经腹切开膈肌脚纵隔内行食管胃或空肠机械吻合术治疗贲门部癌

目的 探索治疗贲门部癌的手术入路新方法。方法 经腹切开膈肌脚入,用国产吻合器行纵隔内食管胃吻合89例、食管空肠吻合16例。结果 在切除肿瘤及其上方7cm食管的同时,清除纵隔下部淋巴结,淋巴结转移率为20．9％。全组病例无手术死亡,无吻合口瘘,亦无食管切缘癌残留。术后并发症发生率4．76％,5年生存率39％。结论 经腹切开膈肌脚纵隔内食管胃（空肠）机械吻合术,操作简便,术野暴露良好,创伤及生理扰乱较小,能有效地预防吻合口瘘,且便于切除足够长度食管和扩大淋巴结清除范围。适用于浸润食管长度＜2cm的贲门部癌的外科治疗。     

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贲门癌发生于食管 -胃交界处 12ｃｍ的特殊部位 ,不同于食管癌也不同于胃癌 ,有双向转移的特点。关于经何种手术径路 ,能达到根治效果 ,国内外学者作了许多研究 ,有经腹、经胸、经胸腹联合切口入路 ,各有优缺点。本文总结了 19982 0 0 1年间经腹切开食管裂孔膈肌及左膈肌脚入路 ,应用吻合器吻合食管胃或食管空肠治疗 78例贲门癌。报告如下。1　临床资料本组 78例 ,男 5 5例 ,女 2 3例。年龄 45 82岁 ,平均5 5 6岁。ＴＮＭ分期Ⅰ期 10例 ,Ⅱ期 2 5例 ,Ⅲ期 3 2例 ,Ⅳ期 11例。术前胃镜、钡餐、胸部ＣＴ检查 ,食管被癌浸润2ｃｍ以内 ,纵隔无…     

先天性食管闭锁的外科治疗

目的 总结32例先天性食管闭锁手术治疗经验。方法 手术均采用食管上盲端前壁肌层U形翻转，即经胸膜外入路充分游离食管上端及瘘管，近气管侧缝扎切断瘘管。用剪刀将远端食管前壁纵行剪开5min，吻合前距吻合口上方10min处行食管上下两端浆肌层缝合3针，然后距吻合口上方15～20min处将食管前壁肌层切开，从切开处向吻合口方向从两侧纵行切开肌层至吻合口约5mm，轻轻分离前壁肌瓣，形成U形向下翻转，缝合在食管远端浆肌层上。结果 32例中17例采用此方法未发生吻合口瘘，1例吻合口狭窄。2例成功行一期胃代食管术。结论 食管上盲端前壁肌瓣U形翻转能有效预防吻合口瘘及狭窄。Ⅰ、Ⅱ型食管闭锁采用一期胃代食管术，可避免二次手术。     

腹腔镜胃癌手术中近端胃切除单肌瓣吻合难点与对策

腹腔镜下近端胃切除右开襟单肌瓣成形术（ROSF）是一种用于治疗胃上部早期癌和胃食管结合部癌的新型手术方法，其特点是利用胃壁浆肌层制作一个单肌瓣，将其覆盖在食管胃黏膜侧侧吻合口上，以增强抗反流效果和防止吻合口狭窄。该手术简化了手术操作，经临床观察，是一种安全、有效的术式，可保障手术安全和改善病人术后生活质量。     

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。     

食管癌和贲门癌术后吻合口重度瘢痕狭窄的外科治疗

目的总结食管癌和贲门癌术后吻合口重度瘢痕狭窄外科治疗的经验。方法对24例重度吻合口瘢痕狭窄并下咽困难的患者行二次手术治疗。其中,原发肿瘤为食管癌17例(9例为颈部食管胃吻合,8例为胸内食管胃弓上吻合),贲门癌7例(6例为胸内食管胃弓下吻合,1例为经腹食管胃膈下吻合);狭窄段长0,3～0．5cm、在瘢痕基础上形成蹼状者18例,狭窄段长0．5～1．0cm、环形狭窄呈收缩状者6例。二次手术解剖吻合区的吻合口上下各1—2cm范围,在距吻合线上下各2～4mm处分别切开一半食管腔和胃腔,然后切除部分瘢痕狭窄环组织,再行食管-胃单层吻合。结果24例成功地完成二次手术,1例出现颈部吻合口瘘,无手术死亡。术后随诊2—3年,患者可顺利进软食和普食,未发生二次吻合口狭窄,生活质量明显提高。结论食管癌和贲门癌术后发生的吻合口重度瘢痕狭窄,可行二次手术切除部分瘢痕狭窄环再吻合,效果较好。     

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。     

CDH园型吻合器在胃底贲门癌外科中的应用

目的:评价CDH圆形吻合器经腹食管、胃吻合中的应用。方法:用该吻合器对45例胃底贲门癌切除术后行食管胃机械吻合,对照组同期18例胃底贲门癌切除术后行手工吻合,复习1989～1994年58例胃底贲门癌切除用上海GF-1型园型吻合器行食管胃机械吻合。结果:45例用CDH圆形吻合器均一次吻合成功,无器械故障,无吻合口瘘,无吻合口狭窄,无手术死亡病例。结论:CDH圆形吻合器设计合理、安全可靠、在胃底贲门癌经腹行食管胃吻合术中应用,可缩短手术时间,减少手术创伤,降低手术难度。     

经腹经后纵隔贲门癌根治术

目的 探讨经腹经后纵隔进行贲门癌根治的可行性和安全性.方法 对26例贲门癌侵及食管下段的患者进行经腹经后纵隔贲门癌根治术,其中根治性近端胃食管切除9例,根治性全胃食管切除17例.结果 本组26例均成功完成经腹经后纵隔贲门癌根治术.平均手术时间:全胃切除(189±39)min,近端胃切除(153±35)min;平均手术出血量:全胃切除(200±80)ml,近端胃切除(168±76)ml;平均清扫淋巴结数:腹腔淋巴结(23.3±7.3)枚/例,食管旁淋巴结(4.1±2.0)枚/例.术后无吻合口出血、吻合口瘘、吻合口狭窄发生,4例患者出现肺部感染,经治疗好转,所有患者恢复良好.术后随访5～51个月,4例出现肝转移,2例发生肺转移,其中1例死亡,其余患者情况良好,无吻合口癌复发.结论 经腹经后纵隔贲门癌根治术安全、可行,适用于膈肌没有受侵犯、食管受侵小于5 cm的胃上都癌.     

食管胃黏膜活瓣式吻合术在食管下段癌、贲门癌切除中的应用

目的 探讨食管下段癌、贲门癌切除后食管胃黏膜活瓣式吻合术的方法及临床体会.方法 肿瘤切除及淋巴结清扫后消化道重建时,剥除食管肌层及胃浆肌层,使黏膜延长3～4 cm,然后食管黏膜与胃黏膜分层吻合,浆肌层包埋,包埋后吻合口置入胃腔内2-3 cm,切除胃超过2/3以上时辅以大网膜包绕吻合口.结果 施行该吻合方法38例,均恢复顺利,近期并发症3例,其中心律失常1例,肺部感染1例,乳糜胸1例,均经保守治疗全部治愈,随访半年后均可顺利进普通饮食,无吻合口狭窄及反流性食管炎表现.结论 食管胃黏膜活瓣式吻合术可有效地预防吻合口漏、狭窄、反流等并发症.     

贲门癌根治术术中管状吻合器的使用优点及技巧探讨

目的 探讨贲门癌根治术(食管空肠吻合及残胃食管吻合)术中管状吻合器的使用优点及技巧.方法 1998年～2007年本院753例贲门癌根治术行食管空肠吻合或残胃食管吻合重建消化管,术中均使用一次性管状吻合器.结果 本组753例,无手术死亡,行胸腹联合手术6例(0.80%),无吻合口漏发生,吻合器切割不全2例(0.26%),发生吻合口狭窄4例(0.53%),腹腔感染1例(0.13%),膈疝1例(0.13%),术后标本病理检查上切缘癌累及1例,下切缘均未累及.结论 在贲门癌根治术中,管状吻合器的运用简化了手工操作程序,可靠、安全、省时,降低贲门癌进胸手术比例,手术创伤小,恢复快,能有效地预防吻合口瘘和狭窄.但吻合器吻合也不是绝对安全的,吻合口瘘、出血、狭窄等并发症仍有一定的发生率,术中技巧值得在今后的工作中进一步总结、探讨.     

管状胃代食管术在食管癌、贲门癌中的临床应用研究

目的探讨管状胃在食管癌、贲门癌切除术中的临床应用及对术后生活质量的影响。方法78例食管癌、贲门癌患者,随机分为常规手术组和管状胃组。常规组37例,男31例,女6例,年龄（62．70±5．89）岁,胸中段食管癌21例,胸下段食管癌14例,贲门癌2例。管状胃组41例,男33例,女8例,年龄（60．56±6．75）岁,胸中段食管癌20例,胸下段食管癌18例,贲门癌3例。观察两组患者手术时间、术中出血、输血,术后心律失常,肺部并发症,吻合口瘘,吻合口狭窄,返流性食管炎,胸胃综合征发生率及住院时间等临床指标。结果丽组患者均顺利完成手术,无围手术期死亡,两组心律失常（40．54％比19．51％,P=0．042）、肺部并发症（32．43％比12．20％,P=0．031）、返流性食管炎（27．02％比4．87％,P=0．007）、胸胃综合征发生率（16．22％比0,P=0．024）及术后住院时间[（12．16±1．99）d比（10．87±1．41）d,P=0．001）]等指标比较差异有统计学意义。而在手术时间,术中出血、输血,吻合口瘘及吻合口狭窄发生率比较差异无统计学意义。结论管状胃在食管癌、贲门癌手术中并发症发生率较低,不增加手术时间、可缩短住院时间,可改善患者的生活质量,具有较好的临床应用价值。     

Application of a suspending abdominal retractor and stapling device in resection of carcinoma of the gastric cardia using a trans diaphragm approach

The article describes the structure assemblage and Clinical application of a Suspending abdominal retractor. From the experience gained in 40 cases of cardial carcinoma operated on, it was found that the device has the following advantages: (1) there is no need for a thoracotomy, and hence the operative trauma is much reduced; (2) good exposure of the upper abdomen and lower mediastinum; (3) adequate length of the lower esophagus and as many as 110 lymph nodes can be resected. Postoperative complications were relatively few. The incidence of residual carcinoma at the esophageal Stump was 2.5%, being much lower than in cases using a single abdominal incision, and similar to those using a combined left thoracoabdominal incision. It was concluded that this operative approach, applying the device recommended, is a relatively ideal procedure for resection of carcinoma of the gastric cardia, especially in elderly patients with poor general health.     

Resection of esophageal and gastric cardiac cancer and esophagogastrostomy by planting esophagus into the stomach: a report of cases

105 cases of esophageal cancer and 46 cases of gastric cardia carcinoma were resected and the continuity of alimentary canal was resumed by planting esophagus into the stomach. This procedure had been designed by authors. There is neither anastomotic leakage nor stricture. Only 1 case died perioperatively. The anastomosis start by suturing the whole thickness of esophageal wall to the mucous membrane of stomach. Then the esophageal stump was telescoped into the stomach by suturing the secomuscular layer of stomach to the outer layer of esophageal muscles, with a distance of about 3 cm from the inner anastomatic line. When the anastomasis was finished, esophageal mucous membrane everted slightly, and prolapsed a little as food bolus passes. We suggest these are the mechanisms preventing the anastomosis from leaking or narrowing. Reflex of gastric content may be prevented too.     

Experimental and clinical study on the lymphatic pathway draining from the distal esophagus and gastric cardia

The intramural and extramural lymphatics draining from the distal esophagus and gastric cardia were studied in 140 mongrel dogs by dye injection technique. A clinical study was also performed on the lymphatic pathway in these regions by radio isotope uptake (RIU). The results were compared with that of lymph node metastases in 113 patients with carcinoma of the distal esophagus and 103 patients with carcinoma of the gastric cardia. The intramural lymphatics between the distal esophagus and gastric cardia were communicated at the central part of the muscularis mucosae. This finding coincided with the results of intramural RIU. The extramural lymphatics from the distal esophagus flowed both upward and downward. Those from the cardia entered the intraabdominal regional lymph nodes, but none was visualized either in the mediastinum or in the thoracic cavity. Similarly, few RIUs were detected in the mediastinal nodes. As the result of partial or total blockade at the cardiac portion of the stomach in dogs, ascending lymphatics reaching the thoracic cavity was observed in 6 of 27 cases. Clinically, the incidence of the mediastinal lymph node metastases were 17.0%. These results indicate that upward lymphatic spreads may occur in cases with cardiac cancer when the descending lymphatic pathway is blocked by the tumor invasion.     

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.     

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.     

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