食管癌术后颈部吻合口瘘引发脓胸的临床特点与处理对策

目的 探讨食管胃颈部吻合术后颈部吻合口瘘导致脓胸的发生特点及处理对策.方法 对2006年1月至2013年1月间河南省安阳肿瘤医院胸外科施行食管癌切除颈部吻合术患者的临床资料进行回顾性分析.结果 全组共计3342例食管癌患者行食管胃颈部吻合术,其中左颈左胸二切口2248例（左颈左胸术组）,右胸三切口1094例（右胸术组）.术后共计发生颈部吻合口瘘237例（7.1％,237/3342）,左颈左胸术组152例（6.8％）,右胸术组85例（7.8％）,差异无统计学意义 （P=0.287）.19例患者引致脓胸（8.0％,19/237）,左颈左胸术组3例（2.0％）,右胸术组16例（18.8％）,差异有统计学意义 （P＜0.01）.脓胸发生在3d以内者14例（73.7％,14/19）.19例脓胸患者均采用保守治疗,包括行胸腔闭式引流,经鼻腔放置十二指肠营养管或通过空肠造瘘管予以肠内营养支持治疗,并辅以肠外营养支持及抗炎对症治疗.最终治愈16例,死亡3例.结论 右侧开胸手术后发生颈部吻合口瘘易导致脓胸.充分引流及良好的营养支持是治疗的重点.     

食管重建术吻合术式的临床研究

研究延长食管胃粘膜吻合、吻合器吻合、传统术式吻合三种不同食管重建术式对吻合口瘘口和吻合口狭窄的影响。方法１９９６年３月－１９９８年３月对食管贲门癌切除食管重建术者采用新术式２４１例，颈吻合２４例，胸内吻合２１７例，吻合器吻合１１０例，均为胸内吻合；１９９５年３月－１９９６年３月采用传统术式２１１例，颈吻合２２例，胸内吻合１８９例。传统术式发生吻合口瘘３例，颈部、弓上、弓上吻合各１例，新术式组及吻合     

吲哚菁绿荧光成像在胸腔镜食管癌手术中的应用

目的评价吲哚菁绿(ICG)荧光成像在胸腔镜食管癌手术中应用的价值。 方法随机选取32例食管癌患者作为实验组,在胸腔镜手术中利用ICG荧光成像技术,判断管状胃血液灌注情况,选择灌注良好的区域完成吻合。术后根据临床症状和影像学来判定吻合口漏是否发生,并记录吻合口瘘发生情况。同期选取38例常规手术组食管癌患者作为对照组。 结果全组未出现由于注射ICG而引起的死亡等不良反应。所有患者采用经纵隔途径食管胃颈部吻合方式。器械吻合52例(实验组24例,对照组28例);手工吻合18例(实验组8例,对照组10例),两组患者的吻合方式无统计学差异(P>0.05)。临床症状和影像学证实的吻合口漏共7例,其中实验组2例(6.25%),显著低于同期不用此项技术的对照组5例(13.15%)。 结论ICG荧光素成像是一种安全可行的技术,术中通过一个可视化的效果,评估管状胃的血流灌注情况,有助于降低食管癌手术后吻合口瘘的发生。     

胃浆肌瓣包套的食管胃吻合术

目的 探讨预防食管,贲门癌手术后吻合口瘘和狭窄,返流性食管炎发生的方法。方法 对２７３例贲门癌,食管下段癌患者,随机分为治疗组１４５例,对照组１２８例,并分别采用胃浆肌瓣包套的食管胃吻合术及传统的食管胃二层同心圆吻合术。结果 治疗组无吻合口瘘及吻合口狭窄,返流性食管炎１０例。     

食管胃颈部器械吻合在食管癌切除术中的应用

目的 探讨食管癌切除后使用消化道圆型吻合器行食管胃颈部吻合的安全性和可行性。方法回顾性分析2009年8月至2011年4月间河南省人民医院采用一次性圆形吻合器行食管癌切除后食管胃颈部吻合病例的临床资料。结果202例患者中除1例因吻合时部分食管撕裂而需手工缝合修补外,其余均一次吻合成功。无手术死亡病例。术后出现颈部吻合口瘘6例（3．0％）,经保守处理后均在短期内愈合;无胸内吻合口瘘或其他吻合器械相关并发症发生;有2例患者在进食后出现较明显的胃食管反流。经10．2个月的中位随访,全组患者均未发现吻合口狭窄。结论食管癌切除后使用吻合器行食管胃颈部吻合安全、可行。     

The esophageal anastomotic leak

Sixty-three esophageal anastomoses were performed on adult patients with esophageal or gastric cancer. A total of thirteen anastomotic leaks occurred, resulting in death in seven patients and serious morbidity in an additional patient. Twelve patients had esophagocolostomy, with five anastomotic leaks. Four leaks occurred in the cervical region and were easily managed by local drainage and irrigation, while the other patient had an intrapleural leak resulting in sepsis and death. Twenty-eight patients had esophagogastrostomy, with a total of five leaks. All anastomoses were intrapleurally located, and death ensued in four patients. Fourteen Roux-en-Y and three loop esophagojejunostomies were performed, with no leaks. Two additional deaths occurred from leakage in the pleural cavity and left upper abdomen after jejunal interposition (3 patients) and esophagoduodenostomy (3 patients). In this study, impaired blood supply of the anastomotic end appeared to be the major cause of anastomotic failure. In addition, postoperative shock appeared to predispose to anastomotic leakage, whereas microscopic tumor at the line of resection, duration of operation and operations for palliation did not appear to increase the leakage rate. The high mortality with esophageal anastomotic leak occurs when diagnosis is delayed and when the site of leakage is in the pleural cavity or left upper abdomen. Conservative treatment is uniformly fatal, whereas operative intervention offers the only chance for survival.     

食管,贲门癌切除一层吻合术210例分析

目的食管、贲门癌手术后吻合口瘘和吻合口狭窄是常见的并发症，为尽可能降低其并发症的发生，我院从１９８８～１９９６年对２１０例食管、贲门癌患者实施手术。方法采用全层、间断、内翻一层吻合法，不附加减张悬吊及包埋重建消化道，颈部吻合３９例，主动脉弓上吻合３６例，主动脉弓下吻合１１５例，全胃切除空肠食管吻合２０例。结果全组患者术后吻合口瘘和吻合口狭窄各发生１例，发生率低于０．５％，无手术死亡。结论本吻合方法降低了食管、贲门癌手术后吻合口瘘和狭窄的发生。     

食管癌贲门癌术后吻合口及胸胃瘘的临床分析

目的　探讨食管癌、贲门癌切除术后吻合口及胸胃瘘发生的高危因素及防治措施。方法　分析 1990年 1月～ 2 0 0 3年 12月间 136 9例行食管癌、贲门癌切除、食管重建术病人的临床资料。结果　本组颈部吻合口瘘的发生率为 16 .2 4 %。胸内吻合口及胃瘘发生率为 2 .0 % ,死亡率2 8.0 % ;前 6年和近 7年相比 ,胸内瘘的发生率为 3.33%对 1.4 6 % (P =0 .0 31)。胸内机械吻合瘘的发生率为 0 .5 1%。结论　吻合口瘘及胸胃瘘是食管重建术后严重的并发症 ,应用机械吻合、熟练掌握手术技巧和加强围术期管理是预防瘘发生的有效方法     

应用《食管瓣成形—食管胃套接》法手术治疗食管癌与贲门癌

自１９８８年至１９９３年我科对６０例食管与贲门癌病人，采用食管瓣成一菜一食管胃套接法进行手术治疗。手术切除肿瘤后行颈部吻合９例，弓上吻合２３例，弓下吻合２８例，术后无吻合口瘘，随访中我吻合口狭窄病例，并就此术式对防止吻合口瘘，狭窄及术后胃内容物返流等进行讨论。     

食管贲门癌切除术后吻合口漏28年回顾(附111例报告)

目的探讨食管贲门癌切除术后吻合口漏的防治方法。方法回顾1977年1月至2004年12月食管贲门癌切除术病例共5402例,分成A、B两组。1977年1月至1995年12月3785例为A组,1996年1月至2004年12月1617例为B组。将A、B两组间吻合口漏的情况进行比较。结果5402例食管贲门癌切除术后发生吻合口漏共11l例,总发生率为2．1％;死亡3l例,总死亡率27．9％。A组吻合口漏发生率为2．2％,吻合口漏死亡率为34．9％;B组吻合口漏发生率为1．7％,吻合口漏死亡率为7．1％。B组吻合口漏死亡率显著低于A组（P〈0．01）。B组胸腔内吻合口漏发生率显著低于A组（61．9％ VS 32．1％,P〈0．01）。结论改进吻合技术、早期诊断吻合口漏和早期积极干预对防治食管贲门癌切除术后吻合口漏有重要意义。     

结肠间置术治疗胃切除术后食管癌

目的 探讨结肠间置术治疗胃切除术后食管癌的疗效。方法 对26例胃切除术后食管癌患的手术方式、并发症、治疗结果及术后胃肠功能进行分析。结果 1例移植段结肠颈段坏死，4例颈部吻合口瘘，1例术后8d死于急性心肌梗死。结肠顺蠕动间置18例，1年生存率77．8％，2年生存率44．5％；结肠逆蠕动间置8例，1年生存率62．5％，2年生存率37．5％。胃肠功能等级评定显示，结肠顺蠕动间置术后胃肠功能优于结肠逆蠕动间置。结论 胃切除术后腹膜腔的严重粘连和胃空肠吻合口的压迫可导致横结肠短缩和结肠左动脉分支变细。手术中应力争行结肠顺蠕动间置。     

下咽及颈段食管癌的手术治疗

目的：探讨下咽及颈段食管癌的手术疗效及颈段食管重建的方法,方法：1980年至2000年6月对86例下咽及颈段食管鳞状细胞癌进行了外科治疗,下咽癌的切除率为97．4％（37／38例）,食管重建包括喉及肿瘤切除后食管与口底吻合4例,咽,喉及颈段食管切除后用颈阔肌皮瓣重建15例,游离空肠间插3例,全咽,全喉,全食管切除后用胃重建12例,3例未行喉切除者采用食管与咽部直接吻合,颈阔肌皮瓣及用胃重建食管各1例,颈段食管癌的切除率为91．7％（44／48例）,均采用非开胸食管拔脱后用胃重建食管,结果：术后发生并发症在胃重建组有57例（35％）,（包括1例术后死于心力衰竭）,游离空肠组1例（33．3％）,颈阔肌皮瓣重建组3例（18．8％）,随访6－108个月（平均57个月）,下咽癌的1,3,5年生存率分别为80．6％,60．0％和31．6％,颈段食管癌分别为70．7％,9．5％和0。结论：下咽及颈段食管癌的切除率甚高,但下咽癌的远期疗效明显优于颈段食管癌,咽,喉及颈段食管切除后采用颈阔肌皮瓣重建是一种安全,有效的手术方法,并发症少,远期效果优良。     

胸腔镜辅助食管内翻拔脱术治疗胸上、中段食管癌(附8例报告)

目的:探讨用简捷的术式治疗胸上、中段食管癌,减少术后并发症。方法:为8例食管癌患者施行胸腔镜辅助食管内翻拔脱术,分析手术操作过程、并发症及术后患者的康复情况等。结果:8例患者均采用胸腔镜辅助食管内翻拔脱术完成手术,1例发生吻合口漏,1例发生对侧气胸,经对症治疗治愈。结论:此术式治疗胸上、中段食管癌优于传统手术。     

不开胸食管剥脱术在颈段食管癌中的治疗价值

目的探讨不开胸食管剥脱术治疗颈段食管癌的效果。方法自1995年7月至2004年12月对21例颈段食管癌患者行不开胸食管剥脱术并Ⅰ期行胃咽吻合或胃食管端侧吻合术。结果本组病人的手术切除率100%。手术后发生各类并发症8例,其中吻合口瘘3例,肺部感染3例,伤口裂开1例,气胸1例。18例患者术后有不同程度的胃液反流。1例住院期间因胃大出血死亡。除2例失访外其余患者获得随访27个月～12年,13例存活超过1年,6例存活超过3年,3例存活超过5年。结论不开胸食管剥脱术手术简单,效果满意,适用于颈段食管癌。食管剥脱术后行胃代食管者胃液反流严重,手术方式有待进一步改善。     

机械吻合在食管外科中的应用：1605例经验总结

１９８０年８月至１９９４年２月应用机械方法对１６０５例食管癌和贲门癌切除后进行吻合。男１２８１例，女３２４例。年龄２８～８１岁，其中５０～６９岁１１８４例（７３．８％）。食管癌１０４４例，贲门癌５６１例。食管胃颈部吻合３５例；超胸顶吻合５８例；弓上吻合８３５例；弓下吻合６７７例。术后发生吻合口瘘１６例（ｌ％），其中颈部吻合口瘘发生率１４．３％（５／３５）；胸内吻合口瘘发生率０．７％（１１／１５７０），前６年胸内吻合口瘘发生率１．４％（８／５７５），近８年胸内吻合口瘘发生率０．３％（３／９９５）。术后发生吻合口狭窄１６例（１％），狭窄明显者经扩张后均恢复正常饮食。作者认为：机械吻合是减少胸内吻合口瘘的有效方法之一。     

Carcinoma of the hypopharynx and the cervical oesophagus: a surgical challenge.

OBJECTIVE: To report our results after reconstruction of the upper digestive tract for locally advanced carcinoma of the hypopharynx and cervical oesophagus. DESIGN: Open study. SETTING: Teaching University hospital, Germany. SUBJECTS: Of the 517 patients who presented with carcinoma of the oesophagus between September 1985 and March 1997, 16 had a locally advanced tumour of the hypopharynx and 25 of the cervical oesophagus. INTERVENTIONS: Free jejunal grafts were used after circular resection in all patients with carcinoma of the hypopharynx, and for the 3 with oesophageal carcinoma in whom we obtained adequate resection margins. In the remainder stomach was used in 21 and colon in 1. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: After jejunal grafting 1 patient died within 30 days and 2 died in hospital. After gastric or colonic reconstruction 2 patients died within 30 days and 4 in hospital. There was 1 anastomotic leak, 1 transplant became necrotic and had to be replaced, in 2 patients the recurrent nerve was damaged, 1 patient developed a wound infection and 1 a cardiac infarction. After gastric or colonic replacement 7 patients had paralysed recurrent laryngeal nerves, there was 6 anastomotic leaks, 1 chylous leak, 1 haemorrhage, and in 1 the transplant necrosed. CONCLUSION: Despite the fact that we compared tumours in different sites, these results suggest that the jejunal graft is safer for upper oesophageal and hypopharyngeal reconstruction.     

Cervical esophagogastric anastomosis with a new stapler in the surgery of esophageal carcinoma.

OBJECTIVE: A new reusable circular stapler for cervical esophagogastric anastomosis (CEGA) has been used to substitute the traditional method of hand-sewn cervical anastomosis. METHODS: Over a 2-year period (09/1998-11/2000), the stapler was engaged on operations of 112 patients with thoracic esophageal carcinoma, and the anastomosis was performed through both cervical and thoracic incision. The operative approaches were through left thoracotomy in 85 cases, and through right thoracotomy in 27 cases. The results were analyzed retrospectively. RESULTS: All of the 112 CEGA operations were successfully performed on the patients who underwent esophageal resections, and no operative mortality and anastomotic leakage occurred. Excluding the two patients with the anastomotic recurrent carcinoma, anastomotic stricture occurred in 12 cases (10.9%, n=110). Median time to the presentation of anastomotic stricture was 4.3 months (range 2.6-25.3 months), and the median number of dilatations was 3 (range 1-5). When divided into the 24 and 26 mm groups, the respective incidences of stricture were 12.3 (7/57) and 9.4% (5/53), respectively, and the statistical results of the two sizes of staplers were essentially the same (P=0.6691). Eight patients experienced nonanastomotic-related complications (7.3%, n=110), in which there were three cases of recurrent laryngeal nerve injury, four cases of the left side pneumothorax, and one case of perforation of the proximal stomach. There was also a case of stapling gauze at anastomosis. Some of the complications were closely related to the initially improper use of the new stapler's craft. CONCLUSIONS: The results indicate that CEGA using the new circular stapling device in surgery of the esophageal carcinoma is a very effective procedure to improve the anastomotic technique from a traditional hand-sewn anastomosis to a stapled anastomosis and can reduce the incidence of complications.     

食管腐蚀性烧伤后严重狭窄的外科治疗

目的探讨食管腐蚀性烧伤后狭窄的外科治疗经验及胃或横结肠代食管重建手术的应用价值。方法对98例食管腐蚀性烧伤后狭窄的患者中72例广泛食管狭窄、病变超过食管中段以上者采用横结肠代食管、保留结肠左动脉升支、胸骨后顺蠕动吻合,其中横结肠咽腔吻合18例,横结肠食管颈部吻合54例,胸段食管旷置不切除;26例狭窄位于中下段,经胸切除瘢痕段食管用胃重建食管,胃食管胸内吻合。结果结肠食管重建72例中,术后死亡4例（5．56％）,发生颈部吻合口瘘14例（19．44％）,后期出现颈部吻合口狭窄7例,经治疗后均痊愈。胃重建食管26例无手术死亡,术后发生胸内吻合口狭窄3例,经扩张治愈。结论食管腐蚀性烧伤后狭窄在伤后20～24周可积极采取食管重建术,根据食管狭窄段严重程度及位置决定是否行狭窄段食管切除、选择食管重建替代物及吻合的位置。可采用横结肠食管颈部吻合或结肠咽腔吻合术,胸内胃食管吻合术。     

Donor site morbidity of free jejunal flap reconstruction of the oropharyngeal cavity

The study was performed to evaluate abdominal complications related to jejunal segment resection for reconstruction after radical oropharyngeal tumor resection. Perioperative complications of 104 patients (median age, 53.7 years; 23 female; 81 male) who underwent surgery for oropharyngeal malignancy after radiochemotherapy and the long-term morbidity of 35 patients after a median follow-up period of 21 months are analyzed. The perioperative mortality was 8.7% (9/104); none of the perioperative deaths was caused by an abdominal complication associated with the jejunal resection. In three cases, repeat laparotomy was performed within 30 days of jejunal autotransplantation: in two of them the reason was not directly associated with bowel resection and one patient had an abdominal wall dehiscence. In six cases there were minor abdominal complications which could be treated nonsurgically. There was no anastomotic leakage, bowel obstruction or postoperative bleeding. In the follow-up re-examination, no late onset abdominal complications were noted except small incisional hernias in six of the 35 patients; only one required a hernia repair. Despite a potentially increased operative risk in these patients, the complication rate after bowel resection for jejunal autotransplantation was low. This is a safe procedure in patients with oropharyngeal carcinoma. Received: 9 March 1998 / Accepted: 14 December 1998     

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.