2023年 · 第61卷第06期

In recent years, with the increasing incidence of upper gastric cancer, laparoscopic proximal gastrectomy has become more and more widely used^{［1, 2, 3］}。 After proximal gastrectomy, the digestive tract can be reconstructed by esophagostomy, dual-channel anastomosis and interposition jejunostomy, among which esophagostomy is the most common reconstruction method^{［4, 5］}。 In order to improve the effect of preventing reflux, avoid anastomotic stenosis, and reduce the difficulty of operation, Japanese scholar Yamashita et al^［6］Side overlap anastomosis was proposed in 2017. However, this method realizes the anastomosis of the lateral wall of esophagus and the anterior wall of residual stomach by rotating the cutting closure device, which depends on the experience and subjective judgment of the operator, and the effect is unstable. Therefore, Yamashita et al.^［7］It was improved to make the anastomosis position more accurate and stable, and the postoperative anti-reflux effect was better. Our department carried out 4 cases of modified Side overlap anastomosis in laparoscopic proximal gastrectomy, hoping to accumulate practical experience and understand its feasibility, safety and short-term efficacy, so as to explore its applicability in Chinese patients.

The patient, a 59-year-old male, was admitted to our hospital in October 2021 due to "liver tumor found for 1 week". One week ago, the patient developed fullness in the right upper abdomen without obvious trigger, which gradually worsened. The MRI results of other hospitals indicated that "the liver occupied multiple space, and the possibility of malignancy was high", so he went to our hospital for further treatment. Physical examination: There was no yellowing stain in the skin and sclera of the whole body, flat abdomen, no varicose veins, mild tenderness without rebound pain, and no moving voices. No prior history of hepatitis; Type 2 diabetes for 8 years, insulin control is acceptable; Hypertension 12 years, oral medication control can. Family history of infectious diseases and hepatobiliary system was denied. Laboratory tests: Hepatitis virus related tests were all negative, liver function Child-Pugh grade A (5 points), alpha-fetoprotein 644.02 μ g/L, blood routine and coagulation function were not abnormal. The results of abdominal gadoxetate disodium enhanced MRI showed that multiple nodules and tumor shadows could be seen in the liver, the larger one was located in the left hemiliver, about 120 mm ×96 mm ×79 mm in size, and the tumor thrombus of the left branch of the portal vein was filled into the main portal vein trunk, showing enhancement; The maximum diameter of the 7-segment tumor of the liver was 36 mm; The maximum diameter of the 6-segment tumor of the liver was 20 mm (Figure 1). Preliminary diagnosis: liver cancer complicated with portal vein tumor thrombosis (Chinese liver cancer stage-IIIA); Type 2 diabetes; Hypertension.

The patient, a 71-year-old female, was admitted to our department on August 11, 2021 due to "intrahepatic cholangiocarcinoma found in examination for more than 1 month". The patient was found to occupy space in the liver 1 month ago, and the imaging examination in the local hospital showed multiple occupying space in the liver with tumor thrombosis in the right anterior branch of the portal vein. A puncture biopsy was performed, and the pathological findings revealed cholangiocarcinoma. transcatheter arterial chemoembolization (TACE) combined with tislelizumab immunotherapy was given by another hospital. The patient had previously been implanted with a pacemaker due to atrial fibrillation with slow ventricular rate, and suffered from cerebral infarction 5 years ago, with grade 2 hypertension (high risk), which could be controlled by oral valsartan and hydrochlorothiazide tablets; Type 2 diabetes can be controlled by oral metformin; Trigeminal neuralgia. There was no history of kidney disease, no history of smoking or drinking, and no family history. Physical examination: clear, lips without cyanosis, superficial lymph nodes throughout the body without swelling, skin sclera without yellowing. Blood pressure 116/68 mmHg (1 mm Hg =0.133 kpa). Arrhythmia, remaining heart and lung physical examination is not special. The abdomen was flat and soft, with no tenderness or rebound pain in the whole abdomen, and no mass. The liver and spleen were not reached under the costs, the gallbladder was not palpable, the Murphy sign was negative, the intestinal sound was 3~5 times/min, and the mobile voiced sound was negative. There was no edema in both lower limbs. Laboratory test: white blood cell count 3.8×10⁹/L, hemoglobin 127 g/L, platelet count 124×10⁹/L, neutrophil percentage 57.1%, neutrophil absolute value 2.2×10⁹/L; Potassium ion 3.45 mmol/L, AST 136 U/L, ALT 215 U/L, alkaline phosphatase 402 U/L, glutamyl transpeptidase 1 104 U/L, albumin 39.3 g/L, total bilirubin 12 μ mol/L, direct bilirubin 5 μ mol/L, hypersensitive C-reactive protein 7.6 mg/L; 68.5 U/ml for CA125, 17.4 μ g/L for carcinoembryonic antigen, 7 116.3 U/ml for CA19-9 and 1 970 μ g/L for alpha-fetoprotein; Prothrombin time 12.1 s. CT angiography of the liver: intrahepatic cholangiocarcinoma with multiple intrahepatic metastases involving the right anterior branch of the portal vein (Figure 1). Diagnosis: (1) intrahepatic cholangiocarcinoma; (2) Portal vein tumor thrombus (right anterior branch); (3) Hypertension grade 2 (high risk); (4) type 2 diabetes; (5) History of cerebral infarction; (6) Atrial fibrillation (pacemaker placement); (7) fatty liver; (8) trigeminal neuralgia; (9) Middle cerebral artery sclerosis.