食管腐蚀性瘢痕狭窄的外科治疗

为了观察食管腐蚀性瘢痕狭窄的外科治疗效果，自1980年至1995年间我们为14例食管腐蚀性瘢痕狭窄病人行结肠移植咽下食管斜切口吻合。结果，吻合口瘘1例，换药2周治愈；吻合口狭窄2例，全组无手术死亡。术后随访10年生存11例，全部进食良好，吞钡检查吻合口正常。我们认为结肠移植咽下食管斜切口吻合治疗食管腐蚀性瘢痕狭窄效果满意。     

食管重建中食管胃吻合术式的改进（附65例分析）

在65例食管癌、贲门癌手术治疗中,对吻合口的处理采用食管胃“两定点吻合”加半边大网膜覆盖。作为术式改进组;另对50例食管癌,贲门癌采用传统吻合方式,将肌层行间断缝合包埋,作为对照组。两组患者在性别,年龄、病灶的病理分类等方面无明显差异。比较两组的吻合口瘘和吻合口狭窄的发生率,术式改进组未发生吻合口瘘和吻合口狭窄;对照组发生吻合口瘘1例。发生吻合口狭窄4例。食管重建中,对吻合口的操作采用食管胃“两定点吻合法”能有效地避免和减少吻合口瘘及吻合口狭窄的发生。     

咽结肠吻合治疗食管烧伤后瘢痕狭窄

目的 总结采用咽结肠吻合治疗食管烧伤后瘢痕狭窄的经验及效果。方法 回顾分析14例应用咽结肠吻合重建食管治疗累及下咽的广泛食管烧伤后瘢痕狭窄患者的临床资料。均采用左半结肠,旷置胸内瘢痕食管、经胸骨后隧道上提至颈部行咽结肠吻合。结果 全组无手术死亡,术后发生颈部吻合口漏4例,腹部切口裂开1例。随访半年至10年,平均4年,2例分别于术后3个月及4个月发生吻合口狭窄,1例扩张,1例行成形术治愈;1例因移植结肠腹腔段呈袋状而致进食后呕吐,行结肠胃侧侧吻合治愈。结论 咽结肠吻合治疗累及下咽的广泛性食管烧伤后狭窄成功关键是较大的下咽开口及良好的吻合技术,咽结肠吻合是安全、有效的。     

婴幼儿食管化学烧伤后狭窄的外科治疗

报告１９８０年至１９９４年应用保留结肠左动脉升支顺蠕动间置横结肠，行结肠下咽腔吻合治疗婴幼儿食管开口以下化学烧伤后狭窄６例的结果，旨在探讨婴幼儿食管良性狭窄的外科治疗方法。本组病例全部一期手术成功，无吻合口瘘及其他并发症发生。随访３～５年，无吻合口狭窄，病儿发育正常。作者认为，横结肠重建食管，结肠下咽腔吻合是治疗婴幼儿全食管良性狭窄较理想的手术方法。     

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。     

食管胃吻合器在食管外科的应用

我科自１９８０年至１９９３年应用吻合器施行食管胃吻合术１８６例，其中经胸顶行颈根部吻合１８例，主动脉弓上吻合９１例，主动脉弓下吻合７７例。术后吻合口痰４例（２．１％），吻合口狭窄５例（２．７％）。作者认为由于吻合器吻合可靠，可降低吻合口瘘发生率；而将吻合器的平行吻合变成近似对端吻合有利于减少吻合口狭窄；对需行颈部吻合者利用吻合器经胸顶行颈根部吻合有它一定的临床实用价值。     

食管严重烧伤171例的外科治疗

目的探讨食管严重烧伤后瘢痕狭窄的预防及治疗效果。方法分析我科1976年4月至2007年6月外科治疗171例食管严重烧伤患者临床资料。其中37例Ⅱb度烧伤患者1个月内采用食管腔内置管预防瘢痕狭窄；108例已形成瘢痕狭窄者采用胃或结肠重建食管80例，胃重建28例；颈部食管局限性烧伤狭窄和术后吻合口狭窄者29例，采用颈阔肌皮瓣修复。结果37例食管腔内置管者中32例痊愈；结肠重建80例，术后死亡6例，颈部吻合口瘘14例，吻合口狭窄4例；胃重建28例，发生吻合口狭窄2例；颈阔肌皮瓣修复29例，无术后死亡，肌皮瓣全部存活，能正常进食。结论食管腔内置管是食管烧伤早期预防狭窄的有效方法；广泛食管瘢痕狭窄可旷置食管行结肠重建，狭窄食管位于主动脉弓以下者可切除狭窄食管用胃重建；局限性颈部食管狭窄或吻合口狭窄颈阔肌皮瓣修复是较理想的方法。     

可吸收线胃食管分层连续缝合法行胃食管吻合术

目的　为了减少食管、贲门癌切除、胃食管吻合术后吻合口瘘和吻合口狭窄的发生率 ,总结可吸收线胃食管分层连续缝合法的经验。　方法　食管、贲门癌切除后 ,采用国产 3- 0带针可吸收线在食管不同平面分层连续缝合行胃食管吻合术 40例。　结果　全组无死亡 ,发生吻合口瘘 1例 ,经治疗痊愈 ;轻度吻合口狭窄 3例 ,进软食无梗阻 ,经行吻合口扩张后能正常进食。　结论　采用可吸收线分层连续缝合法行胃食管吻合术是可行的 ,吻合口瘘发生率低 ,吻合口狭窄发生少、程度轻。     

食管良性狭窄的外科治疗

１９７２年１１月至１９９３年８月对８８例食管良性狭窄患者行手术治疗，其中年龄最小１８个月，最大６３岁。烧伤至手术时间最短１３天，最长１０年，平均１２０天。手术方式：胸肌后横结肠代食管８５例，胃代食管２例，１例横结肠加部分降结肠，术前胃造瘘５例。无手术死亡，除１例术后加年因吻合口狭窄拒绝手术死亡外，余均正确生存，作者对食管重建替代物、手术时机、瘢痕是否切除及吻合口平面等问题进行了讨论。     

食管开口以下狭窄的外科治疗

报道1978～1996年应用保留结肠左动脉升支间置横结肠顺蠕动行结肠下咽腔吻合治疗食管开口以下狭窄14例(其中婴幼儿6例)的结果,旨在探讨食管开口以下狭窄的外科治疗方法。本组病例均一期手术成功,未发生吻合口瘘及其他并发症。随访3～5年,无吻合口狭窄,病儿发育正常。作者认为,横结肠重建食管,结肠下咽腔吻合是治疗食管开口以下狭窄较理想的手术方法。     

小儿消化道化学性烧伤后瘢痕性幽门狭窄的外科治疗

目的探讨小儿消化道化学性烧伤后瘢痕性幽门狭窄的外科治疗效果。方法回顾性分析2008年4月至2012年10月间广州市妇女儿童医疗中心收治的11例化学性烧伤后瘢痕性幽门狭窄患儿的临床资料。所有患儿均经规范的内科治疗和介入下球囊扩张及放置支架无效后,予以幽门切除并胃十二指肠吻合术。记录术中及术后情况。并比较术前1d与术后3月时患儿血清白蛋白、血红蛋白和转铁蛋白等营养指标。结果11例患儿男10例,女1例,平均年龄4．5岁。病变早期累及食管和胃,4周后集中在幽门。表现为瘢痕性幽门狭窄和完全性幽门梗阻。11例患儿均成功施行幽门切除并胃十二指肠吻合术,手术时间（134±26）min,术中出血量（5±2）ml,术后住院时间（10±3）d;无一例手术并发症出现。术后随访3个月,11例患儿均能正常进食,身高、体质量和智力发育正常,血清白蛋白、血红蛋白和转铁蛋白较术前显著改善（均P〈0．05）。术后6个月消化道钡餐显示,胃十二指肠吻合口通畅,无狭窄、溃疡等病变。结论幽门切除并胃十二指肠吻合术是治疗小儿化学性烧伤后瘢痕性幽门狭窄的有效治疗手段,近期效果良好。     

横结肠代食管术治疗小儿食管化学烧伤后瘢痕狭窄

目的 了解横结肠代食管术治疗小儿食管严重化学烧伤后瘢痕狭窄的应用价值.方法 回顾分析1972年11月-2008年9月笔者单位收治的46例食管严重化学烧伤患儿的临床资料.患儿均采用保留左结肠动脉升支、经胸骨后隧道顺蠕动方向间植横结肠的方法重建食管,其中行颈食管-横结肠吻合32例、咽-横结肠吻合14例.结果 46例患儿术后无一例死亡,其中7例出现并发症:颈部吻合口瘘4例、吻合口狭窄2例、术后呼吸困难1例.均经再次处理后痊愈.39例患儿随访1～26年,生长、发育、进食情况与同龄儿童无异.结论 左结肠动脉升支供血、横结肠顺蠕动方向、经胸骨后径路作结肠与下咽或颈食管吻合术,是治疗小儿食管化学烧伤后瘢痕狭窄的较佳方法.     

Minimally invasive surgical enucleation or esophagogastrectomy for benign tumor of the esophagus

Experience in surgical resection of benign tumor of the esophagus is limited. Authors performed a chart review of 5 patients who underwent minimally invasive surgical resection of benign esophageal tumor. Main outcome measures included operative approaches, tumor's location and size, and outcomes. Tumor location were middle esophagus (n = 1), distal esophagus (n = 2), and gastroesophageal junction (n = 2). There were 4 females with a mean age of 55 years. Surgical approaches included thoracoscopic enucleation (n = 1), laparoscopic enucleation (n = 1), and laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy (n = 3). There were no open conversions. Mean operative time for enucleation was 127 minutes and 240 minutes for Ivor Lewis esophagectomy. Mean hospital stay was 5.8 days. There were no major or minor complications. Three patients developed stomal stenosis. The 30-day mortality was zero. Surgical pathology showed leiomyoma in 3 patients and gastrointestinal stromal tumor in 2 patients. Tumor size ranged from 1.1 to 10.5 cm. There has been no tumor recurrence at a mean follow-up of 14 months. Minimally invasive surgical enucleation or esophagogastrectomy for benign esophageal tumor is feasible and safe. The optimal approaches should be tailored based on the location and size of the tumor.     

空肠移植重建咽食管肠咽吻合口并发症的处理

采用空肠移植重建食管治疗咽食管化学性烧伤后狭窄13例。其中4例术后发生肠咽吻合口并发症:1例因吻合口狭窄和喉部损伤严重,反复发生吸入性肺炎而于术后3周应用自体喉气管移植,成功地重建食管通道;3例吻合口高于喉上口者,发生咽下困难,均再次行吻合口成形术,术后恢复了吞咽或语言功能。     

Local esophagoplasty in patients with burn strictures of the esophagus

Local plastic reconstruction of short burn strictures of the esophagus (SBSE) was performed in 14 patients aged from 22 to 37 years, 9 were men, 5--women. Decreased body mass was revealed in all the patients, mass deficit over 20% was in 4 (28.6%) of them. SBSE located in the upper third of the esophagus in 9 (64.3%) patients, in middle third--in 5 (35.7%). Local esophagoplasty was performed from cervical approach in 9 (64.3%) patients, from right-sided thoracotomy--in 5 (35.7%). Dissection of SBSE with 3/4 anastomosis was performed in 5 (35.7%) patients; circulatory resection of esophageal stricture with end-to-end anastomosis--in 7 (50.0%); detour side-to-side anastomosis without stricture resection--in 2 (14.3%). There was no hospital lethality. Postoperative complications were seen in 14.2% cases. Long-term results were good in 10 (71.4%) patients, satisfactory (strictures of anastomosis)--in 3 (21.4%), unsatisfactory--in 1 (7.2%). Local esophagoplasty is indicated for patients with SBSE when bouginage and dilatation of stenosis are not effective.     

Artificial esophagus in children

The aims of the study were: 1) to formulate up-to-date principles of coloesophagoplasty (CEP) and to compare methods of CEP; 2) to determine the optimal age for esophagoplasty in children with esophageal atresia; 3) to evaluate quality of life and long term results after esophagoplasty performed in childhood; 4) to present results of surgical treatment of pharynx stenosis in children. Over the last 50 years more than 2 thousand surgeries on the esophagus in children were performed including more than 600 operations of artificial esophagus creation. From 1995 in some patients we carried out extirpation of the esophagus with one-stage plastic operation coloesophagoplasty taken the transplant in the posterior mediastinum. From 1992 on the pharynx with free revascularized intestinal segment was performed in isolated stenosis of the pharynx. Case histories of 54 children aged from 3 months to 15 years were analyzed to compare methods of esophagoplasty when the esophagus was taken behind the sternum and in posterior mediastinum. Case histories of 27 children with atresia of the esophagus were analyzed for determination of optimal age for coloesophagoplasty. Responses to questionnaires were analyzed to evaluate quality of life. From 1980 ive hase operated 28 patients with scarry stenosis of the pharynx (isolated or in combination with esophageal stenosis). Current policy of surgical treatment of pharyngeal stenosis which is considered as surgery of choice-pharyngoplasty with a free intestinal transplant--is described. Development and clinical appliance of up-to-date principles of CEP permitted to reduce the number of complications and to decrease lethality from 3 to 0.5%. After introduction of antireflux cologastroanastomosis the number of complications due to reflux reduced. Extirpation of the esophagus may be valid in peptic stenosis, Barrett's metaplasia, tumors, portal hypertension or angiodisplasia, and in the majority of cases of scarry stenosis of the esophagus.     

Collis-Nissen Procedure in Patients with Esophageal Atresia: Long-term Evaluation

A subset of patients with esophageal atresia (EA) have an associated short esophagus and require an antireflux procedure. The Collis-Nissen procedure, which consists of a combination of Collis gastroplasty and Nissen fundoplication, is considered an option in such conditions. The long-term results of EA patients undergoing this procedure have rarely been reported. The results of the Collis-Nissen procedure were examined in four EA patients with follow-up for an average of 9 years. The Collis-Nissen procedure was conducted concurrently with segmental esophageal resection for an associated congenital esophageal stenosis close to the esophagogastric junction in two postoperative Gross type C patients (7 months, 2 years), as an antireflux operation in a postoperative Gross type A patient with an unreducible sliding hiatal hernia (10 years), and with primary repair of EA in a Gross type A patient with a long gap (4 months). There were no significant complications except minor anastomotic leakage and an anastomotic stenosis that required postoperative dilation. Significant reflux was negative, as shown by an upper gastrointestinal study and scintigraphy. Limited esophagitis just above the esophagogastric junction was observed in a Gross type A patient with a long mediastinal gastric segment. Swallow-related pressure reduction at the wrapping cuff was detected by manometric examination. The Collis-Nissen procedure is a useful option for treating EA patients who require esophageal lengthening and control of gastroesophageal reflux.     

镍钛合金组合式人工食管替代食管的实验研究

目的 观察镍钛合金组合式人工食管替代一段食管的可行性.方法 镍钛合金组合式人工食管是由柔性硅胶膜覆盖镍钛合金网状支架作管体,距两端1 cm处管体上带有涤纶连接环的组合式人工食管.以10只猪作实验动物,分为Ⅰ、Ⅱ两组（每组5只）,行手术切除一段长约7 cm的胸段食管,应用镍钛合金组合式人工食管替代建立实验动物模型,Ⅰ组用单纯镍钛合金组合式人工食管与正常食管做套入式端端全层吻合连接,Ⅱ组在Ⅰ组连接基础上,于镍钛合金组合式人工食管套入正常食管重叠处的食管外面加用涤纶条环绕固定.术后观察动物的进食及生长情况,3个月内每月做1次X线食管造影、电子纤维食管镜检查,处死3只术后66,100和123 d脱管的实验动物进行解剖,并对新生食管行病理学检查.结果两组共10只实验猪存活超过6个月以上,最长的存活已达20个月余.全组无吻合口漏发生,所有实验动物在人工食管未脱落之前都能正常进食.7只实验猪在术后2～6个月内发生脱管,Ⅰ组3只术后3个月内脱管,脱管后发生新生食管狭窄,进食出现严重梗阻;Ⅰ组1只和Ⅱ组3只术后3个月后脱管,脱管后短时间内发生轻度新生食管狭窄,随后逐渐缓解,无进食困难.Ⅰ组1只、Ⅱ组2只实验猪超过术后10个月未发生脱管,新生食管无狭窄,进食顺畅.结论 镍钛合金组合式人工食管替代猪被切除食管段,近期效果较好.     

颈阔肌皮瓣修复颈段食管狭窄的疗效观察

目的 探讨颈阔肌皮瓣修复颈段食管狭窄的疗效。方法 回顾分析1990年4月至2001年7月，采用单侧颈阔肌皮瓣修复颈段食管狭窄23例的近期及远期效果。结果 全组无手术死亡。肌皮瓣全部成活，3例发生吻合口瘘，更换敷料后愈合，术后随访6-136个月，2例术后4个月和6个月发生吻合口狭窄，分别经扩张和再次手术修复治愈；所有病人均能正常经口进普食。纤维食管镜检查示肌皮瓣无糜烂，溃疡及癌变。结论 颈阔肌皮瓣修复颈段食管狭窄，具有创伤小，转移就近，方便，能一期完成手术，并发症少，远期疗效好等优点，临床上值得推广应用。