改进的贲门癌切除食管胃端侧吻合术

1995年起我们的96例贲门癌病人,行改进的贲门癌切除、食管胃端侧吻合术,无一侧发生吻合口狭窄及吻合口瘘。术后6个月内行头低脚高位钡餐X线检查43例病人中,吻合口直径1.0～1.5cm。食管镜检及活检31例中,13例轻度粘膜充血水肿,余者正常。     

食管、贲门癌切除器械吻合术519例

目的 总结食管、贲门癌切除后应用器械吻合防止吻合口瘘和狭窄的临床经验。方法 回顾性地分析519例食管、贲门癌患者应用吻合器治疗的结果。结果 发生并发症7例,包括吻合口瘘2例,吻合口出血2例,吻合口狭窄3例,无手术死亡和住院死亡。结论 器械吻合完整快捷,明显地减少了手术操作时间和吻合口并发症的发生,降低了手术死亡率。     

食管胃套接术与器械吻合术治疗食管、贲门癌的对比研究

目的对比食管胃套接术与器械吻合术的临床治疗效果,以减少食管、贲门癌根治术后并发症的发生率. 方法将285例诊断明确的食管、贲门癌住院患者按入院顺序随机分为两组,食管胃套接组(套接组)134例,采用食管癌切除食管瓣片成形-食管胃套接术;器械吻合组(吻合组)151例,采用食管癌切除器械吻合术.术后观察吻合口瘘、吻合口狭窄和胃食管反流并发症的发生率,并随访观察3年. 结果套接组术后吻合口瘘、吻合口狭窄和胃食管反流的发生率分别为0%、2.2%和1.5%,而吻合组为1.3%、13.9%和21.2%(P<0.01). 结论食管瓣片成形-食管胃套接术术后并发症少、操作简单,较器械吻合具有一定的优越性.     

Ethicon PROXIMATE ILS吻合器在食管胃弓下吻合术中的临床应用研究

食管胃弓下吻合术是食管胸下段癌、贲门癌食管胃部分切除术后常用的吻合方法。一般采用手工吻合方法,可根据需要采用端端吻合、端侧吻合等方法。由于食管和胃管壁厚度不同、管腔大小不同、胃粘膜存在皱褶、纵隔食管床狭小等因素,     

食管-胃黏膜吻合术治疗食管癌、贲门癌的护理

随着食管外科的普及和手术方法不断改进，食管癌、贲门癌根治术后吻合口瘘、吻合口狭窄和胃食管反流等并发症的发生已明显减少。我院于1998年至2006年共行食管癌、贲门癌切除食管-胃黏膜吻合术139例，经过周密的术后护理，患者恢复满意，现总结如下。     

"种植式"食管胃吻合术

目的 为了预防食管癌、贲门癌手术后吻合口瘘、胃液食管反流、吻合口狭窄等吻合口相关并发症，设计“种植式”食管胃吻合术，总结其临床经验。方法 将196例食管、贲门癌患者分为两组，实验组：116例切开胃壁浆肌层与食管下端等宽，游离黏膜及黏膜下层形成指套状凸起，在其顶部切口与食管下端吻合，最后把浆肌层切缘上提缝合至食管外膜包埋吻合口；对照组：80例采用常规单层食管胃吻合术。术后14天、1、3、6和12个月分别对两组患者进行上消化道X线钡餐造影或纤维胃镜检查。结果 实验组无吻合口瘘发生，发生吻合口狭窄1例，胃液食管反流4例；对照组发生吻合口瘘3例，吻合口狭窄3例，不同程度胃液食管反流60例。结论 “种植式”食管胃吻合术是一种具有预防吻合口瘘、吻合口狭窄和较好的抗胃液食管反流作用，且符合生理的食管胃吻合术。     

胃底贲门癌食管胃切除后"围巾式"吻合术

食管-空肠(胃)吻合术后各种并发症的发生率较高,严重影响患者生存质量。吻合口瘘发生率高达12%～16%,其死亡率为40%～60%犤1-3犦;吻合口狭窄发生率5%～45%犤1犦;反流性食管炎发生率为23%～28%犤4犦。我们从1987年开始设计应用“围巾式”食管-空肠(胃)吻合术,取得满意效果,报告如下。1.临床资料:自1987年1月至2000年12月,共施行“围巾式”食管-空肠(胃)吻合术102例,其中男77例,女25例。中位年龄68(23～75)岁。病种和手术方式见表1。“围巾式”吻合方法:食管空肠吻合者,暴露食管贲门交界处后切断迷走神经前、后干,在膈下向纵隔充分游离食管下…     

食管胃黏膜延长分层吻合的临床应用

贲门及低位食管癌以胃重建食管为常用方法，术后普遍存在胃食管反流，我们采用食管胃黏膜延长分层吻合法临床应用86例，进一步探讨抗反流疗效。     

食管、贲门癌切除食管胃分层吻合术患者生命质量评价

目的 探讨食管、贲门癌切除食管胃分层吻合术的手术效果，评价患者手术后生命质量。方法 根据手术方式不同将264例食管、贲门癌患者分为两组，食管胃分层吻合组：162例，行食管、贲门癌切除，食管胃黏膜连续缝合，食管胃分层吻合术；器械吻合组：102例，行食管、贲门癌切除，食管胃吻合器吻合术。均用欧洲癌症研究与治疗组织(EORTC)QLQ—C30和自制量表对患者术后3—6个月生命质量进行测评，并进行比较。结果 食管胃分层吻合组有137份问卷、器械吻合组有77份问卷符合评分要求。食管胃分层吻合组在体力功能和情感功能维度得分高于器械吻合组(P＜0．05)，吞咽困难维度、胃食管反流症状维度得分低于器械吻合组(P＜0．05)，其他维度两组比较差别无显著性意义(P＞0．05)。结论 食管胃分层吻合术后患者体力功能和情感功能优于器械吻合术，吞咽困难、反流症状少于器械吻合术，生命质量高于器械吻合术。     

兜底式食管胃吻合术的临床应用研究

摘要：目的评价兜底式食管胃吻合术对吻合口瘘、吻合口狭窄和胃食管反流的预防作用及效果,探讨蒙特利尔定义“胃食管反流病”诊断流程、标准在食管重建术后的实用价值和意义。方法回顾性分析2007年6月至2011年6月笔者医院采用两种术式共行食管癌和贲门癌切除1078例的临床资料,参考相关诊断标准制表,问卷调查两组患者术后吻合VI狭窄和胃食管反流的发病情况。试验组（兜底式食管胃吻合术）582例,男403例、女179例,年龄（60．4±12．6）岁。食管癌399例,贲门癌183例,弓上吻合392例,弓下吻合190例。对照组（传统食管胃端侧吻合术）496例,男343例、女153例,年龄（59．2±12．8）岁。食管癌322例,贲门癌174例,弓上吻合317例,弓下吻合179例。结果与传统食管胃端侧吻合术相比,兜底式吻合术后吻合VI瘘的发生率较低[0％（0／582）VS．1．0％（5／496）,x2=5．835,P=O．016）];胃食管反流症状亦较轻,而伴有食管外症状及需要服用制酸剂患者则更少[1．6％（33／541）VS．12．6％（57／453）,矿=23．564,P=O．000],术后吻合口狭窄率各为0．9％（5／539）和7．3％（34／465）（x2=25．124,P=O．000）,尤其是重度吻合I=I狭窄的发生率更低[0％（0／539）VS．4．7％（22／465）,X2=24．883,P=O．000]。两组5年生存率差异无统计学意义。结论兜底式吻合法在预防食管胃吻合VI瘘、吻合VI狭窄和胃食管反流的发生方面较传统术式为优;蒙特利尔定义胃食管反流诊断流程和标准适合于食管重建术后胃食管反流之诊断。     

Difference in main lymphatic pathways from the lower esophagus and gastric cardia

Lymphatic pathways draining the lower esophago-cardiac region were studied in 17 patients with carcinoma of the lower esophagus or gastric cardia, by measuring radioisotope uptakes in the regional lymph nodes. The uptakes were most remarkable in lower mediastinal and upper gastric lymph nodes, when the radioactive colloid was injected at the lower esophagus. A lesser degree of uptakes were observed both in other mediastinal and abdominal lymph nodes. On the contrary, a high degree of uptakes were detected only in abdominal lymph nodes, when the colloid was injected at the gastric cardia. The results indicated that main lymphatic pathways originating from the lower esophagus advance both upward and downward, and that those from the gastric cardia make their way downward to upper gastric, para-celiac and para-aortic lymph nodes. The actual incidences of lymph node metastases were also studied in 108 patients with carcinoma of the lower esophagus and 93 patients with carcinoma of the gastric cardia. In the former group, very high incidences were observed in lower esophageal and upper gastric lymph nodes. In the latter group, the incidence was most remarkable in upper gastric lymph nodes and far less significant in lower mediastinal lymph nodes. The results confirmed those of the radioisotope study. The importance of dissection of para-aortic lymph nodes near the left renal vein was also stressed.     

胃浆肌瓣覆盖式食管胃吻合术的临床应用

为预防食管胃吻合口的并发症，我们设计一种新的吻合方法，即胃浆肌瓣覆盖式食管胃吻合术。采用新吻合方法行食管贲门癌切除术120例，贲门失弛缓症食管部分切除术42例，手术无死亡，术后未发生吻合口瘘。术后半年内38例行头低脚高位食管钡餐检查，吻合口为2.0～2.2cm者6例，1.5～2.0cm者30例，1.0～1.5cm者2例，未见返流现象。术后半年至3年行食管镜检和活检30例中，食管粘膜正常者28例，仅2例有轻度粘膜充血水肿。认为此方法有实用价值。     

Reliable preparation of the gastric tube for cervical esophagogastrostomy after esophagectomy for esophageal cancer

Maintaining sufficient blood flow to the gastric tube is essential to avoid anastomotic leakage after esophageal reconstruction for esophageal cancer. We were able to obtain sufficient blood flow to the tip of the gastric tube by separating the inferior polar branches of the splenic vessels at their origin. By using this procedure, we were able to preserve the junction between the left gastroepiploic vessels and the inferior short gastric vessels without splenectomy. The entire greater omentum also was preserved to use the network between the right and left gastroepiploic vessels. Finally, the anastomotic site was wrapped with the omentum. By using these techniques, the anastomotic site of the gastric tube was well nourished in all patients who underwent esophageal reconstruction for esophageal cancer; anastomotic leakage did not occur.     

食管贲门癌切除消化道重建术后胃狭窄

目的 分析食管癌和贲门癌切除术后胃狭窄的临床特点，探讨其病因、诊断和治疗方法。方法 对1998年1月至2004年12月收治的9例食管癌和贲门癌术后出现胃狭窄患者的临床表现、影像学特征、内镜检查和治疗进行回顾性分析。结果 本组男8例，女1例。年龄49～71岁，中位年龄62岁。症状主要为术后吞咽困难。狭窄部位以吻合口以下的胃黏膜缺失，纤维瘢痕增生为主要特征，其长度为1．5～5．0cm，中位长度2．0cm；宽0．1～0．5cm，中位宽度0．3cm。有7例采用单纯食管扩张术均无效，8例施行经口食管支架置入术，可正常饮食。随访期5—60个月，中位时间12个月。支架置入术后再狭窄11例次（包括6例次支架脱落，1例次支架移位，4例次肉芽生长阻塞），颈部切口化脓感染1例，上消化道大出血1例。结论 食管癌和贲门癌切除术后胃狭窄应结合临床症状、钡餐和内镜检查进行诊断；治疗首选放置非自扩支架或全覆膜自扩支架。     

Preservation of the lower esophageal sphincter during total gastrectomy for gastric cancer to prevent postoperative reflux esophagitis

The lower esophageal sphincter (LES) is usually removed during total gastrectomy to successfully perform a curative operation. In this study, the preservation of the LES in curative total gastrectomy was attempted to reduce the reflux. An experimental study using dogs has revealed that the high-pressure zone of the LES can be preserved by making a resection at the gastroesophageal junction, which thus helps to protect the reflux. A previous clinicopathological study revealed that the LES can be preserved without any fear of recurrence at the resection site, if the tumor is located more than 2.0 cm and 3.0 cm from the gastroesophageal junction to the oral margin in node-negative and -positive cases, respectively. Clinically, 8 patients underwent an LES-preserving total gastrectomy [LES(+) gastrectomy] while 19 had an LES(–) gastrectomy in the same period. Of the five LES(+) cases examined, all showed a high pressure zone, whereas none of the four LES(–) cases examined showed such a high-pressure zone after the operation. Endoscopic examination showed that only one of the seven LES(+) cases but six of nine LES(–) cases revealed esophagitis.     

Aanastomotic leakage after excision of esophageal and high gastric carcinoma

Excision of esophageal or high gastric carcinoma was performed in 207 patients with a primary mortality of 16 per cent. Anastomotic leakage occurred in 9 per cent and was fatal in every other patient. A third of the primary mortality was due to this complication. Leaks were five times more frequent in patients more than seventy years of age than in those between the ages of sixty and sixty-nine. Ruptures leading to death were most often found in connection with proximal gastrectomy with esophagoantrostomy. After total gastrectomy with esophagojejunostomy leaks occurred in 4 per cent and only one patient (1 per cent) died because of this complication.     

食管癌术后胃排空障碍的诊断与治疗

目的探讨食管癌术后胃排空障碍的诊断及治疗。方法对我院于2007年6月至2008年6月间5例食管癌术后胃排空障碍病例的诊断及治疗作回顾性分析。结果1例经保守治疗后出院,4例确诊为机械性胃排空障碍,经手术解除梗阻后治愈出院,术后无严重并发症。结论食管癌术后胃排空障碍根据临床表现、影像学及胃镜检查可确诊,早期鉴别诊断可采用胃排空放射性核素显像。确诊机械性胃排空障碍均必须作外科手术治疗才可以达到满意的效果。     

Anatomic dilatation of the cardia and competence of the lower esophageal sphincter: A clinical and experimental study

Anatomic and clinical data suggest that the gastroesophageal junction or cardia in patients with gastroesophageal reflux disease (GERD) may be dilated. We hypothesized that anatomic dilatation of the cardia induces a lower esophageal sphincter dysfunction that may be corrected by narrowing the gastroesophageal junction (i.e., calibration of the cardia). We measured the perimeter of the cardia during surgery in control subjects and patients with GERD and Barrett’s esophagus. We then tested our hypothesis in a mechanical model. The model was based on a pig gastroesophageal specimen with perpendicularly placed elastic bands around the cardia simulating the action of the “sling” and “clasp” fibers. “Dilatation” of the cardia was induced by displacing the sling band laterally and decreasing its tension. “Calibration” of the cardia was performed by reapproximation of the sling band toward the esophagus but maintaining the same tension as the dilated model. In the “basal,” “dilated,” and “calibrated” states, the perimeter of the cardia was noted and rapid mechanized pullback manometry with a water-perfused catheter was performed. The opening pressure was determined, and three-dimensional sphincter pressure images were analyzed. The average cardia perimeter was 6.3 cm in control subjects, 8.9 cm in GERD patients, and 13.8 cm in patients with Barrett’s esophagus. The arrangement of the bands in the experimental model generated a manometric high-pressure zone similar to that in the human lower esophageal sphincter. Dilatation of the cardia resulted in a decrease in the resting pressure, length, and vector volume of the high-pressure zone, and reduced the opening pressure. Calibration restored the resting and opening pressure, and normalized the three-dimensional pressure image. In patients with GERD and Barrett’s esophagus, the cardia is dilated. Our model supports the hypothesis that lower esophageal sphincter function is compromised by anatomic dilatation of the cardia and can be restored by approximarion of the “sling” fibers toward the lesser curvature (“clasp” fibers). This provides evidence for a correlation between gastroesophageal sphincter dysfunction in reflux disease and its correction by antireflux surgery.     

食管癌与贲门癌患者术前内镜超声检查28例分析

目的 通过对比内镜超声及CT在食管癌、贲门癌术前进行T、N分期中的准确度,评价内镜超声的临床应用价值. 方法 对28例食管癌、贲门患者术前均行内镜超声扫描和CT扫描,并分别进行T、N分期,以术后病理为金标准,比较两者分期的准确性有无差异,同时对比两者对淋巴结转移的准确率(即真实性)的差异,判断内镜超声的应用价值. 结果 本组28例病例中,T分期准确率内镜超声为89.3%(25/28),高于CT的46.4%(13/28),差异有统计学意义(P=0.004,P＜0.01).N分期中,内镜超声与CT的准确率分别为82.1%(23/28)及50.0%(14/28),差异有统计学意义(P=0.035,P＜0.05).对转移淋巴结的分组统计中,内镜超声与CT的准确率分别为88.7%及72.2%,有显著性差异(χ2=7.031,P=0.008,P＜0.01).结论 内镜超声在食管癌、贲门癌术前分期中有重要作用,其T分期准确率明显高于传统CT扫描.以淋巴结短径、S/L(淋巴结短径/淋巴结长径)并结合淋巴结的超声显像特征进行分析,提高了判断淋巴结转移以及N分期的准确性.