食管插人吻合法在二次开胸处理胸内食管吻合口瘘中的应用

本文报告5例食管癌手术后胸内吻合口瘘采用二次开胸，拆除原吻合口，以食管插入法重新吻合并队加空肺造瘘的方法进行处理的经验。5制均获治愈。作者等认为，谈方法具有迅速净化胸腔，防止吻合口再瘘和打开营养通道及时的优点。作者还比较了运用其它方法进行处理的结果，认为本方法是治疗胸内食管吻合口瘘的一种较好方法。     

食管插入吻合法在处理吻合口再瘘中的应用

食管插入吻合法在处理吻合口再瘘中的应用赵雍凡，杨俊杰，伍伫，杨建食管癌切除术后胸内吻合口瘘是一种死亡率很高的并发症，临床处理比较困难。自１９９０年开始，我们采用二次开胸，拆除原吻合口，用食管插入吻合法行再吻合并附加空肠造瘘的方法进行处理，连续５例均获...     

带膜食管支架置入治疗食管癌术后胸内食管吻合口瘘

目的总结覆硅胶膜镍钛合金食管支架置入治疗食管癌术后胸内食管吻合口瘘的临床经验。方法回顾性分析2005年1月至2009年12月上海交通大学医学院附属仁济医院12例食管癌手术后发生胸内食管吻合口瘘经覆硅胶膜镍钛合金食管支架置入治疗的临床资料,其中男7例,女5例;平均年龄65(45～70)岁。胸内食管吻合口瘘发生于术后第5～28 d,均为单个漏口,漏口直径约0.2～1.0 cm。确诊食管吻合口瘘后给予支持治疗7 d,待病情稳定后置入覆硅胶膜镍钛合金食管支架,支架长5～12 cm,内径1.8～2.0 cm。结果术后因进食呛咳死于肺部感染1例。术后出现胸骨疼痛7例,支架移位3例,消化道出血1例,均经相应的治疗后好转或治愈。生存患者于置入食管支架后第3～15 d经口进食。随访11例,随访时间1～6个月,食管吻合口瘘愈合良好9例;支架移位1例,瘘口未愈合,术后4个月死于肿瘤复发;在回收食管支架过程中黏膜撕裂,致吻合口狭窄1例。结论带膜食管支架置入是治疗食管癌术后胸内食管吻合口瘘的一种有效方法。     

胸内食管吻合口隐匿瘘的诊断与治疗

目的探讨胸内食管吻合口隐匿瘘的诊断治疗方法。方法回顾性分析2006年1月至2010年12月青岛大学医学院附属医院32例食管、贲门癌患者行胸内胃食管吻合术后出现脓毒血症表现,并先后行水溶性造影剂食管X线造影+胸部CT扫描患者的临床资料。32例均无造影剂渗漏,但CT显示吻合口周围出现小气泡、包裹性积液。其中15例按"隐匿瘘"处理,给予禁食、广谱抗生素、延长胃肠减压时间、鼻肠管肠内营养等治疗;另17例按非吻合口瘘相关感染处理,仅应用高效广谱抗生素。结果 32例患者中按吻合口瘘处理的15例患者口服水溶性造影剂食管X线造影+胸部CT扫描显示均未发展为吻合口瘘(0%,0/15);而未按吻合口瘘处理的17例患者中有14例发展为吻合口瘘(82.4%,14/17),其中2例发生吻合口主动脉瘘死亡,3例并发多器官功能衰竭死亡。结论口服水溶性造影剂食管X线造影+胸部CT扫描显示吻合口周围有小气泡、不规则包裹性积液为"隐匿瘘"的特异性征象,应按吻合口瘘处理。     

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。     

自制鼻胃肠管治疗胸内食管胃吻合口瘘

目的 报告7例自制鼻胃肠管治疗胸内食管胃吻合口瘘的方法。方法 7例食管胃吻合口瘘均为食管癌、贲门癌切除、胃代食管胸内吻合术后并发症患者，采用自行设计制造的一次性无菌、无毒、无热源硅胶鼻胃肠管行胃减压及十二指肠或高位空肠营养。结果 治愈6例，死亡1例。结论 自制鼻胃肠管治疗胸内食管胃吻合口瘘效果确切、满意，有一定临床价值，建议推广应用。     

胃镜辅助新三管法治疗严重胸内食管胃吻合口瘘

目的探讨胃镜辅助新三管法治疗食管切除术后严重胸内食管胃吻合口瘘的价值。方法对13例胸内食管胃吻合口瘘（瘘口直径≥1．0cm）的患者,在胃镜辅助下经鼻置人瘘腔引流管,行负压吸引,充分引流脓液,同时配合胸腔引流管行闭式引流,鼻肠管行肠内营养支持。结果所有患者均一次置管成功,置管时间为5～9min,平均6min。12例患者痊愈,瘘口愈合时间16～78d,平均31．4d。1例患者死于严重肺部感染。结论胃镜辅助新三管法治疗严重胸内食管胃吻合口瘘安全、有效、经济。     

胸内食管胃吻合口瘘的再手术治疗

198 1年 1月至 2 0 0 0年 12月我们共行食管癌、贲门癌切除、胃代食管胸腔内吻合术 438例。术后发生吻合口瘘 15例 ,发生率为 3 4% ,其中 10例早期吻合口瘘行再手术治疗 ,其效果明显优于保守治疗 ,现报道如下。资料与方法　本组术后胸内吻合口瘘 15例中男 11例 ,女 4例 ;年龄 46～ 6 9岁 ,平均 5 7岁。其中胸中段食管癌 4例 ,胸下段食管癌 8例 ,贲门腺癌 3例。术前均无明显的手术禁忌证。均经左胸径路手术 ,主动脉弓下吻合 10例 ,主动脉弓上吻合 5例。吻合口瘘均在术后第 2～ 8ｄ经口服稀钡或美蓝、胸穿等检查证实。本组 5例胸内吻合口瘘采…     

三管法与两管法治疗胸内食管胃吻合口瘘的对比观察

目的 探讨胸内食管胃吻合口瘘的保守治疗方法.方法 19例食管癌、贲门癌根治术后并发胸内食管胃吻合口瘘的患者,随机分为A组(10例)和B组(9例).A组应用三管法治疗即高位空肠营养管肠内营养治疗+胃管持续食管胃减压+胸内、脓腔内引流管持续负压引流;B组应用两管法治疗即静脉营养治疗+胃管持续食管胃减压+胸内、脓腔内引流管持续负压引流.结果 (1)两组吻合口瘘治愈率均为100%;(2)吻合口瘘治愈后消化道功能障碍的发生率在A组为10.0%,在B组为55.6%;(3)A组治疗所需费用人均3408.22元,B组治疗所需费用人均12078.56元.结论 应用三管法、两管法治疗胸内食管胃吻合口瘘,二者疗效差异无统计学意义;应用三管法吻合口瘘治愈后消化道功能障碍的发生率和治疗所花费用均明显低于两管法,二者差异有统计学意义.三管法优于两管法.     

食管癌切除术后食管-胃粘膜悬入胃腔式吻合5 630例报告

目的探讨防止食管癌术后吻合口瘘及狭窄的吻合术式。方法自1990年1月-2003年12月对5630例食管癌患者行肿瘤切除，均采用食管-胃粘膜悬入胃腔式吻合方法，遵循“窄边距、密针距、锯齿缝、轻打结”的吻合技巧，观察分析术后吻合口瘘及狭窄等并发症的发生情况。结果本组5630例术后发生吻合口瘘49例（0．87％），其中颈部吻合口瘘29例，胸内吻合瘘20例，吻合口狭窄30例（0．53％），其中颈部吻合口狭窄6例，胸内吻合口狭窄24例。结论食管-胃粘膜悬人胃腔式吻合是防止食管癌术后吻合口瘘和狭窄的有效术式。     

食管胃、空肠唇状吻合术的临床应用

目的探讨食管胃空肠吻合术对预防食管癌、贲门癌术后并发症的影响。方法54例食管癌、贲门癌患者采用食管胃、空肠唇状单层Gambee法吻合,食管胃吻合43例,食管空肠吻合11例。结果全组术后恢复顺利,无吻合口瘘、吻合口狭窄及明显反流性食管炎发生。术后3～12月钡餐检查示吻合口口径平均1.6(1.2～2.0)cm。54例平均随访5.8(1.5～8.0)年,术后3年、5年生存率分别为47.6%(20/42)和14.3%(14/28)。结论单层唇状吻合重建消化道有单层吻合和套入式吻合的双重优点,可防止吻合口瘘、吻合口狭窄和反流性食管炎的发生。     

Polyglactin 910 (Vicryl) mesh graft for protection of esophagogastrostomy. A preliminary report

Anastomotic leakage from esophagogastrostomy is associated with a high mortality rate. Polyglactin 910 mesh grafts were used in 16 cases since 1982 to protect anastomoses after resection of the lower esophagus or cardia. No anastomotic dehiscence was seen in these patients and none died of leakage from the anastomosis.     

Experiences with an Invagination Technique for Esophagogastric End-to-End Anastomoses

80 patients with esophageal cancer underwent esophagectomy with the stomach as an esophageal substitute. For end-to-end esophagogastrostomy an invagination technique was used. We describe the technique and the results. An anastomotic leak was observed in 5 of 80 patients (6.3 %) in the total, in 5 of 64 cases with cervical anastomosis (7.8 %) and in none of the 16 patients with thoracic anastomosis. 6 of 80 patients (6.5 %) died, 5 due to nonsurgical complications and one patient due to a necrosis of the esophageal substitute. On the basis of these results we recommend the described anastomotic technique due to its simplicity and low anastomotic leakage rate.     

胃癌切除术后吻合口漏营养支持19例报告

目的:总结胃癌切除术后食管胃或食管空肠吻合口漏的营养支持经验,以提高对食管胃或食管空肠吻合口漏的治疗水平。方法:对1997年1月至2006年12月,中国人民解放军总医院治疗的胃癌切除术后6例食管胃吻合口漏和13例食管空肠吻合口漏共19例病人进行回顾性分析。结果:19例均加强吻合口附近的腹腔引流,采用持续胃肠减压,均先给予肠外营养支持、然后从肠外营养支持逐步过渡到肠内营养支持的治疗手段。16例在肠外营养液中强化了谷氨酰胺,19例均使用生长抑素,5例在吻合口漏愈合期加用了生长激素。在首次胃癌切除术后,4例漏口21～30d自愈,12例漏口30～60d愈合,2例漏口60～81d愈合,1例因严重的左侧胸腔、肺部感染合并腹腔感染于首次胃癌切除术后42d死亡。结论:保证腹腔引流的通畅、持续胃肠减压,特别是肠外结合肠内营养支持、强化谷氨酰胺、生长抑素、生长激素等措施,是促进胃癌切除术后食管胃或食管空肠吻合口漏愈合的重要手段。     

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??Objective:To summarize the nutritional supporting experiences in anastomotic leakage following esophagogastrostomy or esophagojejunostomy after gastrectomy for gastric carcinoma and to increase the level of treatment of anastomotic leakage following esophagogastrostomy or esophagojejunostomy. Methods:A total of 19 cases of anastomotic leakage following esophagogastrostomy (6 cases) or esophagojejunostomy (13 cases) after gastrectomy for gastric carcinoma in PLA General Hospital from January 1997 to December 2006 were analyzed retrospectively. Results:All of the cases were treated with abdominal cavity drainage,continuous gastrointestinal decompression and parenteral nutrition combined with enteral nutrition.Sixteen cases were given glutamine enrichment.Ninteen cases were infused somatostatin.Five cases were supplemented recombinant human growth hormone.Four cases′ fistula had been healed after gastrectomy for gastric carcinoma 21??30d.Twelve cases′ fistula had been healed 30??60d.Two cases′ fistula had been healed 60??81d.One case complicated with severe sepsis of thoracic cavity,lung and abdominal cavity died 42d after gastrectomy for gastric carcinoma. Conclusion:The treatment with abdominal cavity drainage,continuous gastrointestinal decompression,parenteral nutrition combined with enteral nutrition,glutamine,somatostatin and recombinant human growth hormone are the important factors for healing of anastomotic leakage following esophagogastrostomy or esophagojejunostomy after gastrectomy for gastric carcinoma.     

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。     

胸内食管胃吻合口瘘25例临床分析

目的 报告食管癌贲门癌根治术后发生胸内食管胃吻合口瘘治疗经验。方法 1984～1998年,共施行食管癌贲门癌根治术,胸内食管胃手工吻合术1065例,发生吻合口瘘28例,发生率2.6%,3例放弃治疗。主动脉弓上吻合19例,弓下吻合6例。前期17例采用保守治疗,后期8例再次开胸手术。结果 前期17例采用保守治疗,死亡12例,死亡率70.6％;后期8例采用再次开胸手术,死亡1例,死亡率降为12.5％。两种治疗方法临床差别显著。结论 胸部X线检查,口服美兰,食管造影是早期诊断吻合口瘘的主要手段,只要患者全身和局部情况允许,再次开胸手术是治疗成功的关键。     

Does continuous mucosal partial carbon dioxide pressure measurement predict leakage of intrathoracic esophagogastrostomy?

BACKGROUND: Gastroplasty after esophagectomy is associated with relevant morbidity due to anastomotic leakage of the esophagogastrostomy. The aim of this study was to find out whether continuous partial carbon dioxide pressure (pCO2) measurement of the gastric mucosa is an adequate method of monitoring the gastric tube during the postoperative course and of detecting patients with an anastomotic leakage. METHODS: Forty-seven patients with esophageal cancer underwent esophagectomy and gastric tube formation with intrathoracic esophagogastrostomy. Postoperatively, mucosal pCO2 of the gastric tube (pCO2i) was measured using continuous tonometry (TONOCAP, Datex Ohmeda). pCO2i was related to the arterial pCO2 (delta pCO2 = pCO2i - pCO2a). RESULTS: A total of 4,338 delta pCO2 measurements were recorded. On average, the pCO2i of each patient was monitored over a period of 92 hours. In 5 patients an anastomotic leakage of the esophagogastrostomy developed. The mean delta pCO2 of this group was 31.7 mm Hg (+/-19.3 SD) and significantly higher (p < 0.0001) than that of patients without anastomotic leakage (20.7 mm Hg +/- 12.8 SD). With a delta pCO2 cut-off point of 56 mm Hg measured for 5 hours, the sensitivity was 0.8, the specificity 0.9, and the positive predictive value 0.5. In patients with anastomotic leakage, the peak delta pCO2 preceded clinical symptoms. False positive delta pCO2 measurements (n = 4) were mainly due to severe pneumonia with long-term ventilation. CONCLUSIONS: Mucosal pCO2 measurement of the gastric tube can be used as an early indicator of a complicated postoperative course predicting anastomotic leakage of the esophagogastrostomy.     

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。     

A free peritoneal patch does not affect the leakage rate but increases stricture formation of a cervical esophagogastrostomy

BACKGROUND: Healing of a cervical esophagogastrostomy is frequently impaired, resulting in a higher incidence of leakage and stricture formation, as compared to an intrathoracic anastomosis. Lack of mesothelial factors is hypothesized to contribute to this impaired anastomotic healing. The aim of this prospective study was to determine whether a free peritoneal patch around a cervical esophagogastrostomy can improve anastomotic healing. METHODS: In 23 consecutive patients a free peritoneal patch was fixed around a cervical esophagogastrostomy. Results were compared to those of a historical control group of 41 patients. Clinical and/or radiographic leakage and stenosis requiring endoscopic dilatation were used as endpoints. RESULTS: Three patients died in the early postoperative period (in-hospital mortality 3/64 = 5%). Leakage rate was 13% (3/23) in the group with a patch and 15% (6/41) in the control group (p = 0.90). At 6-month follow-up, the incidence of stenosis was significantly higher (65%) in the group with a patch, compared to 31% in the control group (p = 0.02). CONCLUSION: A peritoneal patch does not affect the leakage rate but increases the incidence of postoperative stenosis of a cervical esophagogastrostomy. Therefore, its clinical application is contraindicated. Copyright Copyright 1999 S.Karger AG, Basel