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目的　探讨治疗贲门癌的手术新入路及吻合方法。方法　广东省揭阳市人民医院普通外科 1997年1月至 2 0 0 3年 7月经腹切开膈肌脚入路 ,行胃浆肌瓣覆盖 食管胃黏膜吻合 10 3例。结果　全组病例无死亡、无吻合口瘘 ,亦无食管切缘癌残留。术后并发症发生率 4 82 %。结论　经腹切开膈肌脚 ,行胃浆肌瓣覆盖 食管胃黏膜吻合术 ,操作在腹腔进行 ,创伤及生理干扰较小 ;能有效地预防吻合口漏 ;既能切除足够的食管 ,又能扩大淋巴结的清除范围 ,适用于浸润食管长度 <2cm的贲门癌的手术治疗。     

Esophagogastric anastomosis performed with a stapler: the occurrence of leakage and stricture

The circular stapler has lowered the leakage rate of an esophageal anastomosis to a level hitherto achieved by only a few surgeons performing hand anastomosis on selected patients with carcinoma of the esophagus. However, the esophageal anastomosis performed with a stapler is also associated with a high stricture rate. Our prospective study was conducted to determine the leakage rate and the incidence of stricture after esophagogastric anastomosis was performed with a stapler, the relationship of stricture to the size of the stapler, and the risk of stricture in relation to time. In a group of 174 patients with carcinoma of the thoracic esophagus, resection was performed, and a one-stage esophagogastric anastomosis was constructed. There were 33 hand anastomoses, 64 anastomoses with an EEA stapler (U.S. Surgical Corp., Norwalk, Conn.), and 77 anastomoses with an ILS stapler (Ethicon Ltd., Edinburgh, U.K.). The anastomotic leakage rate was 3.4% (6/174); 3% with the hand technique and 3.5% with the stapler technique (4.7% for the EEA and 2.6% for the ILS). After leakages and hospital deaths were excluded, 133 discharged patients were evaluated for the occurrence of anastomotic strictures. Only those who complained of dysphagia were investigated. The incidence of stricture for hand anastomosis was 8.7%-EEA 20% and ILS 10%; the overall incidence of anastomoses with a stapler was 14.5%. The true incidence would probably be higher if all patients were assessed by endoscopic or radiologic examination after operation. All three sizes of EEA staplers had a high incidence of stricture. For the ILS stapler the 25 mm size had the highest stricture rate (28.6%) of all groups, but for the 29 and 33 mm sizes, the incidences were 5.3% and 0%, respectively. Actuarial analysis showed an increasing risk of stricture with a reduction in the size of stapler used and was 32.5% and 35%, respectively, for the ILS 25 mm and EEA 25 mm staplers at 131/2 months. The risk of stricture occurrence was highest in the first 4 months. Treatment by bougienage was satisfactory. In conclusion, esophagogastric anastomosis performed with a stapler is a very safe procedure with respect to leakage but is associated with a high risk of stricture, except when the largest ILS staplers are used. However, dilatation readily overcomes the stricture occurrence and adequately compensates for the reduced leakage rate and its attendant serious consequences.     

Results of simultaneous resection and plastic surgery of the esophagus with extra-cavitary cervical esophagostomy in esophageal cancer in its thoracic part

The work analyses the results of one-stage resection and plastics of the esophagus with a tube formed from the greater curvature of the stomach and creation of an ++extra-cavitary anastomosis on the neck in combined and surgical treatment of carcinoma of the thoracic esophagus in 279 patients. Various complications occurred in 181 (64.8%) patients. The mortality was 19.3% (16.8% among patients who underwent radical operation and 25.6% among those treated by a palliative operation). The number of complications in the groups of surgical and combined treatment was approximately equal. The results of 5-year survival were better in the group with combined treatment. Postponed + extra-cavitary anastomosis was formed in 65.2% of cases. One-stage resection and plastics of the esophagus with ++extra-cavitary anastomosis is an adequate operation from the oncological standpoint in the treatment of carcinoma of the thoracic esophagus. Its further perfection is necessary for improvement of the immediate and late-term results of treatment.     

Garlock's operation in cancer of the esophagus

Experience in 88 Garlock-type operations carried out in carcinoma of the esophagus allows a certain opinion to be formed on the advantages and shortcomings of this surgical intervention. In esophageal carcinoma with its proximal boundary within the range of the retropericardial segment of the esophagus, a left abdominothoracic approach (Garlock's operation) is adequate in resection of the esophagus in conformity with the oncological principles and allows the formation of the esophagogastric anastomosis at the level of the arch of the aorta without particular technical difficulties. Reduction of the time needed for the operation, determination of the resectability of the esophageal tumor before mobilization of the stomach are obvious advantages of the abdominothoracic approach.     

Successful surgical treatment of aortogastric fistula after an esophagectomy and subsequent endovascular graft placement: Report of a case

An aortogastric fistula is a rare but fatal complication after an esophagectomy and intrathoracic esophagogastric anastomosis. A 54-year-old man underwent an esophageal resection due to carcinoma in his lower esophagus. The alimentary tract continuity was restored by intrathoracic esophagogastric anastomosis. Forty-six days later, he suffered a massive hematemesis due to an aortogastric fistula which had formed at the esophagogastric suture line. The fistula was surgically obliterated twice, but each operation was followed by pseudoaneurysm formation. The patient was finally successfully treated with an endovascular stent graft placement. This is the first report of a patient surviving after developing this complication.     

Minimizing cervical esophageal anastomotic complications by a modified technique

BACKGROUND: The anastomotic leak and stricture formation after esophagectomy and cervical esophagogastric anastomosis deny patients with esophageal carcinoma the benefits of surgery. The present study was designed to ascertain whether a wide cross-sectional area at the site of anastomosis leads to lesser anastomotic complications. METHODS: One hundred patients with resectable carcinoma of the esophagus were randomly distributed into two groups of 50 each. All patients underwent one-stage transhiatal esophagectomy. In group A, 3 x 2 cm gastric crescent was excised from the anterior wall of the gastric tube before constructing the cervical esophagogastric anastomosis. No such intervention was done in group B, which acted as control. All patients were followed up for at least 3 months for detection of anastomotic complications. RESULTS: The incidence of anastomotic leak in the study group was significantly less in comparison with the control group (4.3% versus 20.8%; P = 0.03). Similarly, anastomotic stricture formation was significantly lower in the study group (8.5% versus 29.2%; P = 0.02). CONCLUSIONS: A wide cross-sectional area achieved at the anastomotic site by removal of gastric crescent resulted in significantly lower anastomotic complications.     

腋下小直切口食管癌切除胃-食管颈部器械吻合术

目的探讨腋下小直切口食管癌切除中颈部吻合采用胃-食管消化道吻合器的价值。方法2005年4月~2007年4月,对56例食管癌采用腋下小直切口食管次全切除,吻合器行胃-食管颈部吻合。关键步骤包括:腋下小直切口开胸;胃、食管的游离;颈部吻合器的使用;吻合口的包套;胃和吻合口置于食管床。结果切口长10~15(13.2±1.6)cm,术后无颈部吻合口漏,无吻合口出血、喉返神经损伤及乳糜胸。53例随访4~16个月,平均7.8月,吻合口轻度狭窄1例(1.9%,1/53),有明显的反流症状4例(7.5%,4/53)。结论胸部小切口创伤小、恢复快,颈部器械吻合符合食管癌切除的原则,避免了人为因素对吻合口的影响,增加了吻合的可靠性,术后并发症发生率低。     

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。     

The highest permissible levels of resection of the esophagus in cancer during surgery with intrathoracic or cervical esophagogastric anastomoses

The levels of esophageal resection for squamous carcinoma were determined in 84 patients by measuring the distance from the incisors to the ring of the esophagogastric anastomosis during esophagoscopy. The radicalism of the operations was evaluated from the difference in the distance between the incisors and the upper border of the tumor and the distance between the incisors and the anastomosis. The mean levels of the highest possible resections of the esophagus were at a distance of 33.5 +/- 2.8, 23.6 +/- 2.0, and 20.4 +/- 2.0 cm from the incisors, respectively, in Garlock's operation, Lewis' operation, and Dobromyslov-Torek's operation with esophagoplasty using an antiperistaltic gastric pedicle. It is suggested that the choice of the method of surgical treatment should be based on comparison of the determined levels of the highest possible resection of the esophagus with the endoscopic assessment of the level of the upper border of the tumor in the esophagus.     

经腹经裂孔纵隔内食管-胃和食管-空肠双吻合新技术的应用

目的探讨经腹经裂孔行扩大近端胃或全胃切除术后,在纵隔内完成食管-胃或食管-空肠吻合的方法。方法2010年5月至2012年1月,对15例食管胃交界部腺癌患者在施行开放经腹膈肌裂孔扩大胃切除术或全胃切除术后,采用腹段食管逆向置入抵钉座、弧形吻合器切断食管、利用缝线牵出抵钉座的方法予以双吻合技术完成食管-胃或食管-空肠吻合,其中9例为近端胃大部切除行食管-管状胃端端吻合,6例为全胃切除术行食管-空肠吻合。结果全部病例吻合过程顺利,手术时间（185．5±13．1）min,吻合耗时（42．0±8．6）min,术中出血量（106．7±34．9）ml,食管切缘距肿瘤近端（4．4±1．2）cm．残端均无癌残留。无手术死亡及吻合口瘘发生,术后随访发现1例吻合口狭窄．经扩张后缓解。结论抵钉座逆向置人食管联合弧形切割闭合器双吻合技术能简单而安全地在下后纵隔完成食管-胃或食管-空肠吻合．可能成为食管胃交界处癌行扩大胃切除术后的一种较理想的吻合方式。     

Subtotal esophagectomy with simultaneous retromediastinal plastic surgery using gastric pedicled flap without thoracotomy

Thirty-three operations for subtotal esophagectomy with one-stage plastics with a gastric pedicle without thoracotomy were carried out between 1985 and 1988. The indications for the operation were as follows: carcinoma of the esophagus (17) and of cardioesophageal localization (7), cicatricial stricture of the esophagus (6), IV degree cardiospasm (2), unspecific esophageal ulcer (1). The esophagus was resected through a laparotomo-transdiaphragmatic-cervical access, the graft formed from the greater curvature of the stomach was passed in the posterior mediastinum with the establishment of a cervical esophagogastroanastomosis. Postoperative complications occurred in 29 patients: incompetence of the anastomosis (26), mediastinitis and pyothorax, (4), peritonitis (2), pneumonia (4). Six patients died. With the performance of intrapleural esophagogastroplasty the mortality rate fell from 25 to 18.2%. The authors claim that subtotal esophagectomy with posteromediastinal gastroplasty without thoracotomy is a less traumatic and safer operative intervention.     

经食管床吻合术后对残余食管的压力测定和酸碱度分析

目的探讨食管癌切除胃经食管床主动脉弓上吻合术后，食管、胃功能改变及胃食管反流的情况。方法对20例食管中段癌术后3-6个月患者（研究组）及10例正常人（对照组）采用食管胃压力测定及24h食管酸碱度（pH）监测，并对结果进行分析。结果（1）研究组各项pH监测指标均明显高于对照组（P〈0．01）。（2）胃静息压、残余食管静息压及食管上括约肌静息压研究组均高于对照组（P〈0．01）；残余食管收缩压、食管原发蠕动幅度及食管湿蠕动幅度均低于对照组（P〈0．01）；食管上括约肌关闭压高于对照组（P〈0．01）；胃、吻合口及残余食管静息压三处两两比较，差异均无统计学意义（F=3．08，P〉0．05）。结论经食管床主动脉弓上食管胃吻合术后，残余食管蠕动功能差，廓酸能力降低；吻合口处不存在高压带，普遍存在胃食管反流现象。     

Partial median sternotomy: anterior approach to the upper thoracic esophagus

Based upon experience with cervicothoracic esophageal carcinomas in which resection of the manubrium, adjacent clavicles, and ribs has facilitated exposure of the tumor, it has been found that a partial upper sternal split (without resection) provides access to the upper thoracic esophagus to the level of the carina. With a knowledge of the anatomic relationships of the esophagus in this area, this direct anterior approach has been used for both benign and selected malignant diseases involving the upper thoracic esophagus. A partial median sternotomy has been used in 11 patients with the following esophageal pathology: upper- and/or middle-third malignancy (six), benign upper-third stricture (three), perforation of upper-third esophagogastric anastomotic stricture (one), and cricopharyngeal achalasia in association with a chronic cervical compression fracture that prevented extension of the neck (one). The following operations were performed: blunt esophagectomy with cervical esophagogastric anastomosis (six), segmental esophageal resection with primary anastomosis (three), drainage of perforation (one), and extended cervical esophagomyotomy (one). A chylothorax developed in one patient with carcinoma, the only major postoperative complication in this group. Transient hoarseness occurred in two patients. Careful evaluation of the patient with upper thoracic esophageal pathology, focusing on the type, extent, and location of the abnormality relative to the level of the carina, as well as the habitus of the patient, often indicates that a partial sternotomy can be utilized to facilitate the operation.     

A novel technique for gaining extra length of the abdominal esophagus

During gastrectomies for carcinomas of the esophagogastric junction, it is often desirable to gain additional length of the abdominal esophagus to construct an intra-abdominal esophagojejunal anastomosis. In this report, we describe a technique of esophageal mobilization that combines transhiatal dissection with transection of both vagus nerves at 3 points: first, at a level 2 cm to 3 cm below tracheal bifurcation; second, 3 cm to 5 cm above the hiatus; and, finally, at the level of the hiatus. Using this technique in 11 patients with carcinoma of the esophagogastric junction, we achieved lengthening of the abdominal esophagus by 3.7 cm ± 1.2 cm (mean ± standard deviation). In all cases, the additional esophageal length permitted the completion of an oncologically adequate resection and the execution of a safe intra-abdominal esophagojejunal anastomosis.     

The technic of esophageal extirpation with one-stage esophagoplasty using a stomach tube]

The article deals with the technical aspects of operation for extirpation of the esophagus through a cervico-abdominal approach in carcinoma (133 operations) and benign esophageal strictures (117 operations) with one-stage plastics by means of an isoperistaltic tube formed from the greater curvature of the stomach. The relative safety (2.8% of patients died) and high efficacy of the described operation allow it to be recommended for wide introduction into the practice of institutions engaged in surgery of the esophagus.     

Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial

Objective: The use of a circular stapler in cervical esophagogastric anastomosis remains controversial. This study was to compare the postoperative and long-term results of manual and mechanical techniques for cervical esophagogastric anastomosis after resection for squamous cell carcinoma. Methods: A prospective randomized controlled trial was undertaken in 63 patients with curatively resectable squamous cell cancer of the thoracic esophagus between 1996 and 1999. Patients were randomized to receive either a hand-sewn (32 patients) or circular stapled (31 patients) cervical esophagogastric anastomosis. Results: The mean operating time was longer when the hand-sewn method was used (524 vs. 447 min, P<0.001). Anastomotic leakage was noted in seven patients (22%) in the hand-sewn group and eight patients (26%) in the stapler group (P=NS). Hospital mortality occurred in four patients (13%) of the hand-sewn group and in three patients (10%) of the stapler group (P=NS). After the operation, four patients (14%) in the hand-sewn group and five patients (18%) in the stapler group developed a benign esophageal stricture (P=NS). The mean follow-up time was 24 months, and the rates of freedom from benign stricture and survival were comparable in each group. Conclusions: Performing cervical esophagogastric anastomoses using a circular mechanical stapler had a shorter operating time and a comparable outcome to the hand-sewn method. The circular mechanical stapler could be used as an alternative for cervical esophagogastric anastomosis after resection for esophageal squamous cell cancer.     

Diagnosis and surgical treatment of reflux esophagitis]

Operations were performed on 192 patients with reflux esophagitis, 23 of them had peptic stricture of the esophagus. Esophago-fundoplication was the main operation. Nissen's (106), Tupe (47), Belsi's (3), Dor's (5), and atypical methods were applied. Whenever indicated it was supplemented by crurorhaphy, SPV, pylorotomy, correction of the duodenal junction, etc. Resection of the esophagus (19) was performed with one-stage esophagoplasty by means of the stomach through a left thoracoabdominal approach (14), the whole stomach passed through the posterior mediastinum from an abdomino-cervical approach (2) and the whole stomach with Lewis' intrathoracic anastomosis (3). Distal gastric resection was carried out in 6 and other operations in 3 patients. The mortality was 1%. Reoperations were performed in 5 patients. The results were good in 81.2% of cases. The tactics is individualized according to the presence or absence of a stricture, its length, and localization of the upper border.     

One-stage treatment of obstructing colorectal cancer

Large bowel obstruction is due to colorectal carcinoma in 90% of cases. The optimal management of obstructing left colonic carcinoma is still a controversial matter. The aim of this retrospective study was to evaluate the indications for one-stage treatment of obstructing colorectal cancer. Over the period from January 1998 to June 2001, 17 patients were operated on in our department for obstructing colorectal cancer. Twelve patients underwent a one-stage emergency operation by immediate anastomosis without diversion, while five patients were managed palliatively. We performed resection and primary anastomosis following intraoperative irrigation in obstructing sigmoid cancer lacking colonic wall lesions, while subtotal colectomy was carried out in cases of massively distended colon with ischaemic lesions and in patients with good anal continence. Colostomy treatment was indicated only in high-risk patients with unresectable lesions. The authors believe that, in cases of obstructing left colorectal cancer, an experienced, skilled surgeon can perform one-stage resection and anastomosis on patients in good general condition. On the other hand, a defunctioning colostomy may be ideal for surgeons with little experience in colorectal surgery and in patients with a very poor prognosis.     

Esophageal extirpation with one-stage esophagoplasty

In the period from 1980 to June, 1989 the authors conducted operations on 128 patients for extirpation of the esophagus with one-stage esophagoplasty by means of an isoperistaltic tube formed from the greater curvature of the stomach. Fifty-four of these patients had benign esophageal strictures, 74 had malignant lesions of the esophagus. The authors claim this operation to be the operation of choice in carcinoma of the lower third of the esophagus and in carcinoma of the cardia extending to the thoracic esophagus. It may be carried out in carcinoma of the thoracic esophagus at any level, in benign strictures of the thoracic esophagus, and in stage IV cardiospasm in patients in whom operations had been performed earlier on the cardia. The abdominocervical approach can be supplemented by right thoracotomy in carcinoma of the midthoracic part of the esophagus. Four patients (3%) died after the operation. The authors recommend wider use of the operation.     

Ⅰ期手术治疗左半结肠癌梗阻

对22例左半结肠癌梗阻患者Ⅰ期行切除吻合，效果良好．仅1例发生吻合口瘘，围手术期死亡1例．认为。外科技术的进步、有效抗生素的应用、营养支持手段的提高，左半结肠癌梗阻Ⅱ期手术已不是禁忌，选择好病例．相当一部分患者行Ⅰ期手术是可行的，随着对结肠吻合口愈合生理的深入研究，术中肠道准备简单化也是可行的．