结肠代食管术吻合口瘘及肠段缺血的防治

目的探讨降低结肠代食管术（ERC）后吻合口瘘和肠段缺血发生率的有效措施。方法回顾分析1966年3月至2006年3月间实施ERC术的572例患者的临床资料。在实施ERC时．掌握移植结肠段的长度比预测需要再长3-4cm，并维护移植结肠段的主要供血血管充分供血的原则，保证肠段上提通道宽畅无阻，尽量采用顺蠕动向移植；1996年以后，术中常规首选左结肠动脉和肝曲的边缘血管作为移植肠段主要供血管。结果本组患者以食管癌和食管瘢痕狭窄为主（92．5％）。食管切除重建占55．6％，食管改道占44．4％。全组吻合口瘘发生率为11．9％．其中1996年后的吻合口瘘发生率为5．6％，低于此前的13．6％（P〈0．05）：术中采用顺蠕动向移植者其吻合121瘘发生率为6．2％．低于逆蠕动向移植者的65．5％（P〈0．01）。全组无1例出现结肠段缺血坏死。结论实施ERC时．采用移植结肠段的足够长度和维护充分供血是预防肠段缺血和吻合121瘘的主要措施。移植肠段通道通畅有利于肠段存活。顺蠕动向移植有利于降低吻合口瘘的发生率。

Prevention and treatment of anastomotic leakage and intestinal ischemia after esophageal replacement with colon

Objective To explore the effective management to prevent anastomotic leakage and intestinal ischemia after esophageal replacement with colon(ERC). Methods Clinical data of 572 cases received ERC from March 1966 to March 2006 were analyzed retrospectively. Results Most of patients received ERC were diagnosed as esophageal cancer and esophageal stenosis (92.5%). 55.6% of cases underwent esophageal reconstruction and 44.4% of cases underwent esophageal bypass. During ERC procedure, the colon interposition graft length should be 3-4 cm longer than expectation; good blood supply was maintained; the lifted passage was unobstructed, and the physiological peristalsis direction was kept. The incidence of anastomotic leakage was analyzed among different periods, which were 14.2%, 13.5%, and 5.6% during 1966-1975, 1976-1995 and 1996-2006 respectively (P<0.05). No intestinal ischemia was observed in all the patients. Conclusions When performing ERC, the main preventional managements of anastomotic leakage and intestinal ischemia are fully blood supply maintenance and intercepting enough length of the colon graft. Ensuring unobstructed passage is good for survival of the colon graft.Correct physiological peristalsis direction of colon interposition is beneficial to the healing of the anastomosis.