食管癌切除术后不同重建途径吻合口瘘的原因及预防

目的了解食管癌切除术后经不同径路重建,发生吻合口瘘的情况;探讨系统性淋巴结清扫后,经胸骨后胃代食管颈部吻合口瘘发生率较高的原因及预防方法。方法1105例行食管癌切除术的患者,229例经左胸行胸内吻合(A组),716例经右胸食管床胃代食管行颈部吻合(B组),160例予以系统性淋巴结清扫术后经胸骨后行颈部吻合(C组)。分析比较不同手术径路的3组患者术后吻合口瘘发生的情况。结果吻合口瘘发生率分别为:A组5/229(2.2%)、B组85/716(11.9%)、C组31/160(19.4%),C组吻合口瘘发生率显著高于A、B组(P<0.01和P<0.05)。比较C组不同重建方式吻合口瘘发生率显示,手工吻合与器械吻合(22.2%与11.6%,P=0.133)、全胃重建与管状胃重建(25%与15.6%,P=0.146)间吻合口瘘发生率无明显差异,而延长胃肠减压管留置时间至术后7d,吻合口瘘发生率由23.3%降至9.1%(P<0.05)。结论胸骨后胃代食管吻合口瘘发生率较高的主要原因,是前纵隔内的胃体受压、冲击吻合口所致;通过延长胃肠减压管留置时间能有效减少瘘的发生。

Canses and prevention of anastomotic leakage after esophagectomy and reconstruction through different routes for esophageal cancer

Objective To compare the anastomotic leakage rates after esophag ec tomy and reconstruction through different routes for esophageal cancer and analy ze the canses for higher anastomotic leakage rate after esophagectomy,systemic l ymph node dissection and reconstruction through retrosternal route and its preve ntion. Methods Data of 1105 cases of esophagectomy were reviewed retrospectively . Patients in group A(n=229) underwent esophagectomy through left thoracotomy an d intrathoracic anastomosis,patients in group B(n=716), esophagectomy through ri ght anterio lateral thoracotomy and cervical reconstruction through posterior m ediastinal route,patients in group C(n=160) esophagectomy,systemic lymph node di ssection and cervical anastomosis through the retrosternal route. Results The le akage rate was significantly higher(19.4%) in group C than that in group B(11.9 %,P< 0.05) and much significantly higher than that in group A(2.2%,P< 0.01). I n group C,there was no significant difference in leakage rate between the patien ts with hand sewn or mechanical anastomosis(22.2%vs.11.6%,P=0.133),between th e patients who had whole stomach or tube typed gastric reconstruction (25%vs.1 5.6%,P=0.146).The leakage rate was significantly decreased from 23.3%to 9.1%a fter prolonged nasal gastric drainage for seven days(P< 0.05). Conclusions The high anastomotic leakage rate after retrosternal reconstruction is mainly due to compression of the stomach in the anterior mediastinum. Prolonged nasogastric d rainage is an effective way to decrease the leakage rate after systemic lymphade nectomy.