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。     

横结肠代食管全机械吻合在食管癌根治术中的应用

食管癌切除后,胃、空肠和结肠等器官均可用于食管重建。在不能用胃代食管的情况下,结肠代食管是一种理想的术式。2001年5月至2010年1月间淮安市第一人民医院对14例既往接受过胃大部切除术的食管癌患者．施行胸腹两切口食管癌根治结肠代食管胸内吻合术．均获成功．现报告如下。     

同时发生的食管胃重复癌的外科治疗

目的探讨同时发生的食管、胃重复癌的外科治疗方法及效果.方法1985年1月至2005年1月收治同时发生的食管、胃重复癌12例,均为男性,平均年龄56.8岁.全组均行手术治疗,成功完成同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道10例,食管内翻拔脱并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道1例,手术探查1例.结果全组无围术期死亡.术后颈部吻合口瘘2例,不全肠梗阻1例,均经保守治疗后痊愈;术后腹部切口裂开1例,二期缝合治愈.9例获得随访,1、3、5年生存率分别100%、44.4%、22.2%.结论同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道是根治同时发生的食管、胃重复癌安全有效的外科治疗方法.     

食管切除胃代食管后胸胃功能的研究现状

食管切除胃代食管后胸胃功能的研究现状陈克能师晓天综述杨国梁程邦昌审校食管部分或全部切除是当今治疗食管恶性肿瘤的主要手段［１～３］。食管切除后消化道的主要重建器官是胃，其次是结肠或空肠。结肠代食管能很好地恢复患者的吞咽功能，术后返流发生率低，这已为多数...     

结肠代食管重建术

虽然食管切除后胃是首选的替代器官,但当胃已被切除或有病变时,则结肠代食管通常为第一选择。因而,结肠代食管是食管重建不可或缺的手术方式。本文就结肠代食管的历史、解剖、技术要点及应用前景作一阐述,供大家参考。     

胃大部切除术后中下段食管癌术式的改进

长期以来外科切除食管癌后，习惯用胃重建消化道；对曾因胃及十二指肠疾患而行胃大部切除的食管癌病人，常采用结肠或空肠代胃术重建消化道或改行放疗。我们自１９８５年１月至１９９５年１２月，对７例胃大部切除术后食管癌病人改进术式，将残胃、脾、胰尾移入胸腔内，行...     

空肠代食管术在食管外科中的现状与展望

空肠代食管术是既往有胃切除史或同期行食管胃切除术病人重建消化道的一种可选术式.该术式一般是指切取一段带蒂血管的空肠,将其提入胸腔或颈部,近端与近段食管吻合、远端保持空肠连续性的一种手术,用于不能用胃或结肠代替食管的情况.空肠管具有血液循环丰富,肠腔开放后手术野的污染机会少等优点.我们回顾了使用空肠管进行食管重建的相关文...     

结肠重建食管围手术期的处理体会

当食管失去功能或因病变被切除后,最常用于代替食管的脏器是胃,其次是结肠或空肠。若胃已被切除或因某些原因不能以胃代食管时,则结肠为理想的代食管器官。我科1962～     

结肠或胃重建食管治疗食管烧伤后瘢痕狭窄100例

目的 总结结肠或胃重建食管治疗食管烧伤后瘢痕狭窄的临床经验及疗效。方法回顾分析100例应用结肠或胃重建食管烧伤后食管瘢痕狭窄的临床资料。74例未切除瘢痕段食管，结肠经胸骨后隧道上提至颈部或咽部吻合；26例经胸切除瘢痕段食管，行食管胃胸内吻合23例，颈部吻合3例。结果结肠重建食管死亡5例（6．8％），术后发生颈部吻合口瘘14例（18．9％），吻合口狭窄5例（6．8％）。26例胃重建食管者无死亡，术后发生吻合口狭窄2例，脓胸1例。结论食管烧伤后高位的广泛狭窄可旷置瘢痕段食管采用结肠重建，中下段病变能在主动脉弓下吻合者可切除瘢痕段食管用胃重建，提高外科技术可明显降低结肠重建食管的并发症。     

管状胃在食管癌手术应用的临床研究进展

正食管切除后的食管重建是食管外科需要面对的主要问题。传统的代食管器官包括胃、结肠和空肠等。临床上常用的胃代食管方式包括全胃、次全胃、半管状胃和细管状胃等~([1])。Haverkamp等~([2])调查世界范围内435位胸外科医生代食管器官选择,95.0%选择管状胃,3.0%选择间置空肠,1.0%选择间置结肠,1.0%选择全胃。管状胃是食管癌术中代食管的首选器官。     

食管缺损的显微外科修复与重建

目的 探索食管狭窄,闭锁或缺损的修复与重建,手术适应证,手术要点及并发症的防治。方法 采用吻合血管的带蒂空肠,游离空肠,肠瓣及前臂皮瓣移植等手术对化学灼伤或其它原因致全食管,上胸段及颈段食管狭窄或闭锁的病人进行修复与重建,结果 成功４４例,失败１例,结论吻合血管的带蒂或游离空肠及肠瓣移植修复与重建是治疗食管狭窄,闭锁,缺损的理想手术方法。经腹部多次手术的颈段食管缺损病人可采用吻合血管的皮瓣或皮管移     

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.     

Reconstruction of the voice after laryngectomy

Voice reconstruction and rehabilitation are important for quality of life for patients after surgical ablation of tumors in the larynx or pharynx. In addition to the esophageal voice, the artificial larynx, and external voice devices, the following procedures have been developed: (1) after laryngectomy with preservation of pharynx, neoglottis or TEP can be performed; (2) after laryngopharyngectomy a forearm flap with TEP, or a jejunal transfer with TEP or voice tube shunt can be selected; and (3) after laryngopharyngoesophagectomy, either pharyngogastrotomy with TEP, or colon segment interposition with TEP can be employed. The voice tube shunt is improving, and allograft transplantation is currently under investigation.     

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.     

Subcutaneous placement of a free jejunum and pedicled colon segment to create a diversionary conduit for total esophageal reconstruction

In this report, we describe a case of difficult esophageal reconstruction with a pedicled colon segment interposition and a free jejunal flap. Laryngectomy and bilateral neck dissection for larynx carcinoma had been attempted in a 59-year-old patient 6 years previously. The patient then received radiotherapy. One year later, large resection was performed due to recurrence of the tumor. Since then the patient had been fed through a gastrostomy tube. Previous attempts at esophageal reconstruction in other institutions were unsuccessful. We reconstructed the total esophagus with subcutaneously tunneled pedicled colon segment interposition and a free jejunal flap using the diversionary loop technique to divert the passage of the foot from the pharynx to the new inlet at the buccogingival sulcus, thus keeping the native esophagus untouched. Following a postoperative training period, the patient learned to swallow successfully and smoothly via the new inlet. The patency of the newly reconstructed esophagus was corroborated by radiological imaging. In summary, although the technique requires complex surgical procedures, it is effective and may be considered as an alternative and reliable option in selected cases.     

Free jejunal flap transfer for pharyngoesophageal reconstruction in patients with intestinal malrotation: Two case reports

Intestinal malrotation results from failure of intestinal rotation and fixation during fetal life. We report two cases of esophageal reconstruction with free jejunal flaps following total laryngopharyngectomy of hypopharyngeal and cervical esophageal carcinoma in which intestinal malrotation was detected during the jejunal flap harvesting. In both cases, the ligament of Treitz was absent, and the laparotomy incision was thus extended to identify the jejunum. In case 1, harvesting an adequate length of the vascular pedicle of the flap was impossible because of the abnormal position of the pancreas; thus, a jejunal flap of maximal length was harvested for optimal pedicle positioning in the recipient site. In case 2, Ladd's ligament prohibited the release of the jejunum from the ascending colon and required its dissection. Both patients underwent successful reconstruction. When the ligament of Treitz is absent during jejunal flap harvesting, investing the whole bowel by extended laparotomy incision is recommended. When anatomical abnormality caused by intestinal malrotation is detected, releasing an adhesion of the jejunum from circumferential organs and identifying the adequate vascular pedicle of a jejunal flap are necessary. If harvesting the long vascular pedicle is impossible, a jejunal flap of maximal length should be harvested for optimal positioning for vascular anastomosis at the shortest distance in the recipient site. © 2014 Wiley Periodicals, Inc. Microsurgery 34:582–585, 2014.     

Combined use of the cephalic vein and pectoralis major muscle flap for secondary esophageal reconstruction

Secondary reconstruction of thoracic esophageal defects is a challenging problem for microsurgeons. Because of previous surgeries and coexisting disease, gastric pull‐up, and creation of a pedicled colon conduit are often impossible. Transfer of a supercharged pedicled jejunum flap or free jejunal interposition is usually the last resort; however, identifying appropriate recipient vessels and adequately covering the reconstructive conduit are often difficult. We performed secondary thoracic esophageal reconstruction with combined use of the cephalic vein as a recipient vein and the pectoralis major muscle flap for coverage in three patients. Two patients underwent transfer of a supercharged pedicled jejunum flap, and the other patient underwent free jejunal interposition. No wound complications occurred, and all patients could resume oral intake. The cephalic vein is a more reliable recipient vein than is the internal mammary vein. The skin graft‐covered pectoralis major muscle flap provides secure external coverage to prevent anastomotic leakage even in complicated cases. Combined use of the cephalic vein and the skin graft‐covered pectoralis major muscle flap is a versatile option for secondary thoracic esophageal reconstruction. © 2013 Wiley Periodicals, Inc. Microsurgery 34:319–323, 2014.     

Double vascular pedicled free jejunum transfer for total esophageal reconstruction

A double vascular pedicled free jejunum was transferred in two patients with complete esophageal defect. When the stomach and colon, which are usually employed for esophageal reconstruction, cannot be used due to previous operations or for other reasons, the jejunum is the next alternative. However, pedicled jejunal transposition is limited in length and may not reach a suitable level over the lower cervical esophagus, even if the distal portion is supercharged. Under such circumstances, a long jejunal segment with two vascular pedicles can be transferred as a free flap and used to reconstruct the whole esophagus in one stage. The paper describes two cases and discusses the advantages of double vascular pedicled free jejunum transfer.     

Combination of a free jejunal flap and a Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report

Pneumatic perforation of the esophagus caused by blast injury is very rare. Our patient presented with esophageal stricture in the context of a previous reconstruction of an esophageal rupture secondary to a distant air-blast injury. The ruptured esophagus was initially reconstructed with a left pedicled colon interposition in an antiperistaltic pattern. However, dysphagia developed 4 years later because of severe reflux-induced stenosis at the junction of the cervical esophagus and the left pedicled colon segment. A free isoperistaltic jejunal flap was performed to replace the cervical esophagus, with an anti-reflux Roux-en-Y colojejunostomy between the caudal segment of the left pedicled colon and the jejunum. The patient was discharged uneventfully 29 days later with smooth esophageal transit and no further reflux, as shown by scintigraphic scan. Esophageal reconstruction in an isoperistaltic pattern using a free isoperistaltic jejunal flap combined with an anti-reflux Roux-en-Y colojejunostomy has never been reported in the literature and appears to be an effective method to provide smooth passage of food and prevent restenosis of the esophagus.     

Intussusception of a transferred jejunal flap in cervical esophagus reconstruction

Although jejunal flaps have been used frequently for esophageal reconstruction, and the techniques for transfer, as well as subsequent modification, have been well described, a variety of complications still poses problems for both physicians and patients. The challenge exists in avoidance and management of complications. The purpose of this report is to present an unusual but severe complication involving a jejunal flap that was transferred to the neck for esophageal reconstruction. Intussusception of the jejunal flap occurred 1 year after flap transfer due to redundancy of the transferred segment. The patient was a child who had esophageal reconstruction for severe dysphagia that was due to a previous history of radiation injury. The disorder was successfully treated surgically with manual reduction of the intussuscepted segment, followed by shortening of the jejunal flap to prevent future recurrence. One should keep in mind that redundancy of the reconstructed esophagus may cause dysphagia due to kinking or, in this case, intussusception, which may result in necrosis of a segment of the transferred jejunum. One of the measures that should be taken during the initial reconstruction to prevent these serious complications is to perform the final inset of the jejunal flap after revascularization. This allows for proper assessment of jejunal length, which undergoes a significant change after restoration of the vascular supply.