完全腹腔镜与腹腔镜辅助全胃切除后食管-空肠圆形吻合短期疗效的倾向性评分匹配研究（附视频）

Short-term outcomes of circular-stapled esophagojejunostomy after totally laparoscopic versus laparoscopy-assisted total gastrectomy: a propensity score-matched study (with video)

摘要:

背景与目的 食管胃结合部腺癌（AEG）发病率近年来持续升高，腹腔镜全胃切除术已成为其重要治疗方式。圆形吻合器食管-空肠吻合有助于保证高位肿瘤的近端切缘安全，但在完全腹腔镜下实施仍存在操作难度。目前，关于完全腹腔镜全胃切除术（TLTG）与腹腔镜辅助全胃切除术（LATG）后圆形食管-空肠吻合临床疗效的比较研究尚少。本研究采用倾向性评分匹配（PSM）方法，比较两种术式的围手术期安全性及短期临床结局。方法 回顾性收集2023年1月—2025年6月江苏省盐城市第一人民医院及陕西省汉中市中心医院接受腹腔镜全胃切除并行Roux-en-Y食管-空肠圆形吻合的AEG患者临床资料。根据手术方式分为TLTG组与LATG组。比较两组基线特征、手术指标、术后恢复情况及并发症发生情况，并采用1∶2 PSM平衡混杂因素后进行围手术期结局分析。结果 共纳入患者436例，其中TLTG组98例，LATG组338例。PSM后纳入TLTG组80例、LATG组160例，两组基线资料均衡。TLTG组手术时间及吻合时间长于LATG组（均P<0.001），但术中出血量、清扫淋巴结数及住院费用差异均无统计学意义（均P>0.05）。与LATG组相比，TLTG组术后24 h疼痛评分更低，首次排气时间及术后住院时间均明显缩短（均P<0.001）。两组总体并发症发生率及Clavien-Dindo并发症分级Ⅰ~Ⅲ级并发症发生率差异均无统计学意义（均P>0.05），且均未发生Ⅳ级并发症及围手术期死亡。结论 TLTG后食管-空肠圆形吻合在围手术期安全性方面不逊于LATG，且在减轻术后疼痛、促进胃肠功能恢复及缩短住院时间方面具有明显优势。借助腹腔镜荷包缝合钳及多功能密封盖技术，完全腹腔镜下圆形吻合能够安全、稳定地完成消化道重建，尤其适用于需保证足够食管切缘的Siewert Ⅱ型AEG患者。

Abstract:

Background and Aims The incidence of adenocarcinoma of the esophagogastric junction (AEG) has increased steadily in recent years, and laparoscopic total gastrectomy has become an important treatment option. Circular-stapled esophagojejunostomy may provide better proximal margin control for high tumors, but remains technically challenging under a totally laparoscopic approach. Comparative evidence between totally laparoscopic total gastrectomy (TLTG) and laparoscopy-assisted total gastrectomy (LATG) using circular-stapled esophagojejunostomy is still limited. This study aimed to compare the perioperative safety and short-term outcomes of these two procedures using propensity score matching (PSM).Methods Clinical data of patients with AEG who underwent laparoscopic total gastrectomy with Roux-en-Y circular-stapled esophagojejunostomy at Yancheng First People's Hospital and Hanzhong Central Hospital between January 2023 and June 2025 were retrospectively analyzed. Patients were divided into the TLTG group and LATG group according to surgical approach. Baseline characteristics, operative outcomes, postoperative recovery, and complications were compared. A 1∶2 PSM analysis was performed to minimize baseline bias.Results A total of 436 patients were enrolled, including 98 in the TLTG group and 338 in the LATG group. After PSM, 80 patients in the TLTG group and 160 patients in the LATG group were successfully matched with balanced baseline characteristics. Operative time and anastomosis time were significantly longer in the TLTG group (both P<0.001). However, intraoperative blood loss, number of retrieved lymph nodes, and hospitalization cost were comparable between the two groups (all P>0.05). Compared with the LATG group, the TLTG group showed lower postoperative 24-h pain scores, earlier first flatus, and shorter postoperative hospital stay (all P<0.001). No significant differences were observed in overall postoperative complications or Clavien-Dindo grade Ⅰ-Ⅲ complications between groups (all P>0.05). No grade Ⅳ complications or perioperative deaths occurred.Conclusion Circular-stapled esophagojejunostomy after TLTG is as safe as that after LATG in the perioperative setting and offers significant advantages in postoperative pain relief, gastrointestinal recovery, and hospital stay reduction. With the assistance of laparoscopic purse-string devices and multifunctional sealing caps, intracorporeal circular anastomosis can be performed safely and reliably, particularly in patients with Siewert type Ⅱ tumors requiring adequate proximal esophageal margins.