基于倾向性评分匹配的近端胃切除改良双通道吻合术与全胃切除Roux-en-Y吻合术疗效对比分析

doi:10.3877/cma.j.issn.1674-0793.2025.04.007

目的

通过对比腹腔镜近端胃切除改良双通道吻合与全胃切除Roux-en-Y吻合的疗效，探究改良双通道在食管胃结合部腺癌（AEG）根治术中的应用效果。

方法

采用回顾性队列研究方法，收集长治医学院附属和济医院2020年1月至2021年12月择期行腹腔镜下AEG切除术的188例患者临床数据，采用Logistic回归模型对两组患者的基线资料进行1∶1倾向性评分匹配（PSM），比较近端胃切除改良双通道吻合（改良双通道组）与全胃切除Roux-en-Y吻合（Roux-en-Y组）治疗AEG的临床效果分析，比较两组患者的手术情况、术后并发症、术后吻合口炎、吻合口狭窄情况、营养状况和术后生存率等指标。

结果

188例患者中Roux-en-Y组161例，改良双通道组27例，匹配后两组各13例。与Roux-en-Y吻合组相比，改良双通道组术后排气时间、术后进食时间更短，消化道重建时间更长（48 h vs 72 h，P=0.012；6 d vs 11 d，P<0.001；65.46 min vs 46.62 min，P<0.001）。两组各术后并发症差异无统计学意义，而改良双通道组术后并发症总发生率低于Roux-en-Y组（P=0.047）。两组在术后并发症Clavein-Dindo Ⅰ级、生活质量Visick 1分方面，差异均有统计学意义（P=0.047、0.017）。改良双通道组在术后9、12个月的血红蛋白、白蛋白、总蛋白水平增长率，以及术后12个月的体质指数增长率均高于Roux-en-Y组（P<0.05）。随访截至2024年11月，改良双通道组患者术后3年生存率显著高于Roux-en-Y组（P=0.033）。

结论

相较于全胃切除Roux-en-Y吻合，改良双通道吻合治疗AEG在术后营养、术后并发症、术后生存率等临床结局方面是安全可靠的，更有助于患者术后恢复。

关键词: 食管胃接合处, 吻合术，Roux-en-Y, 双通道吻合, 胃切除术, 倾向性评分

Objective

To compare laparoscopic modified double-tract reconstruction after proximal gastrectomy versus total gastrectomy with Roux-en-Y anastomosis, evaluating the efficacy of this modified technique in adenocarcinoma of esophagogastric junction (AEG) surgery through surgical outcomes, postoperative recovery, and nutritional assessments.

Methods

This retrospective cohort study analyzed clinical data from 188 patients undergoing elective AEG resection in Heji Hospital Affiliated to Changzhi Medical College between January 2020 to December 2021. After 1∶1 propensity score matching using Logistic regression to balance baseline characteristics, modified double-tract reconstruction following proximal gastrectomy (modified double-tract group) and total gastrectomy with Roux-en-Y anastomosis (Roux-en-Y group) in treating AEG were compared. Outcomes included operative parameters, postoperative complications (anastomositis, stricture rates), nutritional status, and survival rates.

Results

This retrospective analysis of 188 patients (161 Roux-en-Y vs 27 modified double-tract) achieved balanced cohorts through matching (13 in per group). Compared to Roux-en-Y group, the modified double-tract group demonstrated earlier postoperative recovery (flatus: 48 h vs 72 h, P=0.012; oral intake: 6 d vs 11 d, P<0.001) despite longer reconstruction time (65.46 min vs 46.62 min, P<0.001). While complication subtypes (reflux esophagitis, anastomositis, pulmonary emphysema, pneumonia, intestinal obstruction, pelvic effusion, duodenal stasis) showed comparable incidence, the modified technique exhibited lower overall complication rates (4 cases vs 10 cases, P=0.047). Significant differences emerged in Clavien-Dindo gradeⅠcomplications (P=0.047) and Visick grade 1 quality-of-life scores (P=0.017). Nutritional advantages were observed in the modified double-tract group with superior hemoglobin, albumin, and total protein recovery at 9 and 12 months, alongside higher body mass index restoration at 12 months (all P<0.05). Notably up to November 2024, the modified double-tract technique demonstrated superior 3-year survival rates (P=0.033).

Conclusion

Compared to total gastrectomy with Roux-en-Y anastomosis, modified double-tract reconstruction demonstrates comparable safety and reliability in clinical outcomes for AEG, including postoperative nutrition, complications, and survival rates, while facilitating enhanced postoperative recovery.

Key words: Esophagogastric junction, Anastomosis, Roux-en-Y, Double-tract reconstruction, Gastrectomy, Propensity score

图1 近端胃切除改良双通道吻合术中过程　A.于胃底和胃体的交界点处，采用60 mm直线切割闭合器从大弯侧向小弯侧进行横向切断；B.于胃小弯侧，距胃大弯3~4 cm的部位实施纵行切割操作，从而构建宽度3.5~4.0 cm、长度可达15 cm的管型胃；C.在Treitz韧带远端20~25 cm处离断空肠及其血管系膜后，将空肠远端向头侧牵引，使用圆形吻合器完成空肠与食管残端之间的端侧吻合，采用直线切割闭合器处理空肠断端，使其形成2~3 cm的闭合盲端；D.在距离食管空肠吻合口远端45 cm的空肠位置，进行近端空肠与远端空肠的侧侧吻合，然后使用倒刺线缝合将共同开口关闭；E.双通道重建：食管空肠吻合口以远10~15 cm处，将空肠与管状胃前壁（距残胃断端3 cm处）进行侧侧吻合；F.采用3-0可吸收缝线对食管空肠吻合口、胃肠吻合口、胃切除断面以及空肠断端等关键部位，实施全层间断缝合

图2 近端胃切除改良双通道吻合手术示意图

图3 倾向性评分匹配（PSM）流程

表1 倾向性评分匹配前后Roux-en-Y组与改良双通道组术前及术后资料比较

变量	匹配前				匹配后
变量	Roux-en-Y组	改良双通道组	统计值	P值	Roux-en-Y组	改良双通道组	统计值	P值
例数	161	27			13	13
性别^a
男	139(86.3)	22(81.5)	0.443	0.506	12(92.3)	10(76.9)	-	0.277
女	22(13.7)	5(18.5)			1(7.7)	3(23.1)
年龄(岁)^bc	67(62,72)	65(59,67)	1.838	0.066	57.92±8.005	65.38±7.206	2.498	0.020^a
ASA分级^a
Ⅰ/Ⅱ	143(88.8)	22(81.5)	1.160	0.283	12(92.3)	11(84.6)	-	0.539
Ⅲ	18(11.2)	5(18.5)			1(7.7)	2(15.4)
术前体质指数(kg/m²)^bc	23.7(21.7,25)	22.9(20.9,24.9)	0.871	0.383	23.02±4.520	22.87±1.824	0.114	0.912
肿瘤分化程度^a
低	40(24.8)	3(11.1)	20.414	<0.001^a	3(23.1)	2(15.4)		0.940
中低	68(42.2)	3(11.1)			2(15.4)	2(15.4)
中	44(27.3)	16(59.3)			6(46.2)	6(46.2)
高	9(5.6)	5(18.5)			2(15.4)	3(23.1)
pTNM分期^a
T1	6(3.7)	5(18.5)	-	<0.001^a	1(7.7)	1(7.7)	-	1.000
T2	2(1.2)	2(7.4)	-		0(0)	0(0)	-
T3	47(29.2)	5(18.5)	-		2(15.4)	3(23.1)	-
T4a	106(65.8)	12(44.4)	-		10(76.9)	9(69.2)	-
T4b	0(0)	3(11.1)	-		0(0)	0(0)	-
N0	16(9.94)	7(25.9)	-	0.113	2(15.4)	1(7.7)	-	0.761
N1	18(11.2)	2(7.4)	-		2(15.4)	1(7.7)	-
N2	42(26.1)	8(29.6)	-		3(23.1)	5(38.5)	-
N3	85(52.8)	10(37.0)	-		6(46.2)	6(46.2)	-
肿瘤最大径(cm)^b	4(3,4)	3(1,3.5)	4.900	<0.001^a	4.00(2.75,4.00)	3.50(2.75,4.00)	0.435	0.663
清扫阳性淋巴结数(枚)^b	3(3,10)	1(0,4)	2.649	0.008^a	1.00(0,5.00)	1.00(0,4.50)	0.290	0.772
清扫淋巴结总数(枚)^b	20(6,32.5)	10(5,25)	2.363	0.018^a	18.00(5.50,31.50)	16.00(5.00,25.00)	0.488	0.625
术前癌胚抗原(μg/L)^b	2.52(1.505,5.5)	1.63(1.12,2.4)	2.989	0.003^a	1.83(1.135,2.320)	1.65(1.35,3.77)	0.051	0.959

表1 倾向性评分匹配前后Roux-en-Y组与改良双通道组术前及术后资料比较

变量	匹配前				匹配后
变量	Roux-en-Y组	改良双通道组	统计值	P值	Roux-en-Y组	改良双通道组	统计值	P值
例数	161	27			13	13
性别^a
男	139(86.3)	22(81.5)	0.443	0.506	12(92.3)	10(76.9)	-	0.277
女	22(13.7)	5(18.5)			1(7.7)	3(23.1)
年龄(岁)^bc	67(62,72)	65(59,67)	1.838	0.066	57.92±8.005	65.38±7.206	2.498	0.020^a
ASA分级^a
Ⅰ/Ⅱ	143(88.8)	22(81.5)	1.160	0.283	12(92.3)	11(84.6)	-	0.539
Ⅲ	18(11.2)	5(18.5)			1(7.7)	2(15.4)
术前体质指数(kg/m²)^bc	23.7(21.7,25)	22.9(20.9,24.9)	0.871	0.383	23.02±4.520	22.87±1.824	0.114	0.912
肿瘤分化程度^a
低	40(24.8)	3(11.1)	20.414	<0.001^a	3(23.1)	2(15.4)		0.940
中低	68(42.2)	3(11.1)			2(15.4)	2(15.4)
中	44(27.3)	16(59.3)			6(46.2)	6(46.2)
高	9(5.6)	5(18.5)			2(15.4)	3(23.1)
pTNM分期^a
T1	6(3.7)	5(18.5)	-	<0.001^a	1(7.7)	1(7.7)	-	1.000
T2	2(1.2)	2(7.4)	-		0(0)	0(0)	-
T3	47(29.2)	5(18.5)	-		2(15.4)	3(23.1)	-
T4a	106(65.8)	12(44.4)	-		10(76.9)	9(69.2)	-
T4b	0(0)	3(11.1)	-		0(0)	0(0)	-
N0	16(9.94)	7(25.9)	-	0.113	2(15.4)	1(7.7)	-	0.761
N1	18(11.2)	2(7.4)	-		2(15.4)	1(7.7)	-
N2	42(26.1)	8(29.6)	-		3(23.1)	5(38.5)	-
N3	85(52.8)	10(37.0)	-		6(46.2)	6(46.2)	-
肿瘤最大径(cm)^b	4(3,4)	3(1,3.5)	4.900	<0.001^a	4.00(2.75,4.00)	3.50(2.75,4.00)	0.435	0.663
清扫阳性淋巴结数(枚)^b	3(3,10)	1(0,4)	2.649	0.008^a	1.00(0,5.00)	1.00(0,4.50)	0.290	0.772
清扫淋巴结总数(枚)^b	20(6,32.5)	10(5,25)	2.363	0.018^a	18.00(5.50,31.50)	16.00(5.00,25.00)	0.488	0.625
术前癌胚抗原(μg/L)^b	2.52(1.505,5.5)	1.63(1.12,2.4)	2.989	0.003^a	1.83(1.135,2.320)	1.65(1.35,3.77)	0.051	0.959

表2 Roux-en-Y组与改良双通道组患者术中及术后资料比较

项目	Roux-en-Y组	改良双通道组	统计值	P值
例数	13	13
手术时间(min)^a	282.31±64.279	263.85±60.489	t=0.754	0.458
术中出血量(ml)^b	100(100,150)	100(78.5,115.5)	U=-0.698	0.485
术后拔除胃管时间(d)^b	7(6,9.5)	7(5,8.5)	U=-0.496	0.620
术后拔除腹腔引流管时间(d)^a	9.46±3.821	8.46±5.570	t=0.531	0.598
术后住院天数(d)^b	13(12,17.5)	12(10,14)	U=-0.610	0.107
住院总费用(元)^a	66 668.27±11 331.273	66 851.12±9 432.001	t=-0.045	0.965
消化道重建时间(min)^a	46.62±7.730	65.46±6.009	t=-6.944	<0.001^a
术后首次排气时间(h)^b	72(72,96)	48(36,72)	U=-2.525	0.012^a
术后恢复进食时间(d)^b	11(9.5,12.5)	6(6,8)	U=-3.587	<0.001^a
术后接受化疗人数(例)^c	8(61.5)	9(69.2)	-	1

表2 Roux-en-Y组与改良双通道组患者术中及术后资料比较

项目	Roux-en-Y组	改良双通道组	统计值	P值
例数	13	13
手术时间(min)^a	282.31±64.279	263.85±60.489	t=0.754	0.458
术中出血量(ml)^b	100(100,150)	100(78.5,115.5)	U=-0.698	0.485
术后拔除胃管时间(d)^b	7(6,9.5)	7(5,8.5)	U=-0.496	0.620
术后拔除腹腔引流管时间(d)^a	9.46±3.821	8.46±5.570	t=0.531	0.598
术后住院天数(d)^b	13(12,17.5)	12(10,14)	U=-0.610	0.107
住院总费用(元)^a	66 668.27±11 331.273	66 851.12±9 432.001	t=-0.045	0.965
消化道重建时间(min)^a	46.62±7.730	65.46±6.009	t=-6.944	<0.001^a
术后首次排气时间(h)^b	72(72,96)	48(36,72)	U=-2.525	0.012^a
术后恢复进食时间(d)^b	11(9.5,12.5)	6(6,8)	U=-3.587	<0.001^a
术后接受化疗人数(例)^c	8(61.5)	9(69.2)	-	1

表3 Roux-en-Y组与改良双通道组患者术后并发症情况[例（%）]

项目	Roux-en-Y组	改良双通道组	P值
例数	13	13
反流性食管炎	5(38.5)	1(7.7)	0.160
吻合口炎	3(23.1)	1(7.7)	0.593
肺气肿	1(7.7)	2(15.4)	1.000
肺炎	4(30.8)	1(7.7)	0.322
肠梗阻	1(7.7)	0(0)	1.000
盆腔积液	2(15.4)	2(15.4)	1.000
十二指肠瘀滞症	0(0)	1(7.7)	1.000
总计	10(76.9)	4(30.8)	0.047^a
术后并发症Clavein-Dindo分级			0.211
Ⅰ级	4(30.8)	10(76.9)	0.047^a
Ⅱ级	6(46.2)	3(23.1)	0.411
Ⅲ级	2(15.4)	0(0)	0.480
Ⅳ级	1(7.7)	0(0)	1.000
生活质量Visick评分（分）			0.023
1	3(23.1)	10(76.9)	0.017^a
2	8(61.5)	3(23.1)	0.111
3	0(0)	0(0)	-
4	2(15.4)	0(0)	0.480

表3 Roux-en-Y组与改良双通道组患者术后并发症情况[例（%）]

项目	Roux-en-Y组	改良双通道组	P值
例数	13	13
反流性食管炎	5(38.5)	1(7.7)	0.160
吻合口炎	3(23.1)	1(7.7)	0.593
肺气肿	1(7.7)	2(15.4)	1.000
肺炎	4(30.8)	1(7.7)	0.322
肠梗阻	1(7.7)	0(0)	1.000
盆腔积液	2(15.4)	2(15.4)	1.000
十二指肠瘀滞症	0(0)	1(7.7)	1.000
总计	10(76.9)	4(30.8)	0.047^a
术后并发症Clavein-Dindo分级			0.211
Ⅰ级	4(30.8)	10(76.9)	0.047^a
Ⅱ级	6(46.2)	3(23.1)	0.411
Ⅲ级	2(15.4)	0(0)	0.480
Ⅳ级	1(7.7)	0(0)	1.000
生活质量Visick评分（分）			0.023
1	3(23.1)	10(76.9)	0.017^a
2	8(61.5)	3(23.1)	0.111
3	0(0)	0(0)	-
4	2(15.4)	0(0)	0.480

图4 两组患者术后血红蛋白（Hb）改变　 ^***P<0.001

图5 两组患者术后白蛋白水平变化　 ^***P<0.001

图6 两组患者术后总蛋白水平变化　 ^***P<0.001

图7 两组患者术后体质指数（BMI）变化　 ^*P<0.05

图8 两组患者术后生存曲线　 ^*P<0.05

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Comparative analysis of the efficacy of proximal gastrectomy with modified double-tract reconstruction and total gastrectomy with Roux-en-Y reconstruction based on a propensity score-matched study

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Comparative analysis of the efficacy of proximal gastrectomy with modified double-tract reconstruction and total gastrectomy with Roux-en-Y reconstruction based on a propensity score-matched study