食管胃结合部腺癌腹腔镜经腹-左膈肌路径近端胃加食管下段切除高位消化道重建现状

doi:10.16139/j.1007-9610.2023.03.009

摘要/Abstract

摘要：

近年来，随着食管胃结合部腺癌（adenocarcinoma of esophagogastric junction, AEG）的发病率不断上升及早期病例的增加，AEG的手术治疗成为热点问题。由于AEG的解剖位置及肿瘤生物学的特殊性涉及到胸腔和腹腔两个不同的手术领域，在治疗策略的选择上仍然存在较多争议。淋巴结清扫的彻底性和消化道重建的安全性是影响治疗策略选择的关键要素。腹腔镜下经腹食管裂孔路径在完成腹腔淋巴结清扫的同时可保证下纵隔淋巴结清扫的肿瘤学安全性，是治疗食管浸润长度≤4 cm的AEG之首选手术路径。经腹食管裂孔路径操作时，可打开左侧膈肌，将下纵隔空间扩大或将腹部与左侧胸腔直接相通。这样避免传统开胸，增加操作空间和改善手术视野，既可以减轻胸部创伤，又可以更清晰、完整地清扫下纵隔淋巴结，尤其是充足的操作空间和足够的食管游离度可以使纵隔或左侧胸腔内的高位消化道重建变得更安全、可行。本中心将此路径称为经腹-左膈肌（abdominal-left diaphragmatic, ALD）路径。以食管胃侧壁吻合和双肌瓣吻合为代表的功能性消化道重建术式可经ALD路径逐步应用至更高的吻合平面，拓展了消化道重建的适应证。在保证手术安全性的同时，兼顾良好的抗反流效果。

关键词: 胃癌, 食管胃结合部腺癌, 近端胃切除, 消化道重建, 左侧胸腔

Abstract:

In recent years, the rising incidence of adenocarcinoma of esophagogastric junction (AEG) and the subsequent surge in early detections have transformed the surgical treatment of AEG into a topic of substantial interest. The anatomical positioning of AEG, combined with the unique nature of its tumor biology, which encompasses two distinct surgical domains, the thoracic and abdominal cavities, has sparked numerous debates regarding the selection of treatment strategies. The comprehensiveness of lymph node dissection and the safety of digestive tract reconstruction are instrumental in shaping these strategies. The laparoscopic abdominal transhiatal (TH) approach offers a balance of addressing both these conside-rations. It ensures the oncological safety of inferior mediastinal lymph node dissection, while simultaneously performing abdominal lymph node dissection. This approach becomes a prime choice for AEG when the esophageal invasion length is ≤ 4 cm.When implementing the TH approach, surgeons have the ability to either augment the inferior mediastinal space or establish a direct connection between the abdomen and the left thoracic cavity by performing a strategic opening of the left diaphragm. Such a maneuver circumvents the need for traditional thoracotomy, thus enlarging the operating space and enhancing the surgical field of view. This method reduces chest trauma and enables a clearer and more comprehensive removal of inferior mediastinal lymph nodes. Moreover, ample operating space and sufficient esophageal dissection make high digestive tract reconstruction in the mediastinum or left thoracic cavity safer and more feasible. Our center has dubbed this approach the abdominal-left diaphragmatic (ALD) approach. Functional digestive tract reconstructions such as side overlap esophagogastrostomy （SOFY） anastomosis and double-flap technique can be progressively applied to a higher anastomosis plane through the ALD approach. Consequently, the ALD approach expands the indications for digestive tract reconstruction, ensures operational safety, and maintains an effective anti-reflux effect simultaneously.

Key words: Gastric cancer, Adenocarcinoma of esophagogastric junction, Proximal gastrectomy, Digestive tract reconstruction, Left thoracic cavity

中图分类号:

R735.2

胡文庆, 杨垠浩, 崔鹏, 魏伟. 食管胃结合部腺癌腹腔镜经腹-左膈肌路径近端胃加食管下段切除高位消化道重建现状[J]. 外科理论与实践, 2023, 28(03): 226-232.

HU Wenqing, YANG Yinhao, CUI Peng, WEI Wei. Current status of high-positioned digestive tract reconstruction after laparoscopic proximal stomach and lower esophagus resection through the abdominal-left diaphragmatic approach for adenocarcinoma of esophagogastric junction[J]. Journal of Surgery Concepts & Practice, 2023, 28(03): 226-232.

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