腹腔镜袖状胃切除术联合胃底折叠术后胃漏1例诊疗体会

doi:10.3877/cma.j.issn.2095-9605.2024.01.010

胃漏是腹腔镜袖状胃切除术（LSG）联合胃底折叠术后最主要及最严重的并发症。本文报道1例内镜负压治疗LSG联合胃底折叠术后发生胃漏的病例。患者术前诊断为代谢综合征合并胃食管反流病（GERD），行LSG联合胃底折叠术，术后第10天因胃漏再次入院，行折叠瓣及漏口切除术。术后第5天再次发生胃漏，行内镜下负压装置及鼻-空肠营养管置入，术后予以肠内肠外营养，治疗过程中多次腹腔脓肿穿刺引流。术后2个月复查上腹部CT及上消化道造影，提示治愈。本病例提示我们对于有GERD的肥胖患者，LSG联合胃底折叠术的安全性需要进一步评估。对于术后发生胃漏的患者，内镜负压治疗操作简单安全，值得临床借鉴。

关键词: 袖状胃切除术, 胃底折叠术, 胃漏, 胃食管反流病, 内镜负压治疗

Gastric leakage is the most critical and severe complication after laparoscopic sleeve gastrectomy (LSG) combined with fundoplication. We aimed to report a case treated with endoscopic negative pressure therapy for gastric leakage after LSG combined with fundoplication. The patient was diagnosed with metabolic syndrome and gastroesophageal reflux disease (GERD) before surgery. The patient underwent LSG combined with fundoplication. The patient was readmitted to the hospital due to gastric leakage on postoperative day 10 and underwent fundoplication flap resection and leakage site resection. The patient was complicated with gastric leakage on postoperative day 5. Endoscopic negative pressure therapy and a nasojejunal feeding tube were inserted and given enteral and parenteral nutrition. Multiple abdominal punctures and drainage were performed during the whole treatment process. CT of the upper abdomen and gastric radiography identified a cure for the leakage 2 months after surgery. For obese patients with GERD, the safety of LSG combined with fundoplication needs to be further evaluated. For patients with postoperative gastric leakage, endoscopic negative pressure therapy is effective and safe, which is worthy of clinical reference.

Key words: Sleeve gastrectomy, Fundoplication, Gastric leakage, Gastroesophageal reflux disease, Endoscopic negative pressure therapy

图1 手术示意图。1A：保留部分胃底的袖状胃切除术；1B：胃底折叠术；1C：漏口位于胃底折叠瓣处（箭头所指处）

图2 患者腹腔镜下胃漏示意图。2A：漏口位于胃底折叠瓣处（箭头所指处）；2B：漏口处大量脓液

图3 手术切除折叠瓣及胃漏口。3A：切除折叠瓣及漏口；3B：加固缝合胃切缘

图4 患者第二次术后影像结果提示胃漏。4A：CT示胃切缘不完整（箭头所指处）；4B：上消化道造影示造影剂外溢（箭头所指处）

图5 负压装置制作示意图。5A：截取海绵；5B、5C：将海绵固定于胃管尖端

图6 负压装置置于胃漏口处进行持续引流。6A：内镜引导负压吸引装置；6B：通过胃镜将负压装置置于胃漏口处

图7 患者术后2个月影像结果提示胃漏愈合。7A：CT影像示胃切缘完整；7B：上消化道造影示无造影剂外溢

[1]	Olmi S, Cesana G, D'Angiolella L, et al. Sleeve gastrectomy with tailored 360°fundoplication according to Rossetti in patients affected by obesity and gastroesophageal reflux: a prospective observational study [J]. Surg Obes Relat Dis, 2021, 17(6): 1057-1065.
[2]	Turkyilmaz A, Eroglu A, Aydin Y, et al. The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma [J]. Dis Esophagus, 2009, 22(2): 119-126.
[3]	Von Renteln D, Vassiliou MC, Rothstein R I. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies [J]. Endoscopy, 2009, 41(12): 1056-1061.
[4]	Jung DH, Yun HR, Lee SJ, et al. Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis [J]. J Clin Med, 2021, 10(11): 2346.
[5]	Lalezari S, Lee CJ, Borovikova A A, et al. Deconstructing negative pressure wound therapy [J]. Int Wound J, 2017, 14(4): 649-657.
[6]	Erba P, Ogawa R, Ackermann M, et al. Angiogenesis in wounds treated by microdeformational wound therapy [J]. Ann Surg, 2011, 253(2): 402-409.
[7]	中华医学会外科学分会甲状腺及代谢外科学组, 中国医师协会外科医师分会肥胖和糖尿病外科医师委员会, 中国医疗保健国际交流促进会代谢外科学分会, 等. 腹腔镜胃袖状切除术后胃漏诊断,预防及处理中国专家共识(2021版) [J]. 中国实用外科杂志, 2021, 41(6): 633-638.
[8]	Manos T, Nedelcu M, Nedelcu A, et al. Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment [J]. Obes Surg, 2021, 31(11): 4861-4867.
[9]	Degrandi O, Nedelcu A, Nedelcu M, et al. Roux-en-Y Gastric Bypass for the Treatment of Leak Following Sleeve Gastrectomy [J]. Obes Surg, 2021, 31(1): 79-83.
[10]	Csendes A, Braghetto I, León P, et al. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity [J]. J Gastrointest Surg, 2010, 14(9): 1343-1348.
[11]	Crawford C, Gibbens K, Lomelin D, et al. Sleeve gastrectomy and anti-reflux procedures [J]. Surg Endosc, 2017, 31(3): 1012-1021.
[12]	Del Genio G, Tolone S, Gambardella C, et al. Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD [J]. Obes Surg, 2020, 30(5): 1642-1652.
[13]	Soong TC, Lee MH, Lee WJ, et al. Long-Term Efficacy of Bariatric Surgery for the Treatment of Super-Obesity: Comparison of SG, RYGB, and OAGB [J]. Obes Surg, 2021, 31(8): 3391-3399.
[14]	皮尔地瓦斯·麦麦提玉素甫, 艾克拜尔·艾力, 买买提·依斯热依力, 等. 腹腔镜胃底折叠术联合胃袖状切除术治疗肥胖合并胃食管反流病临床研究[J]. 中国实用外科杂志, 2020, 40(04): 437-440+443.
[15]	Nocca D, Skalli E M, Boulay E, et al. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study [J]. Surg Obes Relat Dis, 2016, 12(10): 1832-1837.
[16]	Olmi S, Caruso F, Uccelli M, et al. Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux [J]. Surg Obes Relat Dis, 2017, 13(12): 1945-1950.
[17]	Lee WJ, Han ML, Ser KH, et al. Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results [J]. Obes Surg, 2014, 24(9): 1447-1452.
[18]	向展华, 孙善全, 梅勇, 等. 左膈下动脉及其分支的应用解剖学观察[J]. 重庆医学, 2012, 41(35): 3695-3696.
[19]	Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients [J]. Surg Endosc, 2013, 27(1): 240-245.
[20]	Gronnier C, Chambrier C, Duhamel A, et al. Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study) [J]. Trials, 2020, 21(1): 448.
[21]	Ribeiro-Parenti L, De Courville G, Daikha A, et al. Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass [J]. Surg Obes Relat Dis, 2017, 13(2): 243-248.

[1]	孟令凯, 李大勇, 王宁, 王桂明, 张炳南, 李若彤, 潘立峰. 袖状胃切除术对肥胖伴2型糖尿病大鼠的作用及机制研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 638-642.
[2]	杨波, 胡旭, 何金艳, 谢铭. 腹腔镜袖状胃切除术管胃固定研究现状[J]. 中华普外科手术学杂志(电子版), 2024, 18(04): 452-455.
[3]	邢益民, 张天飞, 戴慧勇. 胃肠充盈超声造影检查在反酸、嗳气患者临床诊断中的应用[J]. 中华普外科手术学杂志(电子版), 2024, 18(03): 303-306.
[4]	赵帅, 王伟, 李瑞奇, 周家杰, 王道荣. 3D腹腔镜下袖状胃切除术治疗肥胖合并2型糖尿病的临床疗效及影响因素分析[J]. 中华普外科手术学杂志(电子版), 2024, 18(02): 146-149.
[5]	刘盾, 潘晟. 不同入路腹腔镜袖状胃切除术用于肥胖症合并2型糖尿病的效果[J]. 中华普外科手术学杂志(电子版), 2024, 18(02): 150-154.
[6]	胡志伟, 吴继敏, 汪忠镐, 张美光. 胃食管反流病食管外症状抗反流手术适应证及术前评估[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(03): 241-246.
[7]	梁艳, 胡志伟, 刘健男, 宋庆, 陈冬, 田书瑞, 李冉, 毛建新. 高分辨率食管测压在胃食管反流病食管运动功能评价中的应用[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(01): 89-92.
[8]	胡志伟, 吴继敏, 邓昌荣, 战秀岚, 纪涛, 王峰, 田书瑞, 陈冬, 张玉, 刘健男, 宋庆. 抗反流黏膜套扎治疗顽固性胃食管反流病[J]. 中华腔镜外科杂志(电子版), 2024, 17(04): 227-233.
[9]	孙武青, 郭震, 郝少龙, 孙海涛, 姬阆, 白日星, 韩威. LSG中保留胃窦部及His角完整性对术后胃食管反流病的影响[J]. 中华腔镜外科杂志(电子版), 2024, 17(02): 95-99.
[10]	唐小久, 胡曼, 许必君, 肖亚. 肥胖合并胃食管反流病患者严重程度与其焦虑抑郁及营养状态的相关性研究[J]. 中华消化病与影像杂志(电子版), 2024, 14(04): 360-364.
[11]	庄茜钧, 江典轩, 肖英莲. 中国胃食管反流病的诊疗进展[J]. 中华胃食管反流病电子杂志, 2024, 11(02): 75-80.
[12]	吴瑜, 王玉, 荀敬, 郎琳, 王宏磊, 姚希, 高琪. 腹腔镜前180°胃底折叠术治疗反流性食管炎89例临床分析[J]. 中华胃食管反流病电子杂志, 2024, 11(02): 85-90.
[13]	李治仝, 胡珂琳, 刘冰熔, 韩新巍, 李晶晶, 张浩然, 张旭航, 季锋, 汪忠镐. 抗反流手术治疗胃食管反流病合并食管裂孔疝相关性顽固性呃逆的临床疗效[J]. 中华胃食管反流病电子杂志, 2024, 11(02): 91-94.
[14]	孙海涛, 闫文貌, 郝少龙, 孙武青, 韩威, 白日星. 保留His角完整性对腹腔镜袖状胃切除术后胃食管反流的影响[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 84-87.
[15]	邢颖, 闫文貌. 单孔腹腔镜袖状胃切除术发展现状[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 133-137.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Diagnosis and treatment experience of gastric leakage after laparoscopic sleeve gastrectomy combined with fundoplication

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Diagnosis and treatment experience of gastric leakage after laparoscopic sleeve gastrectomy combined with fundoplication