胃癌に対する遠位胃切除術における術後短期合併症と内視鏡検査のBillroth I再建とBillroth II再建の比較

[Comparison of postoperative short-term complications and endoscopy scan in distal gastrectomy for gastric cancer between Billroth I and Billroth II reconstruction].

• Nan Zhang
• Kai Xu
• Xiangqian Su

抄録

目的:

胃癌に対する遠位胃切除術におけるBillroth I再建とBillroth II再建の安全性と短期的な内視鏡所見を比較する。

OBJECTIVE: To compare the safety of Billroth I and Billroth II reconstruction in distal gastrectomy for gastric cancer and short-term endoscopic findings.

方法:

レトロスペクティブコホート研究を実施した。2013 年 1 月から 2017 年 7 月までに北京大学がん病院消化器外科第 4 部でビルロス I またはビルロス II 再構築を伴う遠位下総胃切除術を受けた胃腺がん患者の臨床データをレトロスペクティブに収集した。ステージIV胃癌、緊急手術、術前化学療法、複合臓器切除術、その他の悪性腫瘍を有する患者は除外した。合計277例が登録され、Billroth I群143例、Billroth II群134例が登録された。術中の状態、術後早期回復、術後合併症、術後1年の内視鏡所見を両群間で比較した。正規分布変数はt検定で分析し、非正規分布変数はMann-Whitney U検定で分析し、ソート変数はχ²検定またはFisher's exact検定を用いて群間で比較した。

METHODS: A retrospective cohort study was carried out. Clinical data of gastric adenocarcinoma patients who received distal subtotal gastrectomy with Billroth I or Billroth II reconstruction at Department 4 of Gastrointestinal Surgery, Peking University Cancer Hospital from January 2013 to July 2017 were collected retrospectively. Patients with stage IV gastric cancer, emergent operation, preoperative chemotherapy, combined organ resection and other malignancies were excluded. A total of 277 patients were enrolled in the study with 143 patients in the Billroth I group and 134 patients in the Billroth II group. The intra-operative conditions, postoperative early recovery, postoperative complications, and postoperative 1-year endoscopic findings were compared between the two groups. The normal distribution variables were analyzed by t test; the non-normal distribution variables were analyzed by Mann-Whitney U test; sort variables were compared between groups using the χ² test or Fisher's exact test.

結果:

Billroth I群では、93例（65.0%）が男性で、平均年齢は58.1±10.9歳、体格指数は(23.3±3.2)kg/mであった。BillrothⅡ群では、94例（70.1％）が男性で、平均年齢は（58.3±9.5）歳、体格指数は（23.7±2.9）kg/mであった。ベースラインデータは両群間に有意差はなかった（いずれもP>0.05）。Billroth I群と比較して、Billroth II群は手術時間が有意に長く［平均(230.7±44.6)分 vs. (210.3±41.4)分、t=3.935、P<0.001］、初回ダイエットまでの時間が有意に短く（中央値7.0日 vs. 8.0日）、初回ダイエットまでの時間が有意に短かった（中央値7.0日 vs. 8.0日）。0 vs. 8.0日、Z=3.376、P=0.001）、初回の腹部ドレナージチューブ抜去までの期間（中央値8.0 vs. 8.0日、Z=2.176、P=0.030）、術後の入院期間（中央値9.0 vs. 10.0日、Z=3.616、P<0.001）が有意に短くなった。腹腔鏡下手術の割合、術中出血、摘出リンパ節数、初回フラタス時間には2群間に有意差はなかった（いずれもP>0.05）。Billroth I群では、吻合部出血1例、吻合部漏出3例、空洞化障害4例、腹腔内感染4例が発症し、いずれも保存的治療で治癒した。Billroth II群では、吻合出血1例、腹腔内出血1例、空腸障害3例、腹腔内感染3例で、いずれも保存的治療後に治癒したが、術後十二指腸切片漏出1例で再手術を行った。術後合併症の罹患率は、Billroth I群で8.4％（12/143例）、Billroth II群で6.7％（9/134例）であった（χ²=0.277、P=0.599）が、統計学的に有意差はなかった。術後1年間の内視鏡検査は、Billroth I群78例、Billroth II群57例で実施した。内視鏡所見では、食物滞留率［21.8％（17/78）対33.3％（19/57）、χ²=2.242、P=0.134］、残存胃炎率［48.7％（38/78）対47．4% (27/57)、χ²=0.024、P=0.877]、胆汁逆流の発生率[12.8% (10/78) vs. 10.5% (6/57)、χ²=0.166、P=0.684]は2群間で有意差はありませんでした。

RESULTS: In the Billroth I group, 93 (65.0%) cases were male, mean age was (58.1±10.9) years and body mass index was (23.3±3.2) kg/m. In the Billroth II group, 94 (70.1%) cases were male, mean age was (58.3±9.5) years and body mass index was (23.7±2.9) kg/m. There were no significant differences in baseline data between in the two groups (all P>0.05). As compared to the Billroth I group, the Billroth II group had significantly longer operation time [mean (230.7±44.6) minutes vs. (210.3±41.4) minutes, t=3.935, P<0.001], significantly shorter time to first diet (median 7.0 vs. 8.0 days, Z=3.376, P=0.001), to first abdominal drainage tube removing (median 8.0 vs. 8.0 days, Z=2.176, P=0.030) and significantly shorter postoperative hospital stay (median 9.0 vs. 10.0 days, Z=3.616, P<0.001). There were no significant differences between two groups in proportion of laparoscopic surgery, intra-operative blood loss, number of harvested lymph nodes and the first flatus time (all P>0.05). In the Billroth I group, 1 case developed anastomotic bleeding, 3 cases anastomotic leakage, 4 cases emptying disorder, 4 cases peritoneal cavity infection, and all of them healed after conservative treatment. In the Billroth II group, 1 case developed anastomotic bleeding, 1 case peritoneal cavity bleeding, 3 cases emptying disorder, 3 cases peritoneal cavity infection, and all of them healed after conservative treatment, while 1 case developed postoperative duodenal stump leakage and underwent a second operation. Morbidity of postoperative complication was 8.4% (12/143) and 6.7% (9/134) in the Billroth I group and Billroth II group respectively (χ²=0.277, P=0.599) without statistically significant difference. Postoperative one-year endoscopy was performed in 78 cases of the Billroth I group and 57 cases of the Billroth II group. Endoscopic findings revealed that ratio of food retention [21.8% (17/78) vs. 33.3% (19/57), χ²= 2.242, P=0.134], ratio of residual gastritis [48.7% (38/78) vs. 47.4% (27/57), χ²=0.024, P=0.877] and incidence of bile reflux [12.8% (10/78) vs. 10.5% (6/57), χ²=0.166, P=0.684] were not significantly different between two groups.

結論:

遠位胃切除術では、Billroth I再建の方が手術が容易であり、Billroth II再建では消化管機能の回復が早く、入院期間が短い。両群間の術後合併症の罹患率と短期内視鏡所見は同等である。

CONCLUSIONS: For distal gastrectomy, Billroth I reconstruction is easier to operate, while Billroth II reconstruction presents faster recovery of gastrointestinal function and shorter hospital stay. The morbidity of postoperative complication and short-term endoscopic findings between two groups are comparable.