食管胃分层吻合法的应用与实验观察

Clinical Application and Experimental Study of Layered Anastomosis in Esophagogastrostomy

目的通过临床和动物实验观察食管胃分层吻合法的临床应用结果及吻合口愈合质量。方法采用食管胃分层吻合法施行食管癌、贲门癌手术1024例,同期用该手术方法做动物实验并观察吻合口情况。将24只犬采用抽签法分成两组,实验组:12只,采用食管胃分层吻合法;对照组:12只,采用传统吻合方法作为对照。分别在术后5d、8d、14d和42d测量两组大体标本的吻合口口径、瘢痕长度、瘢痕厚度,组织学观察炎性细胞数、成纤维细胞数和毛细血管数,并进行表皮生长因子(EGF)和转化生长因子β1(TGF-beta1)的免疫组织化学实验(LsAB法)。结果临床结果:术后分别随访至3个月,1024例患者术后无吻合口瘘发生,仅6例发生轻度狭窄,经扩张一次缓解。实验结果:实验组黏膜对合良好、吻合口柔软、瘢痕薄,术后早期炎性细胞数和成纤维细胞数增多(P<0.05),术后第42d炎性细胞数和成纤维细胞数减少(P<0.05);对照组吻合口瘢痕厚、黏膜对合不齐、常有肌层暴露,早期炎性细胞数和成纤维细胞数较少,而术后8～14d明显增加,一直持续到术后42d仍有增加的趋势。实验组细胞因子早期活跃,高表达,至术后42d时仅有少量表达;而对照组早期表达低,术后第8d明显增加,第42d仍有较高表达。结论食管胃分层吻合法患者吻合口愈合质量高、瘢痕小,其细胞增生和生长因子的表达有利于伤口正常愈合且达到了一期愈合的标准,值得临床推广应用。

Objective To summarize the clinical application of esophagogastrostomy with layered anastomosis and to observe the healing quality of anastomotic stoma in animal experiments. Methods One thousand and twenty-four patients suffered from carcinoma of esophagus or carcinoma of gastric cardia had undergone esophagogastrostomy by layered anastomosis with absorbable suture. Twenty-four experimental dogs (adult male healthy hybrid dogs) were divided into two groups: the experimental group and the control group. The former (experimental group) underwent the layered anastomosis, the diameter of esophagogastric stoma and the length and depth of stomal scar were measured under anesthesia in both groups on 5th,8th,14th,and 42th postoperative day, respectively. So were done the histological measurement, such as the count infiltrating inflammatory cells, the proliferation of blood capillary and other cells. And the cytokines related to wound healing (LsAB technique) such as epidermal growth factor(EGF), transforming growth factor-beta 1 (TGF-beta 1) were detected, either. Results One thousand and twenty-four patients had no anastomotic leakage. There were only 6 patients suffered from mild anastomotic stricture, and they got well after one dilatation. The results of the measurement of 24 experimental dogs revealed that, in the experimental group, the mucosa was in good connecting condition, had a soften anastomotic stoma and a thin scar. The counts of inflammatory cells and fibroblast showed more in number at the early time after operation (P<0.05), while showed less in number at the advanced time of operation (P<0.05). In the control group, however, the mucosa were in a bad connecting condition, the scar was thicker, and the muscle layer was frequently exposed. The counts of inflammatory cells and fibroblast were fewer at the early time after operation, however, they had a clearly tendency of increasing at the anaphase after the operation. On the cytokines related to the healing of wound in the experimental group, there was a high expression and activity at the early period. There were a little expression up to postoperative 42 d. Whereas, in the control group, there had a low expression level,increased clearly on postoperative 8 d, and still a higher expression up to postoperative 42 d. Conclusions The esophagogastrostomy by layered anastomosis has a high healing quality with a thin scar. The proliferation of cells and the expression of growth factors benefits the normal healing of wound by first intention.