下咽环周缺损重建方法的选择

Reconstruction of hypopharyngeal circumferential defects: pharyngogastric anastomosis or free jejunal interposition

目的 比较下咽环周缺损的两种主要重建方法,即游离空肠移植术(简称游离空肠)和胃上提咽胃吻合术(简称咽胃吻合)的优缺点。方法 回顾性分析1979年7月-2002年7月行喉全切除下咽全切除的晚期下咽癌或喉癌复发患者共125例的资料,其中采用咽胃吻合术式92例,游离空肠术式33例。结果 咽胃吻合组出现并发症40例(43％),手术死亡10例(11％),游离空肠组并发症7例(21％),没有手术死亡病例,两组差异有显著性(P值分别为0.023和0.048)。多因素分析发现与重建有关的并发症发生的危险因素分别是:咽胃吻合术式(风险比2.97;95％可信区间1.14;7.76)和术前血浆白蛋白水平<40.0g/L(风险比2.87;95％可信区间1.33;6.16)。咽胃吻合组发生进食反流或梗阻的比例(76％)明显高于游离空肠组(12％),差异有显著性(P=0.00)。前者术后体重平均下降3.3 kg(95％可信区间-5.7;-1.0),后者术后体重平均增加了2.8kg(95％可信区间0.9;4.7)。结论 选择游离空肠术的患者手术死亡率、外科并发症均明显低于咽胃吻合术的患者,游离空肠组生活质量明显好于咽胃吻合组的患者。建议下咽环周缺损重建首选游离空肠移植术。

Objective To choose the optimal reconstruction for circumferential defects of the hypopharynx between pharyngogastric anastomosis and free jejunal interposition is. Methods Retrospective review of the archives of 125 patients who underwent pharyngoesophageal reconstruction with pharyngogastric anastomosis ( n = 92) or free jejunal interposition (n =33). Analysis was confined to patient with advanced hypopharygeal cancer or recurrent laryngeal cancer who had hypopharyngeal circumferential defects after tumor ablation. Results The morbidity and mortality associated with reconstructive procedures were significantly higher in the pharyngogastric anastomosis group than in the free jejunal interposition group (43% versus 21%,P = 0.023 and 11% versus 0% ,P = 0. 048). The risk factors related to complications associated with the procedures were reconstruction with pharyngogastric anastomosis ( OR 2. 97; 95% CI 1. 14 ;7. 76 ) and albumin < 40. 0 g/L ( OR 2. 87; 95% CI 1. 33; 6. 16 ) . The occurrence of swallow obstruction or regurgitation was higher in the pharyngogastric anastomosis group than in the free jejunal interposition group(76% versus 12% ,P =0. 00). Patients in the pharyngogastric anastomosis group had lost weight of 3. 3 kg (95% CI -5. 7; -1. 0) postoperatively, on the contrary, patients in the free jejunal interposition group had gained weight of 2. 8 kg(95% CI 0.9;4.7) postoperatively. Conclusion Patients reconstructed with free jejunal interposition had lower mortality and complications than with pharyngogastric anastomosis. Furthermore, the former seems to have better quality of life than the latter. The first choice of reconstructive strategy for hypopharyngeal circumferential defects is free jejunal interposition.