原发食管贲门二元癌的外科治疗6例

目的探讨原发食管贲门二元癌的外科治疗及效果。方法1991年1月至2006年12月收治的原发食管贲门二元癌6例,全组均行手术治疗,5例采用消化道缝合器切除贲门病变,缝合成管状胃,完全切除食管病变,胃代食管胸腔内吻合重建消化道,1例行全胃切除,行食管-空肠端侧吻合,空肠"U"袢代胃重建消化道。结果全组无围术期死亡,无吻合瘘发生。全组均获得随访,1、3、5年生存率分别是100%、50%、33.3%。结论原发食管贲门二元癌应用消化道缝合器切除贲门病变可提高胃的利用距离,下段食管癌胃全切后,利用空肠"U"袢代胃,均可行胸腔内吻合,使手术治疗方便、安全。     

3S型与P袢型空肠代胃在全胃切除后消化道重建中的应用比较

目的 比较3S型空肠代胃和P袢型空肠代胃在全胃切除术消化道重建中的临床作用.方法2005年2月至2009年2月间河南科技大学附属第一医院肿瘤科进行全胃切除术85例,其中46例采用3S型空肠代胃、39例P袢型食管空肠Roux-en-Y吻合进行消化道重建,比较两种重建术后6个月的并发症发生情况、营养状况及生活质量.结果 两...     

胃大部切除术后食管癌的手术治疗

目的 探讨胃大部切除术后食管癌的手术治疗方式和效果。方法 对1972年至1998年间20例胃切除术后食管癌的手术治疗进行分析。结果 左、右后外开胸、上腹正中开腹及左颈3切口,食管癌切除、移植结肠至颈部与食管吻合,腹腔结肠与残胃吻合7例;胸腹联合切口,食管癌切除,将残胃、脾、胰体尾移入左胸内,行食管残胃弓上吻合,空肠Roux-en-Y重建消化道3例;食管残胃弓上吻合,空肠Roux-en-Y重建消化道4例;食管空肠Roux-en-Y重建消化道4例;探查并行小肠造瘘术2例。本组食管癌切除率为90．0％（18／20）。总并发症为30．0％（6／20）。1、3、5年生存率分别为90．0％、64．3％和36．4％。结论 胃大部切除术后食管癌的手术治疗需根据病变部位和病情选择手术方式。胸上段癌采用移植结肠代食管术,胸中、下段癌采用残胃及小肠代食管术,胸下段癌采用选择性小肠代食管术,其方法较为合理。残胃、脾、胰体尾移植入左胸内、食管癌切除、食管残胃吻合、空肠Roux-en-Y重建消化道可供临床作为一种新术式,值得推荐。     

胃大部切除术后食管癌患者消化道重建

目的探讨胃大部切除术后食管癌患者上消化道重建的策略。方法胃大部切除术后食管癌患者31例,其中结肠代食管重建消化道16例,空肠代食管8例,残胃代食管7例。结果全组无手术死亡患者,术后发生并发症8例(25.8%),治疗后全组患者均痊愈出院,患者1、3、5年生存率分别为96.8%、45.2%和32.3%。结论胃大部切除术后再发食管癌患者可通过手术根治,结肠、空肠或残胃均可用于消化道重建,掌握不同术式特点及适应证,有利于提高手术成功率,改善患者预后。     

全胃切除术后三种消化道重建术式的比较研究

目的 探讨全胃切除术后合理的消化道重建方式。方法对189例胃癌患者全胃切除术后分别采用了Orr式Roux-en-Y空肠食管吻合术、P形空肠袢空肠食管Roux-en-Y吻合术和Moynihan式吻合术进行消化道重建，对其手术时间、手术并发症、术后1、3年饮食状况和消化道症状及营养指标进行对比观察。结果3种术式的患者手术死亡率、术后1年和3年的饮食状况、腹泻和倾倒综合征的发生率比较，均P〉0．05；差异无统计学意义。术后1、3、5年的累计生存率比较，P〉0．05，差异也元统计学意义。Orr式空肠食管Roux-en-Y吻合术和P形空肠袢空肠食管Roux-en-Y吻合术后均能有效地防止反流性食管炎，明显优于Moynihan式吻合术（P〈0．01）。Orr式空肠食管Roux-en-Y吻合术较P形空肠袢空肠食管Roux-en-Y吻合术操作简单、手术时间短、手术并发症也较少。结论Orr式空肠食管Roux-en-Y吻合术是胃癌全胃切除后消化道重建较为合适的术式。     

全胃切除消化道重建的探讨

为提高患者全胃切除术后生活质量 ,我科于 1992年1月至 1998年 6月对 5 0例胃底、胃体癌行全胃切除空肠Ｐ袢(单通道消化道重建 )和空肠间置袢式代胃进行对比分析。临床资料1.一般资料 :本组 5 0例 ,按术式分为 2组 ,行全胃切除空肠Ρ袢组 2 5例 ,行空肠间置袢式代胃组 2 5例。空肠间置袢式代胃组平均年龄为 5 6岁 ,平均手术时间 3 2ｈ ,术中出血40 0ｍｌ,术后无吻合口瘘 ,术后进食时间为 7ｄ。2 手术方法 :空肠间置袢式代胃术式 :全胃切除后 ,将空肠距屈氏韧带 2 0～ 40ｃｍ处切断 ,将吻合器经空肠远端置入 ,于 70～ 80ｃｍ处与近端肠管行…     

介绍一种新的消化道重建术

从 198 9年 6月～ 1997年 11月我们在改良Ｒｏｕｘ Ｙ消化道重建的基础上 ,又重新设计了一种新的消化道重建方式———十二指肠异向排空重建术 ,现报告如下。1　资料和方法1 1　一般资料　完成手术 38例 ,男 32例 ,女 6例。年龄 48～ 79岁。术前诊断为贲门癌 13例 ,胃小弯癌 5例 ,胃体癌 3例 ,胃溃疡 12例 ,十二指肠溃疡 5例。1 2　手术方法　行全胃切除或胃次全切除后 ,十二指肠残端嵌加不缝合 ,备用。再行结肠前的空肠食管或空肠胃 (输出袢对胃小弯 )的吻合 ,然后将十二指肠残端与输出袢空肠在结肠上区行端侧吻合 (如图 1,2 )。术后常规胃…     

胃癌全胃切除术后3种消化道重建方式的比较研究

目的：探讨胃癌全胃切除术后理想的消化道重建方式。方法：对191例胃癌患者按全胃切除术后消化道重建方式的不同,分为Roux-en-Y空肠食管吻合术组（R组）、袢式Braun吻合术组（B组）和袢式空肠代胃改良Ⅰ式吻合术组（L组）,比较3种术式患者的手术死亡率、术后并发症发生率、进食量、营养指标及存活率。结果：3种术式的患者手术死亡率、术后并发症发生率、3年累积存活率比较差异无统计学意义（P〉0.05）;与其他2组比较,L组术后6、12个月时单餐进食量明显占优（P〈0.05）;L组术后1年的平均体重、血清学营养指标及预后营养指数均优于R组和B组,差异有统计学意义（P〈0.05）。结论：袢式空肠代胃改良Ⅰ式吻合术能明显改善患者的生活质量,是胃癌行全胃切除消化道重建较理想的术式。     

胃癌全胃切除术后两种消化道重建术式的比较

目的 探讨全胃切除术后消化道重建方式的选择. 方法我院2001年6月至2006年6月期间对182例胃癌患者全胃切除术后分别行空肠ρ袢代胃术(PRY)69例和非离断式食管空肠改良Roux-en-Y吻合术(URY)113例. 分析手术时间、术后进食情况、消化道症状及营养状况的差异.结果 非离断式食管空肠改良Roux-en-Y吻合术手术时间短于空肠ρ袢代胃术,且无Roux潴留综合征(RSS)发生. 2种术式术后患者营养状况并无明显差异.结论 非离断式食管空肠改良Roux-en-Y吻合术操作简单、并发症少、术后恢复良好,可以推荐作为全胃切除术后的消化道重建术式.     

食管癌和食管胃结合部癌术后复发与再发癌的手术疗效

目的 探讨食管癌和食管胃结合部癌术后复发与再发癌的手术疗效.方法 回顾性分析2002年4月至2012年10月河北医科大学第四医院收治的15例食管癌和食管胃结合部癌术后复发或再发癌患者的临床资料.12例复发癌患者确诊距第1次手术平均时间为28个月(8～ 66个月),3例再发癌患者确诊距第1次手术平均时间为196个月(60 ～288个月).对吻合口局部复发患者,如果切除复发癌后残胃大小足够重建食管,则用残胃重建食管.复发癌切除后残余胃不足以重建食管或需同时进行全胃切除,则根据患者的身体状况采用结肠或空肠代食管.术后对所有患者每半年随访1次,随访时间截至患者死亡或2012年12月31日.术后2年内每半年进行1次胸腹部CT与上消化道造影检查,术后2年每年进行1次胸腹部CT与上消化道造影检查,对于可疑患者进行胃镜检查.根据患者第2次术后临床病理分期,采用Kaplan-Meier方法计算生存率,生存分析采用Log-rank检验.结果 15例手术患者中,10例贲门腺癌术后吻合口复发患者,4例行复发癌切除+残胃与食管胸内吻合术,4例行结肠代食管术,2例行空肠代食管术;3例贲门腺癌术后再发食管鳞癌患者,2例行肿瘤切除+结肠代食管术,1例行食管下段癌与残胃切除+食管空肠Roux-en-Y吻合术;2例食管癌术后吻合口复发患者,行复发癌切除+颈部食管胃吻合术.患者平均手术时间为460 min(390～540 min);术中平均出血量为430 ml(200～700 ml);术后发生ARDS、肺部感染、颈部切口感染各1例;死亡2例,其中1例为突发心肌梗死,另1例为术后出现顽固性低蛋白血症合并肺部感染死亡;平均住院时间为29.5 d(25 ～36 d).15例再手术患者中,Ⅰa期1例、Ⅰb期1例、Ⅱa期4例、Ⅱb期4例、Ⅲa期5例.13例获得随访的患者中,6例Ⅰ、Ⅱa期患者中位生存时间为25个月,7例Ⅱb、Ⅲ期患者中位生存时间为16个月,两者比较,差异有统计学意义(x2=8.91,P＜0.05).结论 食管癌、食管胃结合部癌术后复发与再发癌患者再手术治疗在技术上安全可行,可使患者生存获益.但再手术风险较大,要严格掌握手术适应证.     

A two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap

When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.     

Cancer of the gastric tube reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer.

Among 750 patients diagnosed with esophageal carcinoma in our department between 1972 and 1997, we reviewed our 10 cases in which cancer occurred within gastric tubes reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer. The interval between esophagectomy and cancer onset in the reconstructed gastric tube was relatively long (mean interval: 72 months). Five of our 10 subjects had gastric tube cancer detected at follow-up endoscopy. Four underwent total or partial gastric tube resection with open thoracotomy using colonic or jejunal reconstruction; 3 underwent endoscopic resection. To the best of our knowledge, this is the first report on patients undergoing total resection of gastric tubes reconstructed through the posterior mediastinal route after esophagectomy and rereconstruction using the pedicled colon for the gastric tube cancer.     

Cancer of the gastric tube reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer

Among 750 patients diagnosed with esophageal carcinoma in our department between 1972 and 1997, we reviewed our 10 cases in which cancer occurred within gastric tubes reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer. The interval between esophagectomy and cancer onset in the reconstructed gastric tube was relatively long (mean interval: 72 months). Five of our 10 subjects had gastric tube cancer detected at follow-up endoscopy. Four underwent total or partial gastric tube resection with open thoracotomy using colonic or jejunal reconstruction; 3 underwent endoscopic resection. To the best of our knowledge, this is the first report on patients undergoing total resection of gastric tubes reconstructed through the posterior mediastinal route after esophagectomy and rereconstruction using the pedicled colon for the gastric tube cancer.     

结肠移植食管重建术治疗胃大部切除术后中段以上食管癌

目的探讨应用结肠移植食管重建术治疗胃大部切除术后中段以上食管癌的疗效。方法回顾性分析1999年至2006年期间,胃大部切除术后患中段以上食管癌并接受结肠移植食管重建术治疗的18例患者病历资料。结果18例接受结肠移植食管重建术治疗患者均获手术成功。术后1例并发声音嘶哑,2例并发颈部吻合121瘘,3例并发肺部感染,总并发症发生率为33．3％（6／18）,除1例术后肺内重症感染患者因呼吸衰竭围手术期死亡外,其余5例出现术后并发症患者均治愈。结论胃大部切除术后中段以上食管癌采用结肠移植食管重建术治疗是可行、安全的。为减少术后并发症应加强围手术期的处理和精细手术操作。     

Recurrence of gastric cancer in the jejunal stump after radical total gastrectomy

This is a very rare case of the recurrence of gastric cancer in the jejunal stump after radical total gastrectomy with Roux-en-Y reconstruction.In January 2008,a 65-year-old man underwent radical total gastrectomy with Roux-en-Y reconstruction for stageⅠB gastric cancer of the upper body.At a follow-up in December2011,the patient had a recurrence of gastric cancer on gastroduodenal fibroscopy.The gastroduodenal fibroscopic biopsy specimens show a well-differentiated tubular adenocarcinoma.Computed tomography showed no lymphadenopathy or hepatic metastases.At laparotomy,there was a tumor in the jejunal stump involving the pancreatic tail and spleen.Therefore,the patient underwent jejunal pouch resection,distal pancreatectomy and splenectomy.The patient was diagnosed with gastric cancer on histopathological examination.     

胃手术后患者中、上段食管癌的外科治疗

目的探讨胃手术后再患食管中、上段癌的外科治疗方法。方法回顾分析1980—2004年收治的86例胃手术后食管癌患者的临床资料。食管中段癌50例,上段癌31例,颈段5例。TNM分期：Ⅰ期16例,Ⅱa期62例,Ⅱb期5例,Ⅲ期3例。既往曾行全胃或胃部分切除术,术后至诊断为食管癌的时间为2～22年。手术术式：病变食管切除以残胃上提代食管2例,倒置胃管代食管3例,短段带血管蒂结肠问置代食管5例,长段血管蒂结肠代食管74例,空肠造口减状术2例。结果术后30d内出现并发症10例(12％),经处理治愈。76例(88％)病变食管切除,恢复正常进食;7例(8％)病变食管旷置,经口进食;2例空肠造口给肠内营养;1例死亡。术后随访67例,术后1,3,5年生存率分别为84％(56／67),57％(38／67)和22％(15／67)。结论胃手术后再患食管中、上段癌患者的治疗仍首选手术切除病变食管,大部分的病例可采用结肠代食管。     

Feasibility of esophageal reconstruction using a pedicled jejunum with intrathoracic esophagojejunostomy in the upper mediastinum for esophageal cancer

Objective

An alternative conduit is needed when the gastric tube cannot be used as an esophageal substitute for reconstruction after esophagectomy. We adopted pedicle jejunal reconstruction with intrathoracic anastomosis in the upper mediastinum under such circumstances. The aim of this study was to evaluate the feasibility of this technique.

Methods

Two hundred and ten patients with esophageal cancer underwent esophagectomy and reconstruction from 1998 to 2013. Among them, 6 patients underwent colon interposition (colon group) and 13 underwent jejunum reconstruction (jejunum group) including 8 thoracoscopic anastomosis. The operative results of both groups were compared with those of 191 gastric tube reconstructions (stomach group).

Results

The operative times in the colon and jejunum groups were significantly longer than that in the stomach group (P = 0.001 and P = 0.018, respectively). The colon group showed more operative blood loss and more frequent anastomotic leakage and ischemic stenosis of the conduit than did the stomach group (1605 vs. 530 g, P = 0.007; 50 vs. 12.6 %, P = 0.035; 16.7 vs. 0 %, P = 0.03, respectively). There was no anastomotic leakage, conduit necrosis and mortality in the jejunum group. Ischemic stenosis of the conduit occurred more frequently in jejunum group than in the stomach group (23.1 vs. 0 %, P < 0.001). However, the stenosis could be managed safely with endoscopic treatment. Patient survival in the colon and jejunum groups was consistent with that in the stomach group.

Conclusions

Pedicle jejunal reconstruction with intrathoracic anastomosis can be performed safely under thoracotomy or thoracoscopic surgery when stomach cannot be used as an esophageal substitute after esophagectomy.     

Two-stage operation for synchronous triple primary cancer of the esophagus,stomach, and ampulla of Vater: report of a case

A 69-year-old man with jaundice was diagnosed with cancer of the ampulla of Vater by endoscopic retrograde cholangiopancreatography and abdominal computed tomography. A screening gastrointestinal endoscopy showed middle thoracic esophageal cancer and early gastric cancer on the anterior wall of the lower gastric body. We chose a two-stage operation for synchronous triple primary cancer of the esophagus, stomach, and ampulla of Vater, in order to safely perform the curative resection of these three cancers. The first-stage operation consisted of a right transthoracic subtotal esophagectomy with mediastinal and cervical lymph node dissection, an external esophagostomy in the neck, and a gastrostomy. Thirty-five days after the first surgery, a total gastrectomy with regional lymph node dissection, and a pancreatoduodenectomy with Child’s reconstruction were performed as the second-stage surgery. Esophageal reconstruction was achieved using the ileocolon via the percutaneous route without vascular anastomosis.     

Subtotal or total gastrectomy for gastric cancer: impact of the surgical procedure on morbidity and prognosis—analysis of a 10-year experience

Background Against the background of the continuing controversy as to the surgical procedure of choice for gastric cancer, the aim of the present study was to evaluate perioperative morbidity, prognostic factors of survival, and long-term survival after subtotal, abdominal and abdominothoracic gastrectomy in patients with gastric cancer.Patients and methods Between January 1993 and December 2002, 338 consecutive patients underwent surgery for adenocarcinoma of the stomach. Subtotal gastrectomy was carried out in 80 (23.7%) patients; 240 (71.0%) patients had abdominal gastrectomy, and 18 (5.3%) underwent abdominothoracic gastrectomy.Results At an overall 30-day mortality of 3.6% (hospital mortality, 5.2%), the total complication rate was 16.3%. The estimated 5-year survival rate was 43% in patients after subtotal gastrectomy, 39% in patients with abdominal gastrectomy, and 28% in patients with abdominothoracic gastrectomy after complete tumour clearance, without significant differences between the groups. Patients who underwent left pancreatectomy and had a higher ratio of metastatic/dissected lymph nodes were characterised by a significantly poorer prognosis.Conclusion The lower morbidity and mortality rate with a nearly identical long-term survival yielded by subtotal gastrectomy compared with total gastrectomy leads us to justify subtotal gastrectomy, especially in elderly patients with comorbidity and a high operative risk, on the condition that its performance is radical from an oncological point of view.     

腹腔镜胃癌根治术中医源性损伤的原因分析与防治

目的分析腹腔镜胃癌根治术中医源性损伤的原因。方法 2008年1月~2009年12月共行腹腔镜胃癌根治手术117例(包括全胃切除术32例,近端胃大部切除术27例,远端胃大部切除术58例),发生医源性损伤9例(7.7%)。回顾分析这9例的临床资料。结果脾损伤4例,压迫止血,成功保脾;横结肠损伤1例,辅助小切口以1号线缝合修补;横结肠系膜血管损伤1例,辅助小切口行横结肠部分切除端端吻合;肝左动脉损伤1例,未处理;肝脏挫裂伤1例,辅助小切口以1号线间断缝合挫裂口;残胃浆膜挫裂伤1例,可吸收线间断缝合修补。9例均治愈出院。结论腹腔镜胃癌根治术中医源性损伤多发生在开展本手术的早期,与显露不佳、操作不当有关。