Techniques to simplify esophagogastric circular stapled anastomoses

Stapling devices for end-to-end anastomoses (EEA) have facilitated more rapid and reliable reestablishment of esophagogastric continuity following esophageal resections. Despite their ease of use, various intraoperative problems can arise, especially with the esophageal pursestring or the insertion of the anvil into the fragile, commonly contracted lumen. This paper describes various technical details that are useful adjuncts to allow creation of rapid, consistently successful EEA stapled esophagogastic anastomoses. These techniques are of particular value in the resident teaching setting. © 1994 Wiley-Liss, Inc.     

管状吻合器在食管癌颈部吻合中的改进及应用体会

背景与目的：食管癌颈部吻合与胸内吻合相比能减少术后并发症,但吻合151瘘和吻合口狭窄仍是食管癌颈部吻合的主要并发症,而吻合器则能有效减少此术后并发症。本研究改进了管状吻合器在食管癌颈部吻合的操作步骤并评价其临床疗效。方法：对2006年10月至2008年4月127例食管癌患者行食管癌根治术。胃代食管置入食管床,改进了管状吻合器在颈部的操作步骤并进行食管胃器械吻合。分析术后并发症发生情况。结果：全部患者无手术死亡及吻合口出血,吻合口瘘1例（0．8％）,吻合口狭窄5例（3．9％）,经扩张后好转。结论：改进后的管状吻合器颈部吻合技术安全有效,可降低术后吻合口并发症。     

Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review

Anastomotic complications are responsible for significant morbidity and mortality following esophagectomy for cancer. Conflicting reports exist regarding the superiority of hand‐sewn versus stapled techniques. This systematic review identified eight randomized clinical trials examining this issue. None of the studies reported significant differences in leak rate or early mortality. One study demonstrated a difference in stricture rates, with fewer for hand‐sewn anastomoses. There is insufficient evidence to recommend one anastomotic technique over the other. J. Surg. Oncol. 2010; 101:527–533. © 2010 Wiley‐Liss, Inc.     

食管胃结合部腺癌外科治疗及预后单中心回顾性分析

目的:探讨食管胃结合部腺癌(adenocarcinoma of esophagogastric junction,AEG)的外科治疗效果及影响预后的相关因素。方法:回顾性分析2006-03-01-2007-02-28河北医科大学第四医院胸外科诊治的387例AEG患者的临床资料,采用Kaplan-Meier法进行预后生存分析,Cox比例风险模型进行多因素分析。结果:共行根治性切除术368例,扩大性切除术13例,姑息性切除术6例。5年总生存率为28.7%,中位生存时间27.88个月。5年生存的患者中,姑息术为0,根治术达29.7%,扩大切除术为9.1%。单因素分析显示,性别(P=0.025)、手术方式(P=0.000)、肿瘤最大直径(P=0.000)、病理分化程度(P=0.008)、肿瘤浸润深度(P=0.000)、淋巴结转移个数(P=0.000)、病理TNM分期(P=0.000)、上下残端是否阳性(P值分别为0.025和0.000)及围术期输血情况(P=0.003)是影响预后的主要因素。多因素分析显示,肿瘤最大直径(P=0.000)、淋巴结转移个数(P=0.003)、病理TNM分期(P=0.000)是影响预后的独立危险因素。结论:AEG的预后较差,外科治疗是其主要的治疗手段,而肿瘤最大直径、病理TNM分期是影响预后的独立危险因素。因此,早发现、早诊断和早治疗是提高AEG患者外科治疗效果的主要途径。     

食管癌和贲门癌切除机械吻合术后早期并发症及死因分析

为探讨食管癌和贲门癌切除机械吻合术后早期并发症,并对发生原因及死亡原因进行分析.行食管癌和贲门癌切除410例,均行食管与胃机械吻合.结果示,术后发生吻合口瘘5例（1.2%）,其中3例死亡,2例保守治愈;术后乳糜胸3例（0.7%）,其中1例行开胸探查结扎胸导管治愈,另2例保守治愈;胸腔内出血3例（0.7%）,均经积极地二次开胸探查止血治愈;肺部感染26例（6.3%）,其中1例感染严重死亡,另25例治疗后痊愈;吻合口狭窄1例（0.2%）,经胃镜下食管扩张治愈.     

食管癌和贲门癌切除机械吻合术后早期并发症及死因分析

为探讨食管癌和贲门癌切除机械吻合术后早期并发症,并对发生原因及死亡原因进行分析。行食管癌和贲门癌切除410例,均行食管与胃机械吻合。结果示,术后发生吻合口瘘5例(1·2%),其中3例死亡,2例保守治愈;术后乳糜胸3例(0·7%),其中1例行开胸探查结扎胸导管治愈,另2例保守治愈;胸腔内出血3例(0·7%),均经积极地二次开胸探查止血治愈;肺部感染26例(6·3%),其中1例感染严重死亡,另25例治疗后痊愈;吻合口狭窄1例(0·2%),经胃镜下食管扩张治愈。     

食管胃颈部单层吻合术治疗食管癌方法探讨

目的探讨食管胃颈部单层吻合术治疗食管癌的方法及疗效。方法回顾分析612例食管癌患者采用左侧开胸胃经食管床、主动脉弓后至颈部行食管胃单层吻合的临床资料。结果根治性切除599例,姑息性切除13例,切除率100%;术后出现颈部吻合口瘘12例,肺不张3例,肺部感染8例,返流性食管炎10例,乳糜胸1例,并发症的发生率为5.7%(35/612),无吻合口狭窄及喉返神经损伤发生。结论颈部单层吻合愈合好,对心肺功能影响小,吻合口瘘及狭窄发生率较低,有利于患者恢复和提高术后生活质量。     

带蒂空肠短袖包被预防食管胃吻合口并发症的研究

目的:探讨"带蒂空肠短袖"防止食管贲门癌手术发生吻合口瘘、狭窄和反流的效果。方法:随机将651例食管贲门癌患者分为2组。对照组321例,仅进行传统的食管、贲门癌切除及食管胃吻合术;带蒂空肠短袖组330例,行食管贲门癌切除及食管胃吻合后,在吻合口表面套"带蒂空肠短袖",手术后分析2组患者术后并发症的发生率。结果:带蒂空肠短袖组患者手术后吻合口瘘、狭窄和反流的发生率分别为0.6%(2/330)、3.6%(12/330)和12.5%(40/321),对照组分别为4%(13/321)、10.9%(35/321)和12.5%(40/321),两组比较差异有统计学意义,P均<0.01。结论:"带蒂空肠短袖"外套食管胃吻合口,能明显降低吻合口瘘的发生,同时也明显降低术后反流、狭窄的发生,有较强的实用价值。     

改良Ivor-Lewis术式在食管癌手术中的应用体会

目的　应用改良Ivor -Lewis术式治疗食管癌。方法　 1995年 2月至 1999年 9月我院对 86例食管癌病人应用右胸前外侧、上腹部正中切口切除胸段食管癌。同时采用机械方法经胸内进行食管、胃颈部吻合 (颈段食管胃吻合 )。结果　 86例中无手术死亡。无吻合口瘘、狭窄 ,无乳糜胸发生。 2例发生脓胸 ,经引流、抗感染治愈 ,1例病理检查切缘阳性 ,术后补充放疗。胃排空障碍 4例 ,经保守治愈。结论　改良Ivor-Lewis对食管中下段癌是较理想的术式。     

左胸颈两切口食管癌切除术681例临床分析

为探讨左胸、颈两切口食管癌切除术的手术适应证、并发症的防治及术式的优点,回顾分析了681例左颈胸两切口食管癌切除术患者的临床资料。结果术后痊愈出院653例（95．89％）。术后病理确诊淋巴结转移327例（48．02％）,分组标记证实颈、胸和腹3组淋巴结转移率分别为6．02％（41／681）、40．38％（275／681）和21.43％（146／681）,残端癌发生率为1．32％（9／681）,术后心电图异常者较术前增加明显。术后3、5年生存率分别为58．77％（345／587）和35．66％（184／516）。初步回顾性分析结果提示,左胸颈两切口食管癌切除术具有食管癌病灶切除彻底,残端癌发生率低,可同时清除颈、胸和腹3组淋巴结,严重并发症少等优点。     

国产吻合器附加食管斜形切除新方法临床应用(附143例食管癌弓上吻合报告)

目的　探讨国产GF—Ⅰ型吻合器附加食管斜形切除新方法预防吻合口并发症的临床效果。方法　 1992年 4月至 2 0 0 3年 3月连续对食管中段癌采用弓上机械吻合 ,在切除肿瘤上端食管时 ,与食管长轴呈 3 5°～ 45°斜形角度 ,常规胃底组织包埋加固吻合口。结果　术后 3周钡剂造影 ,吻合口均通畅 ,呈规则或不规则椭圆形。无吻合口瘘 ,仅 1例术后 4个月发生狭窄 ,经扩张置管后治愈。胃液返流情况 :明显返流占 16 2 % ;轻度返流占 45 9% ;无返流占 3 7 8%。结论　此方法能明显改进机械吻合效果 ,显著降低吻合口瘘、狭窄及胃液返流等并发症 ,具有临床实用价值。     

Cancer of the esophagus and esophagogastric junction

BACKGROUND:

Previous American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) stage groupings for esophageal cancer have not been data driven or harmonized with stomach cancer. At the request of the AJCC, worldwide data from 3 continents were assembled to develop data‐driven, harmonized esophageal staging for the seventh edition of the AJCC/UICC cancer staging manuals.

METHODS:

All‐cause mortality among 4627 patients with esophageal and esophagogastric junction cancer who underwent surgery alone (no preoperative or postoperative adjuvant therapy) was analyzed by using novel random forest methodology to produce stage groups for which survival was monotonically decreasing, distinctive, and homogeneous.

RESULTS:

For lymph node‐negative pN0M0 cancers, risk‐adjusted 5‐year survival was dominated by pathologic tumor classification (pT) but was modulated by histopathologic cell type, histologic grade, and location. For lymph node‐positive, pN+M0 cancers, the number of cancer‐positive lymph nodes (a new pN classification) dominated survival. Resulting stage groupings departed from a simple, logical arrangement of TNM. Stage groupings for stage I and II adenocarcinoma were based on pT, pN, and histologic grade; and groupings for squamous cell carcinoma were based on pT, pN, histologic grade, and location. Stage III was similar for histopathologic cell types and was based only on pT and pN. Stage 0 and stage IV, by definition, were categorized as tumor in situ (Tis) (high‐grade dysplasia) and pM1, respectively.

CONCLUSIONS:

The prognosis for patients with esophageal and esophagogastric junction cancer depends on the complex interplay of TNM classifications as well as nonanatomic factors, including histopathologic cell type, histologic grade, and cancer location. These features were incorporated into a data‐driven staging of these cancers for the seventh edition of the AJCC/UICC cancer staging manuals. Cancer 2010. © 2010 American Cancer Society.     

食管贲门癌切除吻合方式与吻合口并发症关系的研究

目的 :研究降低食管、贲门癌切除吻合口瘘及狭窄的发生率的方法 :方法 :对 12 6例病人采用Gambee氏单层吻合 ,并与同期 78例传统双层套入式食管、胃吻合患者比较。结果 :Gambee氏单层吻合发生吻合口瘘 1例 (1 12 6) ,发生率 0 8% ,无吻合口狭窄 ;对照组吻合口瘘 4例 (4 78) ,发生率为 5 1% ,吻合口狭窄 7例 (7 78) ,发生率 9%。结论 :Gambee氏单层吻合是一种操作简便、安全可靠的降低吻合口并发症发生率的吻合方法     

Heterogeneity of first-line palliative systemic treatment in synchronous metastatic esophagogastric cancer patients: A real-world evidence study

The optimal first-line palliative systemic treatment strategy for metastatic esophagogastric cancer is not well defined. The aim of our study was to explore real-world use of first-line systemic treatment in esophagogastric cancer and assess the effect of treatment strategy on overall survival (OS), time to failure (TTF) of first-line treatment and toxicity. We selected synchronous metastatic esophagogastric cancer patients treated with systemic therapy (2010–2016) from the nationwide Netherlands Cancer Registry (n = 2,204). Systemic treatment strategies were divided into monotherapy, doublet and triplet chemotherapy, and trastuzumab-containing regimens. Data on OS were available for all patients, on TTF for patients diagnosed from 2010 to 2015 (n = 1,700), and on toxicity for patients diagnosed from 2010 to 2014 (n = 1,221). OS and TTF were analyzed using multivariable Cox regression, with adjustment for relevant tumor and patient characteristics. Up to 45 different systemic treatment regimens were found to be administered, with a median TTF of 4.6 and OS of 7.5 months. Most patients (45%) were treated with doublet chemotherapy; 34% received triplets, 10% monotherapy and 10% a trastuzumab-containing regimen. The highest median OS was found in patients receiving a trastuzumab-containing regimen (11.9 months). Triplet chemotherapy showed equal survival rates compared to doublets (OS: HR 0.92, 95%CI 0.83–1.02; TTF: HR 0.92, 95%CI 0.82–1.04) but significantly more grade 3–5 toxicity than doublets (33% vs. 21%, respectively). In conclusion, heterogeneity of first-line palliative systemic treatment in metastatic esophagogastric cancer patients is striking. Based on our data, doublet chemotherapy is the preferred treatment strategy because of similar survival and less toxicity compared to triplets.     

食管癌贲门癌切除及食管(管状胃)胃侧侧吻合术

目的探讨食管癌、贲门癌切除、食管(管状胃)胃侧侧吻合术的治疗效果及应用前景。方法共有32例患者行此手术。贲门癌6例、食管癌26例;其中胸下段9例,胸中段12例,胸上段5例。术中按肿瘤手术切除原则常规游离食管及近端胃,切除肿瘤。行主动脉弓下吻合9例,经食管床主动脉弓上吻合10例,左胸左颈两切口4例,右胸顶吻合3例,右胸颈腹三切口6例。22例患者应用管状胃代食管,10例患者应用全胃代食管。行食管胃端端吻合+侧侧吻合术15例;食管胃端侧吻合+侧侧吻合术10例;胸下段食管癌患者行食管管状胃全侧侧吻合术7例。结果本组病例术后分期分别为Ⅱa期9例,Ⅱb期11例,Ⅲ期12例。全部病例手术顺利,术后未出现吻合口瘘,术后2周复查上消化道钡透及胃镜检查均见吻合口通畅、无狭窄,术后随诊0.5～2年不等,均未见吻合口狭窄。结论食管癌、贲门癌切除食管(管状胃)胃侧侧吻合术可降低吻合口并发症尤其是狭窄的发生,值得临床推广。     

食管中下段癌根治性手术入路的探讨

目的 :探讨食管中下段癌手术路径的合理选择、手术技巧以及并发症的预防。方法 :回顾总结我院 1996年 1月～ 2 0 0 3年 12月食管癌根治性手术治疗的 191例食管中下段癌的临床资料 ,其中经左胸切口75例 ,经右胸切口 116例。结果 :经右胸切口切除食管长度足够 ,清除淋巴结彻底 ,不切开膈肌 ,吻合方便 ,对呼吸功能影响较小 ,减少手术并发症方面有一定优势 ,安全性较好。结论 :手术路径的选择主要依据肿瘤的具体情况和个人手术习惯而定 ,合理掌握手术指征。对于食管中下段癌Ⅰ、Ⅱ期优先考虑经右胸路径手术     

食管癌术后吻合口狭窄的预防

目的　探讨改进食管癌手术吻合口吻合方法以减少吻合口狭窄的可行性。方法　回顾性分析5642例食管癌根治术采用不同吻合方法。颈部:胃壁横形切开,常规手工吻合 (简称A1 );胃壁圆形切口,其口径与食管相当(简称A2)。器械吻合(简称A3)。胸内吻合:器械吻合(简称B1);胃壁加缝一直径与吻合器直径相当的荷包器械吻合(简称B2)。结果　吻合口狭窄发生率:颈部吻合A1组 29 /842例(3. 4 % );A2组 4 /372例(1. 07 % );A3组 2 /481例 (0. 4% )。胸内吻合:B1组 73 /3144 (2. 32% );B2组 3 /803 (0. 37% )。狭窄程度:轻度(0. 5~0. 8cm)28例;中度(0. 3~0. 5cm)70例;重度 (0. 3cm以下 )13例。狭窄率相比较,A2和A1组比较,A3和A1组相比较;B2组和B1组相比较,χ2检验,P<0. 05。改进后的方法均优于原先的方法。结论　食管癌手术吻合口吻合方式改进能有效减少吻合口狭窄的发生。     

食管贲门癌术后早期胸内消化道瘘外科诊治体会

目的观察食管贲门癌术后早期胸内消化道瘘的临床表现,探讨应用二次开胸手术治疗胸内消化道瘘的手术适应证及治疗体会。方法食管贲门癌根治术后早期胸内消化道瘘病例6例,均采用二次开胸,充分冲洗胸腔,根据瘘道情况采取切除瘘道二次吻合重建消化道或者手工浆肌层修补瘘道方法缝合胸内消化道瘘。术后密切观察胸腔引流液颜色性状,保持胃肠减压、胸腔引流通畅,加强抗感染,延长术后禁食时间。结果6例术中见瘘口周围水肿,感染不严重,胃食管主要供血血管无明显损伤,重新吻合或窦道修补成功完成,术后未出现二次胸内消化道瘘,其中5例治愈出院,1例因呼吸功能衰竭于术后第8天死亡。结论食管贲门癌根治术后早期胸内消化道瘘通过二次开胸修补或切除瘘道二次吻合重建消化道方法可迅速去除病因,阻断感染、中毒、电解质平衡紊乱及其他相关并发症发生,疗效确切。故早期胸内消化道瘘外科治疗优于保守内科治疗。     

食管胃交界部癌胸腔纵隔及腹腔淋巴结转移的危险因素

目的 探讨食管胃交界部癌(carcinoma of esophagogastric junction,CEJ)发生腹腔及胸腔纵隔淋巴结转移的危险因素,以指导是否清扫胸腔纵隔淋巴结.方法 采用回顾性研究分析行食管胃交界部癌根治术的217例患者,分析术前胃镜及术后病理检查结果.结果 淋巴结转移阳性数目是发生胸腔纵隔淋巴结转移独立的危险因素,且淋巴结转移数目每增加1个,纵隔淋巴结发生转移风险增加34.0％(OR=1.340,95％ CI:1.090 ～1.648;P=0.006);脉管瘤栓(OR=5.83,95％ CI:1.65～20.62,P=0.006)、浸润深度T(OR=2.35,95％ CI:1.30～4.24,P=0.005)和上侵食管长度(OR=1.29,95％ CI:1.02～ 1.63,P=0.033)是发生腹腔淋巴结转移的独立危险因素,而且上侵及食管每增加1 cm,发生腹腔淋巴结转移的风险增加29.0％.结论 浸润深度越深、存在脉管瘤栓且上侵及食管越多的食管胃交界部癌患者发生腹腔淋巴结转移的风险越高.淋巴结转移数目越多,纵隔淋巴结发生转移的风险加大.     

食管癌患者若干体液免疫功能的变化及其影响因素

目的探讨食管癌患者体液免疫功能的改变及其影响因素。方法１２５例食管鳞癌患者及５５例健康志愿者入组研究。检测外周血清中ＩｇＧ、ＩｇＡ、ＩｇＭ、Ｃ３、Ｃ４的含量,对比常人组与患者组;术前、后组;输血组、不输血组各指标的差异。结果食管癌患者体液免疫功能指标中受测各Ｉｇ的含量与常人组比较均见降低（Ｐ＜０．０５）;补体Ｃ３、Ｃ４含量均见升高。手术后７天受损的体液免疫功能仍无明显恢复（Ｐ＜０．０５）。围术期输血能加剧术后Ｉｇ的改变（Ｐ＜０．０５）。补体的变化不明显。结论食管癌患者体液免疫功能受损,血清中Ｉｇ含量降低、补体升高。手术及围术期输血进一步加剧这一损害。