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.     

胃食管吻合术后胃食管反流的研究

目的 研究食管癌和贲门癌术后不同位置的食管胃吻合口和时间因素对胃食管反流程度的影响。方法 对39例食管癌和贲门癌术后病人进行24h食管pH监测、电子胃镜检查，其中食管胃弓上吻合组（A组）21例，弓下吻合组（B组）18例。结果 （1）A组DeMeester评分和反流性食管炎评分均明显低于B组（P〈0．05）。（2）随着时间的推移A组和B组DeMeester评分无明显的改变（P〉0．05）。结论 不同位置的食管胃吻合口影响胃食管反流程度，食管胃吻合口位置越高胃食管反流和反流性食管炎程度越轻。时间因素对胃食管反流程度无明显的影响。     

机械吻合与食管胃分层吻合术治疗食管和贲门癌的对比研究

目的比较机械吻合术与分层吻合术在预防食管和贲门癌手术后吻合口瘘、吻合口狭窄和食管反流并发症发生率的差异。方法将316例食管和贲门癌患者按入院顺序随机分为机械吻合组(162例,采用食管癌切除机械吻合术)和分层吻合组(154例,采用食管癌切除食管胃分层吻合术)。分别比较两组术后吻合口瘘、吻合口狭窄和食管反流并发症发生率。结果机械吻合组术后吻合口瘘和吻合口狭窄发生率分别为1.2%和2.0%,而分层吻合组则分别为3.9%和4.7%,两组比较P<0.01。两组胃食管反流的发生率(88.8%、89.3%)差异无统计学意义(P>0.05)。结论对于预防食管和贲门癌手术后吻合口瘘、吻合口狭窄方面,机械吻合优于分层吻合法。     

黏膜瓣式食管胃吻合术抗反流的食管动力学研究

目的寻找一种实用有效的抗反流食管胃吻合术式。方法将食管癌和贲门癌患者464例随机分为黏膜瓣式食管胃吻合术组(A组,175例)、器械食管胃吻合术组(B组,151例)和单纯手工缝合食管胃一层吻合术组(C组,138例)。应用同位素测定胃食管反流指数和24h监测pH值,进行3组间的食管运动功能比较。结果同位素测定胃食管反流指数显示,A组反流阳性率为0,B组为33.3%,C组为6.7%。食管运动功能及24h监测pH显示,A组检测各项指标均接近正常值,B、C组与正常值比较,差异具有统计学意义(P<0.05)。结论黏膜瓣式食管胃吻合术式具有优异的抗反流功能,并能有效地防止食管癌、贲门癌术后反流性食管炎的发生。     

胃食管吻合术后胃食管反流症状的特征与相关因素的关系

目的探讨胃食管吻合术后胃食管反流症状的特征与相关因素的关系,以降低胃食管反流的发生率。方法回顾性分析239例食管、贲门癌切除胃食管吻合术后胃食管反流症状及与吻合平面、胃镜下表现和吻合口狭窄的关系。结果108例出现胃食管反流症状,发生率45.2%(108/239),主动脉弓下胃食管反流症状的发生率大于主动脉弓上反流症状发生率(70.7%vs.31.8%,P<0.01)。影响生活的反流症状(≥6分)发生率为25.5%,主动脉弓下吻合反流症状程度较主动脉弓上吻合重(43.9%vs.15.9%,P<0.01)。胃镜RE分级0 级、 级出现反流症状的发生率分别为41.7%(63/151)和50.0%(44/88),两者比较差异无统计学意义(χ2=1.541,P=0.214),反流症状的严重程度与RE分级无相关性(r=0.080,P=0.276)。在有症状的反流患者中吻合口狭窄发生率为37%(40/108),无症状的反流患者中未发现吻合口狭窄,两者比较差异有统计学意义(χ2=49.262,P=0.000)。吻合口狭窄与有胃食管反流症状呈正相关(r=0.480,P=0.048)。结论食管胃吻合术后只有部分患者出现反流症状,主动脉弓下吻合反流症状多于主动脉弓上吻合,且程度较重。反流症状的严重程度及发生率与RE分级无关。吻合口狭窄与胃食管反流相关。     

两种弓上食管胃吻合术后胃食管反流的比较

目的比较食管癌手术行"隧道式"式和器械式两种经主动脉弓上食管胃吻合方式术后胃食管反流的状况。方法对两组患者,"隧道式"吻合术组21例,器械吻合方式组35例,术后3个月行24 h食管pH监测;胃镜检查反流性食管炎的程度,并进行分级和评分。结果24小时pH监测显示,两组各项指标均高于正常值,但隧道组各项指标均低于器械式吻合组,差异有统计学意义:DeMeester评分和超过5 min的反流次数、pH低于4的总时间、以及pH<4的时间百分数(P<0.01)、24 h反流的次数和最长的反流时间(P<0.05);胃镜检查结果显示:器械组反流性食管炎的发生率为65.7%(23/35),明显高于隧道组为38.1%(8/21),两组反流性食管炎分级及反流性食管炎评分比较差异有统计学意义(P<0.01),器械组高于隧道组。结论两种吻合方式术后均有胃食管反流,弓上隧道式食管胃吻合术患者术后反流性食管炎的发生率和反流程度均小于器械吻合术式。     

兜底式食管胃吻合术的临床应用研究

摘要：目的评价兜底式食管胃吻合术对吻合口瘘、吻合口狭窄和胃食管反流的预防作用及效果,探讨蒙特利尔定义“胃食管反流病”诊断流程、标准在食管重建术后的实用价值和意义。方法回顾性分析2007年6月至2011年6月笔者医院采用两种术式共行食管癌和贲门癌切除1078例的临床资料,参考相关诊断标准制表,问卷调查两组患者术后吻合VI狭窄和胃食管反流的发病情况。试验组（兜底式食管胃吻合术）582例,男403例、女179例,年龄（60．4±12．6）岁。食管癌399例,贲门癌183例,弓上吻合392例,弓下吻合190例。对照组（传统食管胃端侧吻合术）496例,男343例、女153例,年龄（59．2±12．8）岁。食管癌322例,贲门癌174例,弓上吻合317例,弓下吻合179例。结果与传统食管胃端侧吻合术相比,兜底式吻合术后吻合VI瘘的发生率较低[0％（0／582）VS．1．0％（5／496）,x2=5．835,P=O．016）];胃食管反流症状亦较轻,而伴有食管外症状及需要服用制酸剂患者则更少[1．6％（33／541）VS．12．6％（57／453）,矿=23．564,P=O．000],术后吻合口狭窄率各为0．9％（5／539）和7．3％（34／465）（x2=25．124,P=O．000）,尤其是重度吻合I=I狭窄的发生率更低[0％（0／539）VS．4．7％（22／465）,X2=24．883,P=O．000]。两组5年生存率差异无统计学意义。结论兜底式吻合法在预防食管胃吻合VI瘘、吻合VI狭窄和胃食管反流的发生方面较传统术式为优;蒙特利尔定义胃食管反流诊断流程和标准适合于食管重建术后胃食管反流之诊断。     

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。     

食管癌贲门癌切除术后胃食管反流研究的国内文献荟萃

近20年来，食管外科随着基础理论研究的进展，手术方法的改进，操作技术的提高，吻合器械的应用，使食管癌贲门癌切除食管胃吻合术后与其相关并发症的发生率明显降低，并能有效的防治。胃食管反流是影响食管癌贲门癌病人手术后生活质量的主要因素，现将国内有关文献综述如下。     

改良Gambee吻合法在食管-胃吻合术中的应用

目的探讨食管肿瘤、贲门癌行肿瘤切除后，以胃重建食管时食管-胃吻合技术的改进，预防吻合口瘘及狭窄的发生。方法采用Gambee单层吻合法及全层间断单层吻合法交替应用。结果采用此方法吻合的286例患者，吻合口瘘发生率2．7％（4／146）。吻合口瘢痕狭窄0．7％。束出现胸腔内吻合口瘘及近期吻合口狭窄。结论此法适用于食管-胃吻合术，特别适用于贲门癌胃切除较多的弓下食管-胃吻合术及食管癌切除食管-胃颈部吻合术。迄今，在广泛应用吻合器的情况下。手法缝合食管、胃吻合仍是外科医生必须熟练掌握的基本功，本文介绍的改良Gambee吻合法有推广应用价值。     

A Prospective Randomized Controlled Trial of Semi-mechanical versus Hand-sewn or Circular Stapled Esophagogastrostomy for Prevention of Anastomotic Stricture

Background

Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture.

Methods

Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter.

Results

The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar.

Conclusions

Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.     

食管癌切除后食管胃颈部侧-侧吻合的近期疗效

目的 评价食管癌切除后食管胃颈部侧-侧吻合的近期疗效.方法 回顾性分析2006年1月至2009年3月第三军医大学大坪医院野战外科研究所收治的105例接受手术治疗的食管癌患者的临床资料.全组患者在全麻下行食管癌切除术,其中97例行食管胃颈部侧-侧吻合,8例行食管胃颈部手工端-端吻合.从行食管胃颈部侧-侧吻合的患者中选取9例与行食管胃颈部手工端-端吻合的患者进行比较,采用t检验分析两种吻合方式的术后咽食管功能.结果 97例行食管胃颈部侧-侧吻合的患者无手术死亡,吻合时间为15～30 min,平均为(21±3)min.16例患者术后出现并发症,其中肺部并发症7例,经抗感染和对症支持治疗后痊愈;声带麻痹4例,其中2例于术后3个月内恢复,2例为喉返神经损伤所致永久性声带麻痹,但无需进一步处理;吻合口漏3例,经更换敷料痊愈;吻合口狭窄2例,经扩张1～2次痊愈.术后咽食管功能:行食管胃颈部侧-侧吻合患者的吻合口直径为(3.01±0.17)cm,而行食管胃颈部手工端-端吻合患者为(1.69±0.26)cm,两者比较,差异有统计学意义(t=2.093,P＜0.05);2例行食管胃颈郎侧-侧吻合及4例行食管胃颈部手工端-端吻合的患者主诉有吞咽困难.结论 食管胃颈部侧-侧吻合是简单、安全、有效的吻合方法,吻合区的功能明显优于食管胃颈郎手工端-端吻合.     

Endoscopic Evaluation of the Quality of the Anastomosis After Esophagectomy with Gastric Tube Reconstruction

BACKGROUND: The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. METHODS: A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. RESULTS: The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. CONCLUSION: Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.     

食管胃侧侧吻合预防吻合口狭窄的临床随机对照研究

目的 评价使用食管胃侧侧吻合术预防术后吻合口狭窄的效果.方法 2007年11月至2008年9月连续收治行食管癌、贲门癌切除术的患者160例,2例拒绝随机分组,3例不符合人选标准,其余155患者完全随机分组为食管胃侧侧吻合组、吻合器吻合组与手工吻合组,通过术后3个月食管造影测量吻合口直径确定吻合口狭窄的发生率(吻合口直径≤O.8 cm为吻合口狭窄).结果 术后死亡1例,行剖胸探查1例.术后并发吻合口漏4例(其中手工吻合3例,吻合器吻合1例).随访率为96.1%(失访6例,侧侧吻合组1例,手工吻合组3例,吻合器组2例).共144例患者进行了意向治疗分析(侧侧吻合组45例,手工吻合组52例,吻合器组47例).三组患者术前情况类似,侧侧吻合组术后吻合13狭窄率(0)低于手工吻合组(9.6%)及吻合器组(19.1%,Fisher 精确概率法,P=0.005),而三组之间的术后胃食管反流程度学差异无统计学意义(χ~2=1.681,P=0.432).结论 食管胃侧侧吻合术能够有效地预防吻合口狭窄,同时并不加重胃食管反流.     

切除食管癌两种消化道重建方式术后胃食管反流的对比观察

目的：探讨食管癌切除后胃经食管床和经胸作弓上吻合者术后发生胃食管反流的差别。方法：对２５例病人在术后１～３个月间进行了残留食管内的２４小时ｐＨ监测。结果：（１）两种消化道重建方式病人的ｐＨ总得分、２４小时的总反流次数、＞５分钟的反流次数、最长反流时间和ｐＨ＜４的总时间均超出正常范围。（２）将食管床组和胸内组相比较，２４小时总反流次数差异无显著性（Ｐ＞００５），而其余４项指标食管床组明显低于胸内组（Ｐ＜００５）。结论：（１）两种消化道重建方式术后均在存胃食管反流。（２）胃经食管床吻合术后的反流量和反流持续时间明显低于胃经胸弓上吻合术。（３）胃经食管床吻合病人可以获得较好的生活质量。     

胸腹腔镜联合食管癌切除经胸骨后胃-食管颈部器械吻合术后患者生活质量的评价

目的评价胸腔镜和腹腔镜联合行食管癌切除,经胸骨后胃一食管颈部圆形吻合器吻合术与颈胸腹三切口食管癌切除术对患者术后生活质量的影响。方法南方医科大学南方医院胸心外科于2009年1月至2010年10月手术治疗63例胸部中上段食管癌患者,其中行胸腔镜和腹腔镜联合食管癌切除术33例（A组）,颈胸腹三切口食管癌切除术30例（B组）。采用欧洲癌症研究与治疗组织（EORTC）开发的生活质量核心量表QLQ-C30和食管癌补充量表QLQ—OES18评价患者术后的生活质量。结果两组患者一般资料的比较除吻合方式不同外,差异均无统计学意义（P〉0．05）．A组患者术后分别发生颈部吻合口瘘1例（3．0％,1／33）、颈部切口感染1例（3．0％,1／33）和吻合口狭窄1例（3．0％,1／33）：B组发生吻合口瘘8例（26．7％,8／30）,吻合口狭窄2例（6．7％．2／30）．颈部切口感染1例（3．3％,1／30）,肺部感染6例（20．0％,6／30）;均经保守治疗后好转。A组患者术后在吞咽闲难、进食、疼痛、梗阻、呼吸困难、食欲丧失、疲倦、经济困难、躯体功能、角色功能、情绪功能、认知功能、社会功能及总体健康状况维度方面的评分均优于B组,差异有统计学意义（P〈0．05）：其余维度差异无统计学意义。结论胸腔镜和腹腔镜联合食管癌切除术患者颈部器械吻合后并发症发生率低．生活质量明显优于颈胸腹三切口手术的患者。     

Preoperative Lower Esophageal Sphincter Manometry Data Neither Impact Manifestations of GERD nor Outcome After Laparoscopic Nissen Fundoplication

Background  Experience with laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) and manometrically intact lower esophageal sphincter (LES) is limited. The disease pattern may be different and LARS may fail to control reflux or result in higher rates of dysphagia. This is the first study investigating the impact of preoperative LES manometry data not only on manifestations of GERD and subjective outcome alone but also on objective outcomes 1 year after LARS. Methods  Three hundred fifty-one GERD patients underwent LARS and had subjective symptom and quality of life assessment, upper gastrointestinal endoscopy, barium swallow esophagogram, 24-h esophageal pH monitoring, and manometry pre- and 1 year postoperatively. Patients were divided into those with a preoperatively intact versus defective LES based on intraabdominal length and resting pressure. Baseline and 1-year postoperative follow-up data were compared. Results  Preoperative manifestations of GERD were similar in each group. Postoperatively, all symptoms except flatulence, quality of life scores, and objective manifestations improved significantly in each group. Conclusions  The preoperative manometric character of the LES neither impacts the manifestations of GERD nor subjective and objective outcomes after LARS. Patients with GERD and manometrically intact LES have no higher risk for postoperative dysphagia.     

Functional assessment of the cervical esophagus after gastric transposition and cervical esophagogastrostomy.

OBJECTIVES: The aim of this exploratory study was to investigate swallowing and function of the cervical esophagus after esophageal resection and reconstruction. METHODS: Nine patients (8 males, 1 female; median age 63 years), who underwent esophageal resection for adenocarcinoma, were studied from 6 to 40 months (median 18 months) postoperatively. For all patients, the upper gastrointestinal tract was reconstructed by transposing a narrow gastric tube through the posterior mediastinum to the left neck, where a semi-mechanical anastomosis to the cervical esophagus was performed. No patient had an anatomic obstruction to swallowing or stricture. The oral and pharyngeal phases of deglutition and function of the cervical esophagus were evaluated objectively by video barium swallow, esophagogastroscopy, velopharyngeal examination, manometry and balloon inflation in the cervical esophagus. RESULTS: The median length of the cervical esophagus was 5 cm (range 3-7 cm). Mild reflux laryngopharyngitis was seen in all patients. Although all patients had an objective functional dysphagia measurement (American Speech-Language-Hearing Association) of 7 (normal), five reported subjective dysphagia. Four (of the five symptomatic) patients were found to have high pressure peristalitic activity (mean >100 mmHg) following balloon distention (10-30 ml) of the cervical esophagus, which was painful in three cases. CONCLUSIONS: We conclude that in the absence of an anatomic cause for dysphagia after cervical esophagogastrostomy, a functional etiology may be explained by hypertensive peristalsis resulting from distention of the remaining cervical esophageal remnant. These findings may further explain anecdotal reports of the efficacy of empiric dilation after upper gastrointestinal reconstruction when no stricture is seen.