胃底黏膜下肿瘤的腹腔镜手术治疗

摘要

目的: 腹腔镜切除胃底黏膜下肿瘤, 尤其当其位于胃底后壁、靠近食管贲门连接处(the esophagocardiac junction, ECJ)时, 既困难又费时, 稍不慎还会引起食管狭窄以及脾脏损伤. 为此, 我们采用腹腔镜局部胃楔形切除术来治疗胃底前壁和大弯侧的黏膜下肿瘤; 并设计了腹腔镜胃腔外胃底切除术(laparoscopically extraluminal resection of the gastric fundus)来治疗胃底后壁靠近ECJ的黏膜下肿瘤.

方法: 总结分析32例患者的临床资料. 男性23例, 女性9例; 平均年龄55(36-78岁). 其中, 胃底前壁黏膜下肿瘤11例, 胃底大弯侧黏膜下肿瘤6例, 分别行腹腔镜局部胃楔形切除术; 胃底后壁黏膜下肿瘤15例, 行腹腔镜胃腔外胃底切除术.

结果: 腹腔镜手术平均用时(56.3±19.4 min); 术中平均出血(53.1±30.1 mL); 术后平均住院(4.7±0.5 d). 78.1%患者于术后36 h内恢复胃肠功能, 并开始进食和下床活动. 病理类型包括: 低度恶性间质瘤3例、平滑肌瘤21例、间质瘤7例以及神经纤维瘤1例. 本组手术均获成功, 无病灶遗漏, 也无并发症和手术中转.

结论: 我们采用的方法, 包括所设计的腹腔镜胃腔外胃底切除术完全可以做到避免腹腔污染、脾脏损伤以及食管狭窄的发生; 同时, 胃切除范围也不受限. 因此, 手术安全、有效.

关键词: N/A

Laparoscopic resection of submucosal tumor in gastric fundus

Zhong-Wei Ke, Cheng-Zhu Zheng, Xiao-Ping Zou, Kai Yin, Ji-Hui Li, Ming-Gen Hu, Dan-Lei Chen

Zhong-Wei Ke, Cheng-Zhu Zheng, Kai Yin, Ji-Hui Li, Ming-Gen Hu, Dan-Lei Chen, Department of Minimally Invasive Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China

Xiao-Ping Zou, Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China

Correspondence to: Dr. Zhong-Wei Ke, Department of Minimally Invasive Surgery, Changhai Hospital, Second Military Medical University, 174 Changhai Road, Shanghai 200433, China. weiz@miscenter.cn

Received: February 3, 2004
Revised: February 13, 2004
Accepted: February 21, 2004
Published online: May 15, 2004

Abstract

AIM: Laparoscopic resection of the submucosal tumors on the gastric fundus, especially when they are on the posterior wall and next to the esophagocardiac junction (ECJ), is both difficult and time-consuming. Furthermore, it can lead to the inadvertent esophagus stenosis and injury to spleen. In order to solve these problems, wedge gastrectomy was adopted for the submucosal tumor on the anterior wall and the greater curvature of the gastric fundus, and laparoscopically extraluminal resection of the gastric fundus was designed for the submucosal tumor on the posterior wall of the gastric fundus and next to ECJ.

METHODS: Retrospective analysis was made in 32 cases, including 23 male and 9 female with an average age of 55 (range 36-78). Laparoscopic wedge gastrectomy had been carried out in 11 cases of submucosal tumor on the anterior wall of the gastric fundus and 6 on the greater gastric curvature. And laparoscopically extraluminal resection of the gastric fundus had been carried out on 15 cases on the posterior wall.

RESULTS: The mean operative time and intra-operative bleeding and postoperative hospital stay were (56.3±19.4 min), (53.1±30.1 mL), (4.7±0.5 d) respectively. Within 36 hours post-operation, 78.1% of all the patients resumed their gastrointestinal function and began to eat something and ambulated. The pathological diagnosis included mesen-chymoma of low malignancy (3 cases), leiomyoma (21 cases), mesenchymoma (7 cases), and neurofibroma (1 case). All the procedures were completed successfully with no apparent tumor focus left and no complication or conversion to open surgery happened.

CONCLUSION: The adopted and newly designed procedure can avoid the abdominal cavity contamination, the injury to spleen and the esophageal stenosis. And there is no limit to the range of gastric resection. Therefore, the procedure is both safe and effective.

Key Words: N/A

0 引言

虽然胃恶性肿瘤治疗仍然被认为是腹腔镜禁忌证之一, 然而, 用腹腔镜代替剖腹手术来切除胃良性肿瘤已逐渐被认为是一种可行的术式[1-6]. 当肿瘤位于胃底, 尤其是位于后壁、靠近食管贲门连接处(the esophagocardiac junction, ECJ)时, 腹腔镜手术切除既困难又费时, 稍不慎还会引起食管狭窄以及脾脏损伤. 此外, 虽然大多数胃黏膜下肿瘤是平滑肌瘤, 但仍需广泛切除, 因为仅凭活检难以与平滑肌肉瘤相鉴别. 因此, 在行腹腔镜胃黏膜下肿瘤切除时, 必须切除足够范围的周围正常组织[7-18]. 为此, 我们采用胃楔形切除术来治疗胃底前壁和大弯侧的黏膜下肿瘤; 并设计了腹腔镜胃腔外胃底切除术(laparoscopically extraluminal resection of the gastric fundus)来治疗胃底后壁近ECJ的黏膜下肿瘤, 收效良好.

1 材料和方法

1.1 材料

2000-09/2003-09采用腹腔镜治疗胃底黏膜下肿瘤32例. 男23例, 女9例; 平均年龄55(36-78岁). 其中, 胃底前壁黏膜下肿瘤11例; 胃底大弯侧黏膜下肿瘤6例; 胃底后壁黏膜下肿瘤15例. 23例(71.9%)患者以上消化道出血就治; 8例(25.0%)以腹痛就治; 1例(3.1%)体检发现. 术前检查包括胃镜、超声胃镜和上消化道钡餐. 所有检查均提示胃底黏膜下肿瘤, 边缘整齐; 黏膜下注射生理盐水不能将肿瘤完全提起, 故不适合行胃镜局部肿瘤切除术; 另外, 胃镜发现25例肿瘤表面中央有溃疡存在; 肿瘤直径2.5-6.5(平均4.1 cm). 图1显示的是1例胃底后壁近ECJ的黏膜下肿瘤的术前检查结果.

图1 胃底后壁近ECJ的黏膜下肿瘤. A: 钡餐显示病灶临近ECJ, 边缘整齐; B: 超声胃镜显示病灶边缘整齐, 向腔内突出; C: 胃镜显示胃底后壁半球状隆起, 中央有溃疡形成.

1.2 方法

1.2.1 腹腔镜胃底前壁楔形切除术: 采用气管内插管全麻. 患者取仰卧位、两腿分别外展30°. 术者站在患者两腿之间, 持镜者和手术助手分别站在患者右侧和左侧. 5及10-12 mm穿刺套管分别放在脐部; 左、右锁骨中线和剑突下(图2). 其中, A孔为观察孔; B、C为操作孔, 内视镜切割吻合器(Endo GIA)通过C孔置入腹腔; D孔放置三抓钳, 拨肝脏、显露胃底肿瘤. 腔镜下病灶定位的方法有3种: 肉眼检查、器械探查和术中胃镜检查[19]. 胃前壁肿瘤的定位相对容易, 本组通过肉眼观察和器械探查均可完成定位. 一旦发现肿瘤, 通常"8"字缝合瘤体中央, 将肿瘤牵起以利操作. 然后用Endo GIA行胃底前壁楔形切除术(图3).

图2 胃底黏膜下肿瘤腹腔镜手术治疗的穿刺孔位置.

图3 用Endo GIA行胃底前壁楔形切除术.

1.2.2 腹腔镜胃底大弯侧楔形切除术: 本组有1例胃底大弯侧黏膜下肿瘤通过术中胃镜辅助、余5例通过肉眼观察和器械探查完成定位. 分离脾胃韧带: 用超声刀凝固、切割肿瘤所在部位及其附近的胃短动、静脉, 目的是将肿瘤及其周围正常胃壁游离, 以利肿瘤牵引和Endo GIA放置. 肿瘤游离后, 用丝线"8"字缝合瘤体中央, 将肿瘤向前壁方向牵引. 然后用Endo GIA行局部胃楔形切除术.

1.2.3 腹腔镜胃腔外胃底切除术: 行腹腔镜胃腔外胃底切除术治疗胃底后壁肿瘤时, Endo GIA通常从B孔置入腹腔. 后壁肿瘤的定位相对困难, 通常需要胃镜辅助和/或器械探查. 本组有4例(26.7%)需术中胃镜辅助完成定位. 在行腹腔镜胃底后壁黏膜下肿瘤切除时, 肿瘤定位的内容除确定肿瘤位置外, 还需进一步明确其与ECJ之间的距离. 从脾脏中下极开始, 在网膜血管弓外分离胃大弯侧网膜. 进入网膜囊后, 用三抓钳将胃后壁向右侧翻转. 继续向上分离, 用超声刀凝固、切割胃短动、静脉, 直至脾上极, 将胃底和脾上极完全分开(图4). 游离贲门左侧, 显露ECJ(图5). 用Endo GIA行胃底切除术: 图6A显示的是Endo GIA切割线, 视肿瘤大小通常需用Endo GIA 2-3次. 靠近贲门左侧放置Endo GIA时, 必须仔细检查、确定ECJ不在其中, 以免引起术后食管狭窄(图6B). 肿瘤切除后, 标本置入标本袋后从B孔取出, 常规送快速病理检查. 同时, 术后常规冲洗术野, 于左膈下放置腹腔引流管.

图4 用超声刀将胃底和脾上极完全分离.

图5 游离贲门左侧, 显露ECJ.

图6 用Endo GIA行胃底切除术. A: 蓝线表示Endo GIA切割线; B: Endo GIA放置后, 检查、确定ECJ不在其中.

2 结果

本组腹腔镜手术用时、术中出血、术后住院天数以及术后1 d腹腔引流量见表1. 78.1%患者于术后36 h内恢复胃肠功能, 并开始进食和下床活动; 最慢1例术后60 h恢复. 胃底前壁和胃底大弯侧黏膜下肿瘤的手术切缘距离肿瘤的边距均大于2.5 cm. 图7显示的是胃底后壁黏膜下肿瘤手术切除的标本, 切缘距肿瘤的距离: 与ECJ距离1-1.5(平均1.10.3 cm); 与另三面距离2.5-6(平均3.9 1.2 cm). 本组所有患者术中冰冻切片检查均提示为良性病变. 术后石蜡切片检查发现3例为低度恶性间质瘤: 1例位于胃底前壁; 2例位于胃底后壁: 切缘与ECJ距离分别为1.3 cm和1.5 cm, 另三面距离均大于3 cm; 这3例患者均未再行扩大切除手术; 已分别随访18-28 mo. 另29中平滑肌瘤21例, 间质瘤7例, 神经纤维瘤1例.32例腹腔镜手术均获成功, 无病灶遗漏, 也无并发症和手术中转. 所有病例随访至今3-39 mo, 无异常发现.

表1 胃底黏膜下肿瘤腹腔镜手术情况(mean±SD).

肿瘤位置	n	手术时间(min)	术中出血(mL)	术后1 d引流量(mL)	术后住院(d)
胃底前壁	11	42.7±8.2	14.1±5.4	16.8±7.0	4.7±0.8
胃底大弯侧	6	55.0±7.1	50.8±14.3	32.5±10.8	4.8±0.8
胃底后壁	15	66.2±10.4	89.4±21.7	60.7±14.3	5.3±1.1
合计	32	56.3±19.4	53.1±30.1	40.9±15.3	4.7±0.5

图7 胃底后壁黏膜下肿瘤的手术切除标本. a线表示肿瘤距ECJ的距离.

3 讨论

由于胃良性肿瘤在临床上不能完全排除恶性的可能, 即使为良性以后也可能恶变, 而且可以出现梗阻和出血等严重并发症, 所以, 应积极地予以手术切除治疗. 就胃壁切除深度而言, 近年来也更倾向行全层胃壁切除术[20-25]. 胃镜可以通过黏膜下注射生理盐水的方法切除部分胃肿瘤, 但主要用于黏膜层肿瘤, 而不适用于黏膜下肿瘤, 更无法做到切除全层胃壁. 相对于胃窦和胃体部而言, 胃底部的腹腔镜手术面临更多挑战. 目前, 国内已有不少医院能在腹腔镜下或腹腔镜辅助下完成胃切除术、结直肠切除术以及局部小肠切除术等. 但是, 客观上讲, 有些仅是开头或是尝试性质的. 尽管前景良好, 但仍需不断改进, 包括术式和器械的改进等. 同时, 也需要进一步分析统计和判断手术效果[26-29].胃底、贲门部的黏膜下肿瘤可以采用腹腔镜近端胃切除术治疗, 但术后易并发反流性食管炎. 而且, 对大多数良性胃黏膜下肿瘤来说, 手术损伤和切除范围也过大[30-34]. 腹腔镜胃楔形切除术是治疗胃底黏膜下肿瘤最常用的术式[34-37]. 当肿瘤位于胃底前壁时, 通过应用Endo GIA很容易完成[20]. 当肿瘤位于胃底大弯侧时, 我们通过以下操作即可将侧壁肿瘤"改为"前壁肿瘤, 然后按前壁肿瘤的方法予以切除: (1)分离肿瘤及其周围的血管和韧带; (2)用丝线缝合瘤体中央; (3)将肿瘤向前壁方向牵引. 总之, 位于前壁和大弯侧的胃底黏膜下肿瘤的腹腔镜手术切除并不非常困难.但是, 位于胃底后壁的黏膜下肿瘤, 尤其当肿瘤临近ECJ时, 楔形切除并不容易完成: 手术一方面要注意保护ECJ, 以免引起术后食管狭窄; 另一方面又要注意避免脾脏, 尤其是脾上极的损伤.

在早期, 我们曾采用胃前壁开窗的方法来楔形切除胃底后壁的黏膜下肿瘤[38]. 虽然方法简便, 但术中胃液污染腹腔的情况严重. 另外, 由于不能很好显露ECJ, 因此该方法也不适用于切除近ECJ的胃底后壁肿瘤. Sekimoto et al[20]采用胃腔内全层胃后壁病灶切除(intraluminal resection the full thickness of the posterior gastric wall lesion)的方法来治疗胃底后壁近ECJ的黏膜下肿瘤, 即: 将带气囊trocar直接穿刺进入胃腔, 并在胃腔内充气, 然后在直视下用Endo GIA完成后壁肿瘤局部楔形切除. Sekimoto et al认为: 手术损伤以及腹腔污染均较胃前壁开窗法小; 而且, 由于ECJ一直处于术者的视野之中, 因此损伤引起术后食管狭窄的可能性极小. 但是, 我们认为由于胃短血管未离断, 尤其是脾上极与胃底未完全分离, 上述二种方法都存在切除范围受限、易损伤脾脏的缺陷. 胃腔内过分充气还有引起脾包膜撕裂之虑[15-18,20]. 为此, 我们设计了新的腹腔镜手术切除胃底后壁黏膜下肿瘤的方法. 通过这些措施: (1)游离网膜, 进入网膜囊, 分离脾胃韧带, 将胃底和脾上极完全分开; (2)游离贲门左侧, 显露ECJ; (3)用Endo GIA切割胃底等, 我们设计的胃腔外胃底切除术完全可以做到避免腹腔污染、脾脏损伤以及食管狭窄的发生; 同时, 胃切除范围也不受限. 虽然, 操作步骤增加; 2例低度恶性间质瘤的切除范围是否足够, 仍需时间和病例数的检验. 但是, 只要通过适当的腹腔镜手术操作技能的训练, 手术并不费事、费时, 本组后壁肿瘤手术平均用时仅(66.2±10.4 min). 而且, 由于: (1)胃底切割时, ECJ和脾上极均一直处于术者视野之中; (2)允许更广泛切除. 因此, 手术也更安全、有效.

备注

$[Footnotes]

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