胃管成形术在食管重建中的可行性研究

Feasible Study for Construction of Gastric Tube in Esophageal Reconstruction

目的食管次全切后用胃代替食管行食管-胃颈部吻合术临床上应用最多,为了使替代食管的胃有足够的长度和丰富的血液供应,减少术后吻合口瘘的发病率,我们设计了切除贲门和小弯侧胃组织,将胃作成管状来满足颈部吻合的要求.我们研究的目的就是对这一术式进行基础和临床的可行性研究.方法胃管成形术通过距大弯4～5 cm作一平行曲线,用电刀切开胃的浆肌层,在浆肌层和粘膜下层之间游离,分别切开上述两层,切除贲门和小弯侧胃组织,分别缝合粘膜层和浆肌层.传统方法是在贲门上1 cm切断食管下段,双U字缝合食管断端,用胃浆肌层包埋该断端.本文胃管成形术38例,传统方法60例,将病人分成两组,术中分别测量胃的长度,用激光多普勒血流测量仪测量胃的血流量和吻合口处组织血流量,统计术后吻合口瘘的发病率.结果胃管成形术后胃的长度明显长于传统手术组,分别为38.5±3.2 cm和30.2±3.6 cm (P＜0.01),吻合口处胃组织血流量,胃管成形术为16.8±2.3 ml/min/100 g,传统方法组为10.5±3.2 ml/min/100 g,两者之间存在明显差异(P＜0.01).术后吻合口瘘的发生率后者明显高于胃管成形术(P＜0.05).结论胃管成形术使管状胃明显延长,胃组织血流量也显著增多,此种方法可以使胃有足够的长度在胸腔内或颈部任何部位进行吻合,使吻合口处有丰富的血供和相对无张力,术后吻合口瘘的发生率明显降低.我们认为此种技术对食管癌食管次全切除,用胃重建食管是可靠的并且术后并发症降低.

Objective The stomach was used most commonly for esophageal reconstruction after esophagectomy in cervical anastomosis. In order to allow the stomach to subsitute the esophagus enough length and a sufficient blood flow and decrease the rate of anastomotic leakage, we design the gastric tube to cut out the cardia and the smaller curvature tissue of stomach to be used in the need of successful cervical anastomosis. The objective of this article is a reliable study for the new technique in basic and clinical science, Methods The gastric tube plasty was created by means of cutting out the gastric tissue of cardia and the smaller curvature. The seromuscular layer was invised by electric knife along curved line parallel to and 4-5 cm from the greater curvature. After completion of the seromuscular cut , the gastric tube was stretched as far as possible. The mucosal layer and seromuscular layer was sutured respectively. In the standard group, the lower esophagus above lcm of the cardia was cut and sutured the opening of the esophagus was embedded by gastric seromuscular layer. We compared these 2 types of methods in 38 patients with gastric tube plasty and 60 patients with standard methods in terms of total length of the stomach before and after plasty, blood flow, and the incidence of anastomotic leakage. Blood flow was measured with a laser Dopplar flowmetry during surgical intervention. Result The gastric tube in the stepwise group was significantly longer than that in the standard group from 30.2±3.6cm to 38.5±3.2cm （P〈0.01）. Tissue blood flow at the site of anastomosis in the gastric tube group was significantly greater than that in the standard group from 10.5±3.2 ml/min/100g to 16.8±2.3 ml/min/100 g （P〈0.01）, and the rate of anastomotic leakagewith better blood flow on the gastric tube, and anastomotic leakage is significantly decreased. We consider this technique to be a useful procedure for reconstruction after subtotal esophagectomy for intrathoracic esophageal carcinoma.