Comparison of treatment effects and complications of three kinds of gastrointestinal reconstruction procedures after radical gastrectomy

doi:10.11958/20220615

Abstract

Abstract:

Objective To compare the treatment effects and complications of three reconstruction procedures in patients after radical gastrectomy. Methods A total of 194 patients with radical gastrectomy were selected and divided into the U-RY group (Uncut Roux-en-Y anastomosis, 69 cases), the B Ⅰ group (Billroth-Ⅰ modified delta-shaped anastomosis, 65 cases) and the B Ⅱ+Braun group (Billroth-Ⅱ+Braun anastomosis, 60 cases) according to the gastrointestinal reconstruction methods. The basic data of the three groups were matched by propensity score matching. The surgical status, postoperative recovery status, intestinal barrier function [diamine oxidase (DAO), D-lactic acid, endotoxin (ETX)], inflammatory stress indicators [interleukin-6 (IL-6), interleukin-10 (IL-10), 8-iso-prostaglandin F2α (8-iso-PGF2α), heme oxygenase-1 (HO-1)] and complications were compared between the three groups. Results Before propensity score matching, gender and age were not evenly distributed in the three groups (P<0.05). After matching, 147 cases of 194 patients were successfully matched, with 49 cases in each group. There were no significant differences in general data between the three groups (P>0.05). The surgical time increased successively in the B Ⅰ group, the B Ⅱ+Braun group and the U-RY group (P<0.05). The intraoperative blood loss, postoperative bowel sound recovery time, first exhaust time, extubation time, eating time, first defecation time and hospital stay were less or shorter in the B Ⅰ group than those in the B Ⅱ+Braun group and the U-RY group (P<0.05), but there were no significant differences in the above indicators between the B Ⅱ+Braun group and the U-RY group (P>0.05). At 3 d after surgery, the levels of DAO, D-lactic acid and ETX were significantly lower in the B Ⅰ group than those of the U-RY group and the B Ⅱ+Braun group, while the levels of IL-6, IL-10, 8-iso-PGF2α and HO-1 were higher compared with those in the U-RY group and the B Ⅱ+Braun group (P<0.05). There were no significant differences in the above indicators between the U-RY group and the B Ⅱ+Braun group (P>0.05). There were no significant differences in incidence rates of complications between the three groups (P>0.05). Conclusion Billroth-Ⅰ modified delta-shaped anastomosis has the advantages of shorter surgical duration, less blood loss, faster recovery and smaller effect on the intestinal barrier compared to Billroth-Ⅱ+Braun anastomosis and Uncut Roux-en-Y anastomosis, but the latter two are more suitable for more indications and have milder inflammatory stimulation, and Uncut Roux-en-Y anastomosis can reduce postoperative reflux.

Key words: stomach neoplasms, radical gastrectomy, billroth-Ⅰ modified delta-shaped anastomosis, billroth-Ⅱ combined with braun anastomosis, uncut roux-en-Y anastomosis, intestinal barrier function

CLC Number:

R735.2

Figures/Tables 7

References 23

[1]	CHEN T H, LIN W R, LEE C, et al. Prognostic stratification of advanced gastric signet ring cell carcinoma by clinicopathological factors and GALNT14 genotype[J]. J Cancer, 2018, 9(19):3540-3547. doi: 10.7150/jca.26293.
[2]	潘敦, 李良庆. 进展期胃癌脾脏巨噬细胞表型变化及其共培养对胃癌细胞增殖侵袭迁移的影响[J]. 西安交通大学学报(医学版), 2019, 40(4):531-536.
	PAN D, LI L Q. Phenotypic changes of spleen macrophages in advanced gastric cancer and their effects on proliferation,invasion and migration of gastric cancer cells[J]. J Xi’ an Jiaotong Univ (Med Sci), 2019, 40(4):531-536. doi: 10.7652/jdyxb201904008.
[3]	徐泽宽, 徐皓, 李铮. 全腹腔镜近端胃切除术的适应证及消化道重建方式的选择[J]. 中国肿瘤临床, 2019, 46(1):12-15.
	XU Z K, XU H, LI Z. Indications for total laparoscopic proximal gastrectomy and the following selection of gastrointestinal reconstruction methods[J]. Chin J Clin Oncol, 2019, 46(1):12-15. doi: 10.3969/j.issn.1000-8179.2019.01.071.
[4]	孙强, 周海洋, 胡志前. 全腹腔镜下胃癌根治术腔内吻合技术和消化道重建研究进展[J]. 中华胃肠外科杂志, 2019, 22(2):191-195.
	SUN Q, ZHOU H Y, HU Z Q. Research progression of endoscopic anastomosis technique and digestive tract reconstruction after totally laparoscopic gastrectomy for gastric cancer[J]. Chin J Gastrointest Surg, 2019, 22(2):191-195. doi: 10.3760/cma.j.issn.1671-0274.2019.02.015.
[5]	黄昌明, 涂儒鸿, 林建贤. 全腹腔镜胃癌根治术消化道重建技术与进展[J]. 中华消化外科杂志, 2020, 19(9):931-934.
	HUANG C M, TU R H, LIN J X. Technology and development of digestive tract reconstruction in totally laparoscopic radical gastrectomy for gastric cancer[J]. Chin J Digest Surg, 2020, 19(9):931-934. doi: 10.3760/cma.j.cn115610-20200818-00558.
[6]	汪未知, 吕嘉伦, 徐泽宽. 早期胃癌行腹腔镜手术消化道重建方式选择及评价[J]. 中国实用外科杂志, 2019, 39(5):454-459.
	WANG W Z, LYU J L, XU Z K. Selection and evaluation of laparoscopic digestive tract reconstruction after gastrectomy for early gastric cancer[J]. Chin J Pract Surg, 2019, 39(5):454-459. doi: 10.19538/j.cjps.issn1005-2208.2019.05.12.
[7]	NISHIZAKI D, GANEKO R, HOSHINO N, et al. Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer[J]. Cochrane Database Syst Rev, 2021, 9(9):CD012998. doi: 10.1002/14651858.
[8]	MA Y P, LI F, ZHOU X, et al. Four reconstruction methods after laparoscopic distal gastrectomy:A systematic review and network meta-analysis[J]. Medicine(Baltimore), 2019, 98(51):e18381. doi: 10.1097/MD.0000000000018381.
[9]	中国临床肿瘤学会指南工作委员会.中国临床肿瘤学会(CSCO)胃癌诊疗指南(2018. V1)[M]. 北京: 人民卫生出版社, 2018.
	Guideline Working Committee of Chinese Society of Clinical Oncology. Chinese Society of Clinical Oncology (CSCO) guidelines for the diagnosis and treatment of gastric cancer (2018.V1)[M]. Beijing: People’ s Medical Publishing House, 2018.
[10]	曹惠华, 束平, 唐兆庆, 等. 美国癌症联合会第7版与第8版胃癌TNM分期系统的差异及其对预后评估的比较(附1383例报告)[J]. 中华消化外科杂志, 2018, 17(6):605-611.
	CAO H H, SHU P, TANG Z Q, et al. Differences and comparison of prognostic evaluation between AJCC staging system 7th edition and 8th edition for gastric cancer (A report of 1383 cases)[J]. Chin J Digest Surg, 2018, 17(6):605-611. doi: 10.3760/cma.j.issn.1673-9752.2018.06.013.
[11]	马俊文, 马文, 韩瑞东. 腹腔镜辅助胃癌根治术的临床应用效果及对患者血清学指标的影响[J]. 中国普通外科杂志, 2018, 27(4):518-522.
	MA J W, MA W, HAN R D. Effect of clinical use of laparoscopic-assisted radical gastric cancer resection and the influence on serum indices of patients[J]. Chin J Gen Surg, 2018, 27(4):518-522. doi: 10.3978/j.issn.1005-6947.2018.04.019.
[12]	乔小放, 刘晶晶, 文大成, 等. 腹腔镜胃切除术后消化道重建—腹腔镜辅助:"理想"与"现实"的选择[J]. 中华胃肠外科杂志, 2017, 20(6):871.
	QIAO X F, LIU J J, WEN D C, et al. Reconstruction of digestive tract after laparoscopic gastrectomy--laparoscopic assistance:the choice between "ideal" and "realistic"[J]. Chin J Gastrointest Surg, 2017, 20(6):871. doi: 10.3760/cma.j.issn.1671-0274.2017.08.008.
[13]	WANG Q, NI Q R, YANG K L, et al. Laparoscopic uncut Roux-en-Y for radical distal gastrectomy:the study protocol for a multirandomized controlled trial[J]. Cancer Manag Res, 2019, 11:1697-1704. doi: 10.2147/CMAR.S170355.
[14]	LI J, GE Y G, YANG Y F, et al. Comparison of delta-shaped anastomosis and Billroth I reconstruction after laparoscopic distal gastrectomy for gastric cancer[J]. J Gastrointest Oncol, 2021, 12(2):259-267. doi: 10.21037/jgo-21-109.
[15]	崔昊, 刘国晓, 邓欢, 等. 全3D腹腔镜远端胃切除术Billroth Ⅱ联合Braun吻合与Roux-en-Y吻合的近期疗效分析[J]. 中华消化外科杂志, 2021, 20(5):528-534.
	CUI H, LIU G X, DENG H, et al. Short-term efficacy of BillrothⅡ+Braun anastomosis versus Roux-en-Y anastomosis in totally three-dimensional laparoscopic distal gastrectomy[J]. Chin J Digest Surg, 2021, 20(5):528-534. doi: 10.3760/cma.j.cn115610-20210301-00103.
[16]	CHEN X J, CHEN Y Z, CHEN D W, et al. The development and future of digestive tract reconstruction after distal gastrectomy:A systemic review and Meta-analysis[J]. J Cancer, 2019, 10(4):789-798. doi: 10.7150/jca.28843.
[17]	LEE K, KIM K W, LEE J B, et al. Impact of remnant stomach volume and anastomosis on nutrition and body composition in gastric cancer patients[J]. Surg Oncol, 2019, 31:75-82. doi: 10.1016/j.suronc.2019.09.008.
[18]	CHEN C J, HUANG P J, LAI L F, et al. Dexmedetomidine improves gastrointestinal motility after laparoscopic resection of colorectal cancer[J]. Medicine (Baltimore), 2016, 95(29):e4295. doi: 10.1097/MD.0000000000004295.
[19]	程康文, 王贵和, 束宽山, 等. 腹腔镜辅助与开腹胃癌根治术临床效果及对肠道屏障功能影响的比较[J]. 中国普通外科杂志, 2017, 26(4):450-456.
	CHENG K W, WANG G H, SHU K S, et al. Laparoscopic-assisted versus open radical gastrectomy for gastric cancer:comparison of clinical effects and influence on intestinal barrier function[J]. Chin J Gen Surg, 2017, 26(4):450-456. doi: 10.3978/j.issn.1005-6947.2017.04.008.
[20]	REN Z, WANG W X. Comparison of Billroth I,Billroth Ⅱ,and Roux-en-Y reconstruction after totally laparoscopic distal gastrectomy:A randomized controlled study[J]. Adv Ther, 2019, 36(11):2997-3006. doi: 10.1007/s12325-019-01104-3.
[21]	NOSSO G, LUPOLI R, SALDALAMACCHIA G, et al. Diabetes remission after bariatric surgery is characterized by high glycemic variability and high oxidative stress[J]. Nutr Metab Cardiovasc Dis, 2017, 27(11):949-955. doi: 10.1016/j.numecd.2017.07.004.
[22]	ZHANG L, REN L H, SHAN K S, et al. Serum inflammatory cytokines comparison in gastric cancer therapy[J]. Open Med(Wars), 2019, 14:300-306. doi: 10.1515/med-2019-0027.
[23]	周俊峰, 何庆良, 王家兴, 等. 不同消化道重建方式在腹腔镜远端胃大部切除术中的应用价值[J]. 中华消化外科杂志, 2018, 17(6):592-598.
	ZHOU J F, HE Q L, WANG J X, et al. Application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy[J]. Chin J Digest Surg, 2018, 17(6):592-598. doi: 10.3760/cma.j.issn.1673-9752.2018.06.011.

组别		n	性别（男/女）		年龄（岁）		BMI （kg/m²）		肿瘤长径（cm）
U-RY组		69	47/22		49.13±8.05		24.46±3.51		2.87±0.58
BⅠ组		65	33/32^a		52.14±8.82^a		24.70±3.92		2.93±0.56
BⅡ+Braun组		60	42/18^b		54.60±9.17^a		25.02±4.29		2.98±0.53
χ²或F			6.198^＊		6.451^＊＊		0.324		0.682
组别	分化程度							TNM分期
组别	低			中		高		Ⅱ期		Ⅲ期
U-RY组	27（39.13）			28（40.58）		14（20.29）		38（55.07）		31（44.93）
BⅠ组	28（43.08）			29（44.62）		8（12.31）		44（67.69）		21（32.31）
BⅡ+Braun组	21（35.00）			29（48.33）		10（16.67）		28（46.67）		32（53.33）
χ²或F	2.251							5.734

组别		n	性别（男/女）		年龄（岁）		BMI （kg/m²）		肿瘤长径（cm）
U-RY组		69	47/22		49.13±8.05		24.46±3.51		2.87±0.58
BⅠ组		65	33/32^a		52.14±8.82^a		24.70±3.92		2.93±0.56
BⅡ+Braun组		60	42/18^b		54.60±9.17^a		25.02±4.29		2.98±0.53
χ²或F			6.198^＊		6.451^＊＊		0.324		0.682
组别	分化程度							TNM分期
组别	低			中		高		Ⅱ期		Ⅲ期
U-RY组	27（39.13）			28（40.58）		14（20.29）		38（55.07）		31（44.93）
BⅠ组	28（43.08）			29（44.62）		8（12.31）		44（67.69）		21（32.31）
BⅡ+Braun组	21（35.00）			29（48.33）		10（16.67）		28（46.67）		32（53.33）
χ²或F	2.251							5.734

组别		n	性别（男/女）		年龄（岁）		BMI （kg/m²）		肿瘤长径（cm）
U-RY组		49	34/15		49.65±8.10		24.65±3.68		2.91±0.60
BⅠ组		49	31/18		50.45±8.73		24.61±3.79		2.96±0.52
BⅡ+Braun组		49	33/16		51.78±7.17		24.64±4.46		2.94±0.53
χ²或F			0.429		0.874		0.001		0.096
组别	分化程度							TNM分期
组别	低			中		高		Ⅱ期		Ⅲ期
U-RY组	20（40.82）			22（44.90）		7（14.29）		30（61.22）		19（38.78）
BⅠ组	20（40.82）			21（42.86）		8（16.33）		30（61.22）		19（38.78）
BⅡ+Braun组	20（40.82）			22（44.90）		7（14.29）		24（48.98）		25（51.02）
χ²或F	0.122							2.000

组别		n	性别（男/女）		年龄（岁）		BMI （kg/m²）		肿瘤长径（cm）
U-RY组		49	34/15		49.65±8.10		24.65±3.68		2.91±0.60
BⅠ组		49	31/18		50.45±8.73		24.61±3.79		2.96±0.52
BⅡ+Braun组		49	33/16		51.78±7.17		24.64±4.46		2.94±0.53
χ²或F			0.429		0.874		0.001		0.096
组别	分化程度							TNM分期
组别	低			中		高		Ⅱ期		Ⅲ期
U-RY组	20（40.82）			22（44.90）		7（14.29）		30（61.22）		19（38.78）
BⅠ组	20（40.82）			21（42.86）		8（16.33）		30（61.22）		19（38.78）
BⅡ+Braun组	20（40.82）			22（44.90）		7（14.29）		24（48.98）		25（51.02）
χ²或F	0.122							2.000

组别	手术时间（min）	术中出血量（mL）
U-RY组	145.88±10.38	72.36±15.21
BⅠ组	125.94±12.82^a	54.98±12.53^a
BⅡ+Braun组	132.67±13.16^ab	67.71±12.79^b
F	33.954^＊＊	21.585^＊＊