背景:近年来,食管-胃结合部腺癌(AEJ)的发病率一直在增加。近端胃切除术(PG-EG)后的食管胃造口术是该疾病最常用的手术方法,该方法通过切断食道周围的迷走神经而导致幽门括约肌持续痉挛,因此,H-M型幽门成形术(Heineke-Mikulicz幽门成形术)通常在PG-EG后进行,以防止胃排空延迟。然而,H-M幽门成形术破坏了幽门的抗反流结构,并导致严重的胆汁反流。本研究旨在通过临床研究和动物实验比较近端胃大部切除术中的幽门肌切开术和H-M幽门成形术。
方法:我们回顾性评估了2016年1月至2020年8月期间73例AEJ患者(39例接受PG-EG伴H-M幽门成形术,34例接受PG-EG伴幽门切开术)的结局,并比较围手术期变量。在动物实验中,48只大鼠随机分为四组(n=12):迷走神经切断术组(V组),H-M幽门成形术组(HM组),幽门肌切开术组(PM组),对照组(O组)。各组进行胃排空和胆汁反流评价。
结果:在回顾性临床研究中,幽门肌切开术和H-M幽门成形术均能有效预防胃排空障碍,PM组电子胃镜发现胆汁反流的发生率明显低于HM组(HM,14/39;下午,4/34;P=0.028)。在动物实验中,HM组与PM组的胃排空率(%)无显著组间差异(HM,70.6±16;PM,72.3±12;P=0.68),而V组的胃排空率(%)显着低于HM,PM,和对照组(P值分别为0.037、0.021和0.001)。HM组胃粘膜胆汁酸浓度明显高于其他组(P值均小于0.001)。
结论:与Heineke-Mikulicz幽门成形术相比,对于II型和III型AEJ,幽门切开术可以有效预防PG-EG后胃排空延迟,并减少胆汁反流。
The incidence of adenocarcinoma of esophageal-gastric junction (AEJ) has been increasing in recent years. Esophagogastrostomy after proximal gastrectomy (PG-EG) is the most commonly used surgical method for this disease which causes a constant spasm of the pyloric sphincter by cutting the vagus nerve around the esophagus, so H-M pyloroplasty (Heineke-Mikulicz pyloroplasty) is often operated after PG-EG to prevent delayed gastric emptying. However, H-M pyloroplasty destroys anti-reflux structure of pylorus and leads to serious bile reflux. The present study was designed to compare
pyloromyotomy and H-M pyloroplasty in proximal subtotal gastrectomy through clinical studies and animal experiments.
We retrospectively evaluated the outcomes of 73 AEJ patients (39 underwent PG-EG with an H-M pyloroplasty and 34 underwent PG-EG with a
pyloromyotomy) between January 2016 and August 2020, and perioperative variables were compared. In the animal experiment, 48 rats were randomly divided into four groups (n = 12): vagotomy group (V group), H-M pyloroplasty group (HM group),
pyloromyotomy group (PM group), and control group (O group). Gastric emptying and bile reflux were evaluated in each group.
In the retrospective clinic study,
pyloromyotomy and H-M pyloroplasty could all prevent delayed gastric emptying effectively, and the incidence of bile reflux found by electronic gastroscopy in the PM group was significantly lower than that in the HM group (HM, 14/39; PM, 4/34; P = 0.028). In the animal experiment, there was no significant between-group difference of gastric emptying rate (%) in the HM group and PM group (HM, 70.6 ± 16; PM, 72.3 ± 12; P = 0.68) while the gastric emptying rate (%) was significantly lower in the V group than in the HM, PM, and control group (P values were 0.037, 0.021, and 0.001 respectively). The gastric mucosa bile acid concentration was significantly higher in the HM group than other group (P values were all less than 0.001).
The
pyloromyotomy could prevent delayed gastric emptying effectively after PG-EG for types II and III AEJ and reduce bile reflux compared to Heineke-Mikulicz pyloroplasty.