采用空肠移植重建食管的血供保护

PRESERVATIVE MEASURES FOR BLOOD SUPPLY TO JEJUNAL SEGMENT IN RECONSTRUCTION OF ESOPHAGUS

目的 探讨游离移植空肠重建食管血供保护的有效措施。 方法 采用循证医学回顾性研究方法 ,分析了 1980年～ 2 0 0 1年采用游离空肠移植重建食管 2 8例 ,带蒂空肠移植重建食管 4 1例 ,其中因化学灼伤食管致瘢痕狭窄 4 8例 ,食管癌切除术后 2 1例的术式和移植肠管的血供保护措施。 结果 6 9例均获 1～ 2 1年随访。1996年前施术 4 3例 ,术后发生吻合口瘘 5例 ,因暴饮暴食致移植空肠发生绞窄性梗阻坏死 1例 ;1996年以后施术 2 6例 ,其中游离空肠移植重建食管 6例 ,带蒂空肠移植重建食管 2 0例 ,仅 1例发生吻合口瘘。全组无手术死亡。 结论 保证空肠段和吻合口充分血供的有效措施为 :1空肠段边缘血管弓完整、无张力、供血充分 ;2吻合口血管通畅 ;3空肠段上提通道宽畅 ;4保持围术期稳定的动脉压 (8k Pa以上 ) ;5采用全层缝合术 ;6采取综合性保护措施 ,改善患者全身营养代谢状况。

Objective To study the effective protective measures to ensure sufficient blood supply to the jejunal segment in reconstruction of esophagus. Methods According to evidence based on medicine, we analyzed retrospectively 69 patients(48 cicatricial stenosis due to chemical burn, 21 defects due to excision of esophagus cancer), whose esophagus were reconstructed with free jejunal graft(in 28 cases) and with pedicle jejunal graft (in 41 cases) from 1980 to 2001. Results All patients were followed up for 1 21 years. Of 43 patients treated before 1996, 5 complicated by anastomotic leakage, 1 by strangulated intestinal obstruction; of 26 patients treated after 1996(6 with free jejunal graft, 20 with pedicle jejunal graft), only one case complicated by anastomotic leakage. Conclusion The preservative measures for good blood supply to the jejunal segment include the following aspects: (1) complete marginal vascular arcade without tension in the mesojejunum; (2) vessel anastomosis smooth; (3) 4 finger width pathway of jejunum; (4) the stable arterial blood pressure (more than 8 kPa); (5) a single row anastomosis; and (6) the comprehensive preoperative management.