本文選題：腹腔鏡　切入點：胃癌　出處：《浙江大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：背景和目的 胃癌是最常見的消化道惡性腫瘤之一。目前,手術(shù)根治切除是治療胃癌的主要手段。傳統(tǒng)開腹手術(shù)切口大、疼痛明顯,并有切口感染甚至裂開等切口相關(guān)并發(fā)癥。腹腔鏡胃癌根治術(shù)具有切口小、術(shù)后疼痛輕、恢復(fù)快、住院時間短等優(yōu)點,二十多年來在全球范圍內(nèi)迅速發(fā)展。由于腹腔內(nèi)消化道重建技術(shù)要求高,尤其是腹腔鏡食管空腸吻合,因此目前多數(shù)腹腔鏡全胃切除術(shù)僅在腹腔鏡下完成淋巴結(jié)清掃,其消化道重建通過上腹部小切口進行,即腹腔鏡輔助全胃切除術(shù)(Laparoscopy assisted total gastrectomy, LATG)。如能在腹腔鏡下完成消化道重建,即完全腹腔鏡全胃切除術(shù)(Totally laparoscopic total gastrectomy, TLTG),則整個手術(shù)過程中視野更清,吻合過程張力小,微創(chuàng)優(yōu)勢更為明顯；標本裝袋后取出,切口位置可選,也更為美觀。 本中心于2007年完成首例全腹腔鏡全胃切除術(shù),并逐步探索嘗試多種腹腔鏡食管空腸吻合方法,目前已初步建立一套全腹腔鏡全胃切除術(shù)操作流程。本研究回顧性分析2007年10月至2015年3月在本中心行腹腔鏡全胃切除術(shù)患者的臨床資料,將TLTG與LATG進行對比,同時比較分析TLTG各種食管空腸吻合方法術(shù)中術(shù)后指標,總結(jié)TLTG I臨床經(jīng)驗。 對象與方法 1.研究對象 選取2007年10月至2015年3月期間于浙江大學(xué)醫(yī)學(xué)院附屬邵逸夫醫(yī)院行腹腔鏡全胃切除術(shù)的病例。同時排除以下情況之一患者：(1)全胃聯(lián)合其他臟器切除；(2)術(shù)前TNM分期Ⅳ期；(3)合并嚴重心肺腦疾�。�(4)術(shù)前行新輔助化療；(5)病灶累及食管下段；(6)中轉(zhuǎn)開腹；(7)手助腹腔鏡全胃切除術(shù)。 2.手術(shù)方式 根據(jù)日本胃癌指南,采用全胃切除+D2淋巴結(jié)清掃術(shù)。TLTG食管空腸Roux-en-Y吻合采用以下四種方法：(1)使用圓形吻合器食管空腸端側(cè)吻合(方法A)；(2)使用內(nèi)鏡直線切割閉合器食管空腸側(cè)側(cè)吻合(方法B)；(3)使用內(nèi)鏡直線切割閉合器食管空腸三角吻合(方法C)；(4)腹腔鏡直視手工縫合(方法D)。LATG采用經(jīng)小切口行食管空腸Roux-en-Y吻合。 3.分組 根據(jù)手術(shù)方法分為TLTG組和LATG組。TLTG組根據(jù)不同食管空腸吻合方法分為方法A、方法B、方法C、方法D四個亞組。 3.觀察指標 ①一般指標：性別、年齡、身高質(zhì)量指數(shù)(body mass index, BMI)、合并癥、既往腹部手術(shù)史及ASA分級； ②手術(shù)相關(guān)指標：手術(shù)時間、術(shù)中出血量、輸血情況等； ③腫瘤病理指標：腫瘤大小、分化程度、TNM分期、淋巴結(jié)清掃數(shù)目、近端切緣距離、切緣情況； ④術(shù)后恢復(fù)指標：術(shù)后肛門排氣時間、進流質(zhì)和半流質(zhì)時間、術(shù)后住院天數(shù)、圍手術(shù)期死亡、術(shù)后并發(fā)癥及其治療情況； ⑤隨訪資料：通過門診或電話隨訪而獲得,包括隨訪時間、復(fù)發(fā)轉(zhuǎn)移情況及死亡情況。 4.統(tǒng)計方法 計數(shù)資料用均數(shù)±標準差表示。所有統(tǒng)計分析均使用SPSS18.0完成。p0.05有統(tǒng)計學(xué)意義。 結(jié)果 1.一般情況 研究共納入TLTG,患者103名,其中男性67名,女性36名；平均年齡61.3±10.9歲,平均BMI22.4±3.3kg/m2,43名患者有合并癥。術(shù)前ASA評級I級53人,Ⅱ級45人,Ⅲ級5人。LATG患者125名,男性75名,女性50名；平均年齡59.7±10.5歲,平均BMI21.7±3.2kg/m2,37名患者有合并癥。術(shù)前ASA評級I級62人,Ⅱ級57人,Ⅲ級6人。兩組在年齡、BMI、術(shù)前合并癥、ASA評分等指標上無統(tǒng)計學(xué)差異。 2.患者術(shù)中情況及術(shù)后恢復(fù)情況 TLTG組患者平均手術(shù)時間276.3±51.1min,平均術(shù)中出血71.1±45.9m1,平均淋巴結(jié)清掃數(shù)目34.4±13.9。平均排氣時間3.7±1.0天,平均進食流質(zhì)時間4.3±1.8天,平均進食半流質(zhì)時間6.9±2.4天,平均住院時間10.1±4.1天。術(shù)后并發(fā)癥發(fā)生率13.6%。LATG組患者平均手術(shù)時間247.5±66.2min,平均術(shù)中出血147.1±84.9m1,平均淋巴結(jié)清掃數(shù)目35.1±13.2。平均排氣時間3.9±1.1天,平均進食流質(zhì)時間5.1±1.4天,平均進食半流質(zhì)時間7.9±4.0天,平均住院時間11.3±4.9天。術(shù)后并發(fā)癥發(fā)生率19.2%,兩組均無圍手術(shù)期死亡病例。 兩組之間淋巴結(jié)清掃數(shù)目、術(shù)后并發(fā)癥等指標差異無統(tǒng)計學(xué)意義,TLTG組手術(shù)時間更長,術(shù)中出血少,術(shù)后疼痛輕,術(shù)后恢復(fù)快。 3.TLTG四種食管空腸吻合方法資料 103例TLTG,患者中,行方法A患者18名,平均吻合時間57.5±18.5min,1例患者出現(xiàn)吻合口狹窄,1例患者出現(xiàn)吻合口漏；行方法B患者22名,平均吻合時間40.0±11.2min,2例患者出現(xiàn)吻合口狹窄,1例患者出現(xiàn)腹腔內(nèi)出血；行方法C患者10例,平均吻合時間39.0±3.9min；行方法D患者53例,平均吻合時間56.8±19.3min。 結(jié)論 完全腹腔鏡全胃切除術(shù)是安全可行的。完全腹腔鏡全胃切除術(shù)有出血少、創(chuàng)傷小、術(shù)后恢復(fù)快等優(yōu)點。腹腔內(nèi)食管空腸吻合各種方式各有其利弊。腹腔鏡直視手工縫合法是一種安全、經(jīng)濟、理想的方法。
[Abstract]:Background and purpose
Gastric cancer is one of the most common malignant tumor of digestive tract. At present, the radical resection is the main method for the treatment of gastric cancer. The traditional laparotomy incision, obvious pain, and wound infection and even split incision related complications. Laparoscopic radical resection of gastric cancer with a small incision, less postoperative pain, quicker recovery, shorter hospitalization time etc in more than 20 years, rapid development in the global scope. Due to intra-abdominal digestive reconstruction requirements high, especially with laparoscopic esophageal jejunum, so the majority of laparoscopic total gastrectomy in laparoscopic lymph node dissection, the reconstruction of the digestive tract through abdominal incision, laparoscopy assisted total gastrectomy (Laparoscopy assisted total gastrectomy, LATG). If the completion of digestive tract reconstruction in laparoscopic total laparoscopic total gastrectomy (Totally laparoscopic total gastrectomy, TLTG), the whole operation process is more clear, the tension of the anastomosis process is small and the minimally invasive advantage is more obvious; the specimen is taken out after bag loading, the position of the incision is optional, and it is more beautiful.
The center in 2007 to complete the first laparoscopic total gastrectomy, and gradually explore and try a variety of laparoscopic esophagojejunostomy method, has established a set of totally laparoscopic total gastrectomy procedure. This study retrospectively analyzed the clinical data from October 2007 to March 2015 in the center of laparoscopic total gastrectomy, compared TLTG with LATG, at the same time analysis of various TLTG esophagojejunostomy after index surgery, summarize the clinical experience of TLTG I.
Object and method
1. research objects
During the period from October 2007 to March 2015 in Sir Run Run Shaw Hospital affiliated to the Zhejiang University School of medicine cases underwent laparoscopic total gastrectomy. At the same time out of one of the following conditions: (1) patients with resection of the stomach and other organs; (2) preoperative TNM stage IV; (3) with severe cardiopulmonary cerebral disease; (4) preoperative neoadjuvant chemotherapy; (5) lesions in the lower esophagus (6); Laparotomy; (7) hand assisted laparoscopic total gastrectomy.
2. mode of operation
According to the Japanese gastric cancer guidelines, with total gastrectomy and +D2 lymph node dissection of.TLTG esophagus jejunum Roux-en-Y anastomosis using the following four methods: (1) using circular stapler jejunojejunostomy esophageal (A); (2) the use of endoscopic staplers esophageal jejunum side anastomosis (B); (3) the use of endoscopic staplers esophagojejunal anastomosis triangle (method C); (4) laparoscopic surgery manual suture (method D).LATG used by small incision for esophageal jejunal Roux-en-Y anastomosis.
3. grouping
According to the methods of operation, group TLTG and group LATG.TLTG were divided into A, B, C, and D four subgroups according to the different esophagus jejunostomy methods.
3. observation index
(1) general indicators: sex, age, height mass index (body mass index, BMI), complication, history of previous abdominal surgery and ASA classification;
Surgical related indexes: operation time, intraoperative bleeding, blood transfusion, etc.
Tumor pathological indexes: tumor size, degree of differentiation, TNM staging, number of lymph node dissection, near end margin distance and cutting edge condition;
Postoperative recovery indicators: postoperative anal exhaust time, fluid intake and semi fluid time, postoperative hospitalization days, perioperative mortality, postoperative complications and treatment.
Follow up data: follow up or telephone follow-up, including follow-up time, recurrence and death.
4. statistical methods
The count data were expressed as mean standard deviation. All statistical analyses were statistically significant with the use of SPSS18.0 to complete the.P0.05.
Result
1. general situation
The study included 103 patients with TLTG, 67 males, 36 females; mean age 61.3 + 10.9 years old, the average BMI22.4 + 3.3kg/m2,43 patients had complications. Preoperative ASA rating grade I 53, grade 45, grade 5 in 125.LATG patients, 75 males and 50 females name; average age 59.7 + 10.5 years old, the average BMI21.7 + 3.2kg/m2,37 patients had complications. Preoperative ASA rating grade I 62, grade 57, grade 6. The two groups in age, BMI, preoperative complications, there was no significant difference in ASA score index.
The intraoperative and postoperative recovery of 2. patients
TLTG group of patients with the average operation time was 276.3 51.1min, the average intraoperative bleeding was 71.1 + 45.9m1, the average number of lymph node dissection and 34.4 + 13.9. 3.7 + average exhaust time of 1 days, the average consumption of liquid time 4.3 + 1.8 days, the average semifluid diet time 6.9 + 2.4 days, the average hospitalization time was 10.1 + 4.1 days. The complication rate 13.6%.LATG group of patients with the average operation time was 247.5 + 66.2min after operation, the average bleeding was 147.1 84.9m1, the average number of lymph node dissection and 35.1 + 13.2. 3.9 + average exhaust time of 1.1 days, the average consumption of liquid time 5.1 + 1.4 days, the average semifluid diet time 7.9 + 4 days, the average hospitalization time was 11.3 + 4.9 days. The rate of postoperative complications in 19.2%, the two groups had no perioperative deaths.
There was no significant difference in the number of lymph node dissection and postoperative complications between the two groups. TLTG group had longer operation time, less intraoperative bleeding, less postoperative pain and faster postoperative recovery.
3.TLTG four kinds of esophagus jejunostomy data
103 cases of TLTG patients, 18 patients underwent A, average anastomosis time was 57.5 + 18.5min, 1 cases with anastomotic stenosis, 1 cases of patients with anastomotic leakage; patients with method of B 22, the average anastomosis time was 40 + 11.2min, 2 cases with anastomotic stenosis, 1 cases of patients with the intraperitoneal hemorrhage; 10 cases of patients with C method, the average anastomosis time was 39 + 3.9min; 53 patients were treated with D method, the average time was 56.8 + 19.3min..
conclusion
Totally laparoscopic total gastrectomy is safe and feasible. Totally laparoscopic total gastrectomy with less bleeding, less trauma, quick recovery after operation. Intraperitoneal esophagojejunostomy in various ways have their own advantages and disadvantages. Laparoscopy manual suture is a safe, economical and ideal method.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R735.2

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本文編號：1634786