Objective: To investigate the clinical value of laparoscopic peritoneal dialysis catheter implantation in peritoneal chemotherapy for gastric cancer with peritoneal metastasis. Methods: From January 2019 to June 2019, the clinical data of 6 patients diagnosed as gastric cancer with peritoneal metastasis were retrospectively analyzed in the Gastrointestinal Surgery Department of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine. Five were male and 1 was female. The median age was 69.5 (28-77) years. The median body mass index (BMI) was 22.8 (19.6-23.5). All procedures were performed under general anesthesia with endotracheal intubation. The patient's body position and facility layout in the operating room were consistent with those of laparoscopic gastrectomy. The operator's position: the main surgeon was located on the right side of the patient, the first assistant stood on the left side of the patient, and the scopist stood between the patient's legs. Surgical procedure: (1) trocar location: three abdominal trocars was adopted, with one 12 mm umbilical port for the 30° laparoscope (point A). Location of the other two trocars was dependent on the procedure of exploration or biopsy as well as the two polyester cuff position of the peritoneal dialysis catheter: Usually one 5 mm port in the anterior midline 5 cm inferior to the umbilicus point was selected as point B to ensure that the distal end of the catheter could reach the Douglas pouch. The other 5 mm port was located in the right lower quadrant lateral to the umbilicus to establish the subcutaneous tunnel tract, and the proximal cuff was situated 2 cm away from the desired exit site (point C).(2) exploration of the abdominal cavity: a 30° laparoscope was inserted from 12 mm trocar below the umbilicus to explore the entire peritoneal cavity. The uterus and adnexa should be explored additionally for women. Once peritoneal metastasis was investigated and identified, primary laparoscopic peritoneal dialysis catheter implantation was performed so as to facilitate subsequent peritoneal chemotherapy. Ascites were collected for cytology in patients with ascites. (3) peritoneal dialysis catheter placement: the peritoneal dialysis catheter was introduced into the abdominal cavity from point A. Under the direct vision of laparoscopy, 2-0 absorbable ligature was reserved at the expected fixation point of the proximal cuff (point B) for the final knot closure. Non-traumatic graspers were used to pull the distal cuff of peritoneal dialysis catheter out of the abdominal cavity through point B. The 5-mm trocar was removed simultaneously, and the distal cuff was fixed between bilateral rectus sheaths at the anterior midline port site preperitoneally. To prevent subsequent ascites and chemotherapy fluid extravasation, the reserved crocheted wire was knotted. From point C the subcutaneous tunnel tract was created before the peritoneal steath towards the port site lateral to the umbilicus. Satisfactory catheter irrigation and outflow were then confirmed. Chemotherapy regimen after peritoneal dialysis catheterization: all patients began intraperitoneal chemotherapy on the second day after surgery. On the 1st and 8th day of each 3-weeks cycle, paclitaxel (20 mg/m(2)) was administered through peritoneal dialysis catheter, and paclitaxel (50 mg/m(2)) was injected intravenously. Meanwhile, S-1 was orally administered twice daily at a dose of 80 mg·m(-2)·d(-1) for 14 consecutive days followed by 7-days rest. To observe the patients' intraoperative and postoperative conditions. Results: All the procedures were performed successfully without intraoperative complications or conversion to laparotomy. No 30 day postoperative complications were observed. The median operative time was 33.5 (23-38) min. The median time to first flatus was 1(1-2) days, and the median postoperative hospital stay was 3 (3-4) days, without short-term complications within 30 days postoperatively. The last follow-up was up to July 10, 2019, and the patients were followed for 4(1-6) months. No ascites extravasation was observed and no death occurred in the 6 patients. There was no catheter obstruction or peritoneal fluid extravasation during and after chemotherapy. Conclusion: Laparoscopic peritoneal dialysis catheter implantation was safe and feasible for patients with peritoneal metastasis of gastric cancer. The abdominal exploration, tumor staging and the abdominal chemotherapy device implantation can be completed simultaneously, which could simplify the surgical approach, improve the quality of life for patients and further propose a new direction for the development of abdominal chemotherapy.
目的： 探讨腹腔镜腹膜透析管置入术在胃癌腹膜转移腹腔化疗中的临床价值。 方法： 本研究采用描述性病例系列研究方法，回顾性分析2019年1—6月期间，上海交通大学医学院附属瑞金医院胃肠外科收治的6例因胃癌腹膜转移而接受腹腔镜腹膜透析管置入术，并进行腹腔化疗患者的临床数据。其中男5例，女1例。中位年龄69.5（28~77）岁。中位体质指数（BMI）22.8（19.6~23.5）kg/m(2)。所有手术均在气管插管全身麻醉下进行，患者体位、手术室设备布置均与腹腔镜胃癌手术相同，术者站位：主刀位于患者的右侧，第一助手站立于患者左侧，持镜者站在患者两腿之间，完成探查后持镜者换位至患者右侧近头侧。手术过程：（1）戳孔选择：取腹壁3戳孔穿刺进腹。其中脐孔处为12 mm Trocar放置30°镜头（A点），另两个5 mm Trocar位置则依据探查活检等操作需要，并结合术中腹透管的两个涤纶套环位置而定：一个5 mm Trocar通常选取脐孔下方4~6 cm近中线的位置（B点），该点的选取须保证腹透管的远端头部能到达盆腔Douglas窝；另一5 mm Trocar用于在皮下建立隧道，将腹透管引出固定于皮下，一般选在脐右侧偏下，近腋前线，距离皮下浅涤纶套环2 cm即可（C点）。（2）探查腹腔：自脐下12 mm Trocar置入30°镜头，探查整个腹膜腔，女性还需探查子宫与附件。探查明确腹膜转移，无法接受根治性手术者，即一期行腹腔镜下腹膜透析管置入术，以便后续腹腔化疗。伴腹水者同时取腹水收集，做脱落细胞学检查。（3）腹膜透析管留置：将腹膜透析管从A点送入腹腔内。腹腔镜直视下，先使用勾线针，对深涤纶套管拟固定处的腹壁戳孔（B点）预留2-0可吸收线，以备最后打结闭合该处戳孔。无损伤钳抓住腹膜透析管的近端，通过B点引出体外，同时拔去该5 mm Trocar，并使深涤纶套环固定于腹膜前，将预留在深涤纶套管固定处的戳孔的2-0可吸收线收紧打结，以防后续腹水和化疗液外渗。从C点将穿刺Trocar经腹膜前潜行，建立皮下隧道至B点皮肤戳孔穿出，通过该Trocar用腔镜无损伤钳抓住腹膜透析管近端向着出口处（C点）缓慢拖出，拔除该Trocar，在腹膜透析管近端连接钛接头和短管后向管内注入适量的生理盐水，观察腹腔内腹膜透析管可顺利出水。调整患者体位为头高脚低后，将腹膜透析管近端出口放置低位，确认生理盐水自出口流出呈直线状，证实通畅无阻。腹膜透析管置入术后化疗方案：所有患者均于术后第2天开始腹腔化疗，化疗第1和第8天，经腹膜透析管输注紫杉醇（20 mg/m(2)），并静脉输注紫杉醇（50 mg/m(2)）；同时连续14 d口服替吉奥80 mg·m(-2)·d(-1)，停药7 d，21 d为1个疗程。观察患者术中及术后情况。 结果： 6例患者手术均获成功，中位手术时长33.5（23~38）min，无术中出血、术中并发症和中转开腹。中位排气时间1（1~2）d，中位住院时间为3（3~4）d，无术后30 d内短期并发症。随访截至2019年7月10日，中位随访时间4（1~6）个月，患者术后无腹水外渗，随访期内无死亡病例。化疗过程中无导管堵塞，腹腔化疗过程中及腹腔化疗后，亦均无腹腔液体外渗。 结论： 腹腔镜腹膜透析管置入术用于胃癌腹膜转移的患者，可在完成腹腔探查、进行肿瘤分期的同时，完成腹腔化疗装置的置入，简化手术方式，降低费用，提高患者生活质量，并使长期进行腹腔化疗或腹腔温热灌注化疗成为可能，为腹腔化疗的发展提出了新的方向。.
Keywords: Gastric neoplasms; Intraperitoneal chemotherapy; Laparoscopy; Peritoneal dialysis catheter; Peritoneal metastasis.