预防吻合口瘘的研究现状与进展

吻合口瘘是低位直肠癌癌前切除术的严重并发症,有着较高的发病率和病死率.近年来,许多方法被用来降低吻合口瘘的发病率,本文查阅了PudMed以及万方数据库,聚焦于预防吻合口瘘的方法及对策,主要有:保护性造口、盲肠置管造口术、经肛肠腔减压术、管腔内旁路技术、无需回纳预防性造瘘术,每种方法各有优劣.截止到目前,传统的保护性造口应用较为广泛,其他方法的优势均缺少高水平实验的证据支持,但是,无需回纳预防性造瘘术可以完全转流粪便,不需二次手术回纳造口,初步显示效果良好,值得进一步研究.     

Diagnostic value of routine aqueous contrast swallow examination after oesophagectomy for detecting leakage of the cervical oesophagogastric anastomosis

Background: Water‐soluble contrast swallow examination is routinely carried out after oesophagectomy to detect leakage of the cervical oesophagogastric anastomosis. This study evaluated the diagnostic accuracy and clinical value. Methods: Patients with oesophageal carcinoma who underwent oesophagectomy with gastric conduit formation and a hand‐sewn cervical anastomosis between 1989 and 2003 were reviewed on outcome of routine aqueous contrast swallow examination (RACSE) and appearance of clinical anastomotic leakage. Results: An RACSE was carried out in 207 (82%) of 252 patients on postoperative day 8 (range 3–15). In 45 patients, no RACSE was executed, mainly because of a prolonged stay in intensive care unit. In 18 (9%) of 207 cases, the RACSE could not be interpreted by the radiologist. In 19 (53%) of 36 patients who developed a clinical leakage, the leak had already manifested clinically before the routine contrast examination was planned. Taken together, the false‐positive rate was 8%, the false‐negative rate 48%, sensitivity 52%, specificity 92%, positive predictive value 46% and negative predictive value 93%. No significant differences were found between the accuracy of RACSE in end‐to‐end or end‐to‐side cervical anastomoses. Conclusion: Given the very low sensitivity and low positive predictive value and given the fact that in 53% of patients with a clinical leak, the leakage had appeared clinically before the contrast swallow examination was routinely planned, we propose to abandon the routine contrast swallow examination after oesophagectomy to detect cervical anastomotic leakage. Alternatively, anastomotic integrity can be tested by drinking small amounts of water with simultaneous observation of the cervical wound.     

Poor prognosis in esophageal cancer patients with postoperative complications

n = 100) consisted of cases without postoperative complications. Groups B (n = 58) and C (n = 47) consisted of cases with minor and major postoperative complications. The 5-year survival rates were 41.8%, 21.3%, and 20.2% in groups A, B, and C, respectively. There was a significant difference in the prognosis between groups A and B, and also between groups A and C. Any patients who died within 5 years without a relapse their cases were excluded from the study; the 5-year survival rates were 46.7%, 32.3%, and 22.5% in groups A, B, and C, respectively, with a significant difference between groups A and B. There were no significant differences between the three groups regarding the patient characteristics. These results therefore indicate that postoperative complications might contribute to a poor prognosis in cancer patients. (Received for publication on Jan. 16, 1997; accepted on Sept. 2, 1997)     

食管下段及胃底切除行“围巾式”食管-胃吻合98例分析

目的 介绍“围巾式”食管-胃吻合方法预防食管下段及胃底切除术后吻合口瘘和反流性食管炎的临床经验.方法 回顾分析1996年1月至2013年10月98例食管下段及胃底切除术行“围巾式”食管-胃吻合病例的临床结果.98例中男性61例,女性37例;年龄42～83岁,中位年龄65岁.肝硬化门静脉高压症并食管下段胃底静脉曲张出血78例,早期食管胃结合部癌15例,贲门及胃底部间质瘤5例.术后86例获得随访,随访率为87％,随访时间3～60个月,中位随访时间42个月.结果 98例中,1例术后发生残胃断口处吻合口瘘,其余97例均未发生吻合口瘘.无发生反流性食管炎病例.5例(5.1％)病人术后发生吻合口狭窄,经胃镜下球囊扩张后缓解,改进技术后再无吻合口狭窄发生.结论 “围巾式”食管-胃吻合可减少食管下段及胃底切除术后吻合口瘘和反流性食管炎,是一种安全、有效的消化道重建方式.     

食管癌患者食管-管状胃环形吻合器端侧吻合与半器械侧侧吻合近期治疗效果观察

目的观察食管癌患者食管-管状胃环形吻合器端侧吻合与半器械侧侧吻合术后近期治疗效果。方法回顾性分析66例手术治疗食管癌患者的临床资料。30例采用食管-管状胃颈部半器械侧侧吻合术,36例采用食管-管状胃胸内环形吻合器端侧吻合术,比较两种吻合术后近期吻合口瘘、吻合口狭窄、反流性食管炎的发生率。结果半器械侧侧吻合术食管狭窄和反流性食管炎的发生率分别为3.3%(1/30例)和20.0%(6/30例),均低于环形吻合器吻合术的25.0%(9/36例)和61.1%(22/36例),两组比较差异有统计学意义(P0.05);半器械侧侧吻合和环形吻合器吻合术后吻合口狭窄发生率分别为3.3%(1/30例)和5.6%(2/36例),两组比较差异无统计学意义(P0.05)。结论食管一管状胃半器械侧侧吻合与形吻合器端侧吻合比较,术后近期吻合口狭窄及反流性食管炎发生率较低。     

食管癌切除术颈部机械吻合与手工吻合的疗效分析

目的 评价机械吻合与手工吻合在食管癌切除术颈部吻合中的应用价值.方法 本研究回顾性分析2010年1月至2012年1月四川省肿瘤医院收治的187例食管癌患者的临床资料,根据行食管癌切除术后颈部吻合的方式不同分为机械吻合组(98例)和手工吻合组(89例),比较两组患者吻合时间、总手术时间、术后开始进食时间、住院时间、术后并发症发生率及食管残端癌阳性率的差异,计量资料采用t检验,计数资料采用x2检验或Fisher确切概率法.结果 机械吻合组患者吻合时间、总手术时间、术后开始进食时间及住院时间分别为(7.8±1.4)min、(227±60) min、(6.3±0.9)d、(14±4)d,短于手工吻合组的(28.5±2.3) min、(301±81) min、(8.4±1.0)d、(22±9)d,两组比较,差异有统计学意义(t=75.44,7.14,7.71,7.41,P＜0.05);机械吻合组患者术后吻合口瘘发生率为1％ (1/98),低于手工吻合组的8％(7/89),两组比较,差异有统计学意义(P＜0.05);两组吻合口狭窄发生率分别为5％ (5/98)和7％ (6/89),两组比较,差异无统计学意义(P＞0.05);机械吻合组无食管残端癌,手工吻合组食管残端癌阳性率为4％(4/89),两组比较,差异有统计学意义(P＜0.05).结论 机械吻合在食管癌颈部吻合中不仅能缩短吻合时间、总手术时间及住院时间,而且能降低吻合口瘘发生率和食管残端癌阳性率.     

The application of a thread holding ring for ileoanal and coloanal anastomosis

A thread holding ring, originally developed for valve replacement surgery and now commercially available, was successfully employed when performing ileoanal or coloanal anastomosis in 34 patients. The use of this instrument for ileoanal or coloanal anastomosis shortened the operation time and resulted in a decreased rate of complications related to the anastomosis.     

Laser and suture anastomosis: passive compliance and active force production.

One carotid from each dog underwent a laser anastomosis and the other carotid an interrupted suture repair. One or eight weeks later (n greater than or equal to 4 dogs/time period); four rings (1 mm in length) containing the laser or suture anastomosis or the normal artery (two/dog) were removed. Using a photoelectric force transducer and lever system, the ring was stretched in increments and passive force measured. At each length, the arterial muscle was stimulated and active force measured. The mean laser and control passive length/tension (L/T) curves were not different (P greater than 0.05), but the suture curve was shifted downward (P less than 0.05). The mean laser and suture active L/T curves were similar at 1 week (greater than 0.05) and lower than the control curve (P less than 0.04). At 8 weeks, the laser-repaired vessels produced an active force similar to control muscle (P greater than 0.05) but the suture repairs could not generate this active force (P less than 0.05). These data suggest that the laser repair and normal artery are more mechanically compatible than the suture repair as studied by this method.     

Mechanical suture methods in esophago-gastrointestinal anastomosis

Mechanical suturing procedures have been performed in 10 patients for total gastrectomy, 6 for proximal partial gastrectomy and 7 for esophageal transection. The instrument (SPTU all-round type made in Russia) proved simple to use and produced reliable good quality closures without any other inforcement. There was one minor suture leak in 10 patients with intramediastinal esophagojejunostomy and in 6 with proximal partial gastrectomy respectively, but neither leak nor other problem has been arisen in esophageal transection for varices. It is believed that this staple suturing methods used SPTU all-round type apparatus are safe from anastomotic failure and useful for secure intramediastinal anastomosis in high level, and they represent a significant advance in the technique of thoraco-abdominal surgery.     

经会阴球膜部尿道吻合术治疗骨盆骨折所致后尿道狭窄的术后并发症回顾性研究

目的:回顾性研究骨盆骨折所致的后尿道狭窄而采用经会阴途径球膜部端端吻合尿道成形术患者的术后并发症。方法:本研究对象为573例因骨盆骨折导致的后尿道狭窄患者,均接受经会阴途径球膜部尿道吻合术,联合逆行和顺行膀胱尿道造影对狭窄长度、部位和程度进行评估。所有患者行经会阴途径一期尿道吻合成形术。以患者术后排尿通畅并且不需要其它干预措施作为手术成功的标志。使用国际勃起功能指数(IIEF)-5问卷调查对术前和术后性功能障碍的患病率进行评估,利用尿垫试验对压力性尿失禁的程度进行评估。结果:573例患者中,504例(88%)成功,69例(12%)不成功。手术后4周去除导尿管,测定尿流率平均最大为(20.52±5.1)ml/s。28例术中直肠损伤并一期修复。10例(1.7%)在术后6个月内尿道狭窄复发,45例在术后6个月~1年期间尿道狭窄复发。所有复发患者接受了再次手术。24例(4.2%)有轻度急迫性尿失禁,28例(4.9%)有轻度压力性尿失禁。术前有487例患者(85%)在受伤后出现勃起功能障碍,术后有492例(86%)发生勃起功能障碍,但术前和术后比较,差异无统计学意义(P0.05)。9例(1.6%)发现在后尿道与膀胱颈之间存在假道。结论:若术前进行谨慎评估,明确解剖结构,术中精细操作,经会阴途径球膜部尿道吻合术相关的大部分并发症是可以避免的。     

Safety of endoscopy in the immediate postoperative period following gastric anastomosis

Summary The safety of gastrointestinal endoscopy in the immediate postoperative period following partial gastrectomy was assessed in ten dogs. Endoscopy was performed preoperatively and at 1, 2, 3, and 7 days postoperatively. The mean pressures required to perform an adequate endoscopy varied from 17 to 20 mm Hg. Following partial gastrectomy, the abdominal wall was closed with a zipper to facilitate inspection of the gastric anastomosis. No leakage of air or intra-abdominal abscesses were seen following endoscopy. The results of this study suggest that endoscopy can be safely performed in the immediate postgastrectomy period.     

消化管吻合技术有关问题的探讨

随着对消化管愈合过程认识的进步及新技术的采用,消化管吻合术出现了一些新的发展趋势,如单层吻合法、对合缝合技术及机械吻合.本文就上述问题作一综述.     

Gastropericardial and gastrobrachiocephalic vein fistulae caused by penetrating ulcers in a gastric pedicle following esophageal cancer resection: A case report

The gastric pedicle is commonly used for reconstruction following resection of esophageal cancer. However, we recently experienced a case in which two gastric tube ulcers occurred three months postoperatively; one penetrating into the pericardial cavity and the other into the left brachiocephalic vein. To our knowledge, no other such a case has ever been reported and we therefore report and discuss its etiology and management.     

单层间断套入式胰肠吻合在胰十二指肠切除术中的应用

目的探讨单层间断胰肠端侧套入式吻合在经典胰十二指肠切除术(pancreaticoduodenectomy,PD)—Whipple术中的临床疗效。方法回顾性分析2010年1月至2016年7月苏州大学附属第三医院62例行单层间断胰肠端侧套入式吻合的Whipple术患者临床资料。结果本组患者全部手术成功,除1例发生胰瘘,无再手术和围手术期死亡病例。结论单层间断胰肠端侧套入式吻合方式简单、安全、实用,学习曲线较短,值得推广。     

Esophageal transection using a biofragmentable anastomosis ring in dogs

Since the first publication on the new anastomosis technique using a biofragmentable anastomosis ring (BAR) by Hardy in 1985, various studies have been performed to investigate the superiority of this type of anastomosis, and it has since been reported that the BAR was safely used not only in large and small bowel anastomosis, but in cholecystojejunal and gastrojejunal anastomosis as well. In this study, the feasibility of the BAR for esophageal transection was investigated. Seven dogs were operated on, and one died of intraabdominal bleeding on the operative day while another died of leakage at the site of gastrotomy on the 3rd postoperative day. These deaths were all considered to be due to simple technical errors not directly related to the use of the BAR. The postoperative recovery of the other five dogs was uneventful, and the ring eventually disintegrated into several small fragments that passed out of the body in the faces between the 14th and 21st postoperative days. The dogs were killed on the 28th postoperative day, and both gross and histological examinations, revealed that the transection had been successful. Neither leakage nor significant stenosis at the site of transection was found. Our results suggested that the BAR could be used for esophageal transection and is thus recommended as an easy-to-learn, time-saving, and safe technique for esophageal operations.