the entry hole. After that, a side-to-side jejunojejunostomy(J-J) with another 2 staplers was carried out between the afferent loop stump and the Roux limb 40 cm below E-J, in which the E-J entry hole could also work as the entrance for the stapler. The TLTG-SPLT was therefore completed and the specimen was removed through the incision from the umbilical Trocar site.

結果:

SPLT群は男性66名、女性34名、年齢中央値は64歳であった。両群の臨床病理学的ベースラインデータは同等であった（すべてのP>0.05）。すべての患者が手術に成功し、開腹手術に転換した患者はいなかった。どちらの群でもポジティブマージンは認められなかった。平均手術時間はSPLT群で178.2±35.9分、再建時間は22.9±7.1分であり、いずれも従来群に比べて有意に短かった［(204.4±55.8)分、P=0.003、(30.5±7.2)分、P=0.000］。SPLT群では出血量が少なく［(74.3±72.5)ml vs (104.2±71.6)ml, P=0.017］，初発までの期間が短く［(1.9±1.6)日 vs (2.7±1.3)日, P=0.001］，初発までの期間が短かった。術後の在院日数、病理所見には両群間で有意差はなかった（いずれもP>0.05）。術後合併症はSPLT群の7例に認められた。そのうち1例は消化管出血、膵臓漏れ3例、胆汁漏れ2例で、いずれも術後1週間以内に発見され保存的治療で治癒したが、もう1例は腹膜感染を合併した吻合部瘻孔を発症し、腹腔鏡検査と腹膜スカベンジ、ドレナージを行い、34日後に退院した。従来群では術後に術後合併症を発症した6例は、吻合部出血1例、膵液漏出3例、カイロ漏出1例、腹膜感染症1例であった。術後合併症の罹患率は2群間で有意差はなかった［7.0%(7/100) vs. 11.5%(6/52)、χ=0.414、P=0.520］。2群50例を術後6ヶ月と12ヶ月に内視鏡検査を受けたが、明らかな吻合部狭窄や食道逆流は認められなかった。

RESULTS: There were 66 male and 34 female patients in the SPLT group with median age of 64 years. The clinicopathologic baseline data of two groups were comparable(all P>0.05). All the patients underwent operations successfully, and none was converted to open surgery. No positive margin was found in either group. Mean operation duration was (178.2±35.9) minute in SPLT group, including (22.9±7.1) minute of reconstruction, which both were significantly shorter than those in conventional group [(204.4±55.8) minute, P=0.003; (30.5±7.2) minute, P=0.000]. Less blood loss [(74.3±72.5) ml vs. (104.2±71.6) ml, P=0.017] and earlier time to the first flatus [(1.9±1.6) days vs. (2.7±1.3) days, P=0.001] were observed in SPLT group. There were no significant differences in postoperative hospital stay and pathological findings between the two groups(all P>0.05). Postoperative operation-associated complications were found in 7 cases of SPLT group. Of these 7 patients, 1 case developed gastrointestinal bleeding, 3 pancreatic leakage, 2 chyle leakage, who all were discovered within postoperative 1 week and were cured by conservative treatment, while the other 1 case developed anastomotic fistula complicated with peritoneal infection who received laparoscopic exploration and peritoneal scavenge and drainage, then discharged 34 days later. Six patients in conventional group developed postoperative operation-associated complications, including 1 case of anastomotic bleeding, 3 cases of pancreatic leakage, 1 case of chyle leakage and 1 case of peritoneal infection. Morbidity of postoperative operation-associated complication was not significantly different between two groups [7.0%(7/100) vs. 11.5%(6/52), χ=0.414, P=0.520]. Fifty patients from two groups underwent endoscopic examination at postoperative 6-month and 12-month, and no obvious anastomotic stenosis and esophageal reflux were observed.

結論:

SPLTは、体腔内食道結腸術での安全な術式であり、実現可能性があります。

CONCLUSION: SPLT is a safe procedure with feasibibility in intracorporeal esophagojejunostomy.