线型联合手工缝合关闭overlap吻合共同开口在全腹腔镜全胃切除术中的应用价值

Clinical value of linear stapler combined with hand-sewn closure of the common entry site in overlap esophagojejunostomy during totally laparoscopic total gastrectomy

摘要:

背景与目的 腹腔镜下食管空肠吻合是全腹腔镜全胃切除术（TLTG）的关键技术环节和操作难点，其吻合方式直接影响术后并发症发生率及患者生活质量。传统overlap吻合共同开口关闭方式在防止食管残端回缩及吻合口狭窄方面仍存在一定局限。本研究基于自牵引后离断（SPLT）技术，探讨采用线型+手工（L+H）方式关闭overlap吻合共同开口在TLTG中的安全性、可行性及其对术后生活质量的影响。方法 回顾性分析2024年5月1日—2025年6月1日江苏省扬中市人民医院胃肠外科行TLTG+D₂淋巴结清扫的胃癌患者61例，根据overlap吻合共同开口关闭方式不同分为L+H关闭组（n=43）和传统关闭组（n=18）。比较两组患者术前临床及病理特征、术中相关指标、术后恢复情况、并发症发生率、消化道造影吻合口长径及术后3个月胃癌特异性生活质量量表（QLQ-STO22）评分。结果 两组患者在年龄、性别、基础疾病、美国麻醉医师协会分级、Siewert分型及病理分期等基线临床及病理特征方面差异均无统计学意义（均P>0.05）。两组手术均顺利完成，均获得R₀切除且无中转开腹。L+H关闭组与传统关闭组在总手术时间、食管空肠吻合时间、术中出血量、淋巴结清扫数目、流质饮食开放时间及术后住院时间方面差异均无统计学意义（均P>0.05），术后并发症发生率差异亦无统计学意义（均P>0.05）。与传统关闭组相比，L+H关闭组消化道造影显示吻合口长径更大［（32.2±7.23）mm vs.（28.4±6.34）mm，P<0.05］。术后3个月随访中，L+H关闭组在QLQ-STO22量表的吞咽困难、反流、饮食受限维度评分及总评分均明显低于传统关闭组（均P<0.05）。结论 在SPLT-TLTG中，采用L+H方式关闭overlap吻合共同开口在不增加手术难度和围手术期并发症发生风险的前提下，可有效扩大吻合口长径，减轻术后吞咽困难、反流及饮食受限症状，显著改善患者术后生活质量，是一种安全、可行且具有推广价值的改良吻合技术。

Abstract:

Background and Aim Esophagojejunostomy is a critical and technically challenging step in totally laparoscopic total gastrectomy (TLTG), and the method used for closure of the overlap anastomotic common opening has a direct impact on postoperative complications and quality of life. Conventional closure techniques may be associated with difficulties in preventing esophageal stump retraction and anastomotic stenosis. Based on the self-pulling and latter transection (SPLT) technique, this study aimed to evaluate the safety, feasibility, and effect on postoperative quality of life of a lineal stapler plus hand sewn (L+H) method for closing the overlap anastomotic common opening in TLTG.Methods A retrospective analysis was performed on 61 patients with gastric cancer who underwent TLTG with D2 lymphadenectomy between May 1, 2024, and June 1, 2025. According to the closure method of the overlap anastomotic common opening, patients were divided into the L+H closure group (n=43) and the conventional closure group (n=18). Preoperative clinicopathologic characteristics, intraoperative variables, postoperative recovery, complication rates, anastomotic diameter measured by contrast study, and postoperative 3-month quality of life assessed using the QLQ-STO22 scale were compared between the two groups.Results There were no significant differences between the two groups in baseline clinicopathologic characteristics, including age, sex, comorbidities, American Society of Anesthesiologists classification, Siewert type, and pathological stage (all P>0.05). All procedures were successfully completed with R₀ resection and without conversion to open surgery. No significant differences were observed between the L+H closure group and the conventional closure group in total operative time, esophagojejunostomy time, intraoperative blood loss, number of harvested lymph nodes, time to liquid diet, postoperative hospital stay, or incidence of postoperative complications (all P>0.05). Compared with the conventional closure group, the L+H closure group demonstrated a significantly larger anastomotic longitudinal diameter on postoperative contrast imaging [(32.2±7.23) mm vs. (28.4±6.34) mm, P<0.05]. At 3 months after surgery, patients in the L+H closure group showed significantly lower (better) scores for dysphagia, reflux, eating restrictions, and total QLQ-STO22 score (all P<0.05).Conclusion In SPLT-based TLTG, closure of the overlap anastomotic common opening using the L+H technique effectively enlarges the anastomotic diameter and alleviates postoperative functional symptoms without compromising surgical safety or efficiency, thereby improving postoperative quality of life. This technique is safe, feasible, and worthy of wider clinical application.