食管癌穿孔外科治疗的临床分析

Surgical Treatment of Perforation in Esophageal Carcinoma

背景与目的:食管癌穿孔往往发生在癌肿进展期,易并发胸内感染,病情危重。保守疗法包括食管旷置、肠内或静脉营养支持以及内镜下放置支架,但是这些方法既不能消除癌肿又难以控制胸内感染,近期死亡率高。本研究分析外科治疗食管癌穿孔的手术方法及围手术期治疗特点。方法:对41例食管癌穿孔患者(其中穿入右肺19例,穿入纵隔17例,穿入气管5例)进行手术治疗。开胸手术39例,其中右胸三切口术式16例,分期手术23例,经胸骨后间隙胃或结肠代食管35例,经食管床胃代食管4例。2例只做胃造瘘姑息手术治疗。结果:36例患者获得手术成功,康复期能经口腔进食保证营养,生活自理,术后随访3～72个月,其中生存3个月2例,6～12个月31例,24个月2例,72个月1例,手术后死亡2例,2例胃造瘘姑息手术者和1例术后吻合口气管瘘再通者自动出院后1个月内死亡。结论:手术治疗食管癌穿孔成功恢复消化道的连续性,明显延长了患者的生存期,提高了生活质量;手术径路以右胸三切口术式(胸骨后胃或结肠代食管)或分期手术为佳。

BACKGROUND ＆ OBJECTIVE： Perforation in esophageal carcinoma usually occurs at late stage, and is often accompanied with thoracic infections. Conventional conservative treatments, including parenteral nutritional support and stent placement under the endoscope, can neither eliminate the carcinoma nor control the infection completely. The mortality soon after perforation is fairly high. This study was to investigate the ideal operation patterns and perioperative treatment of perforation in esophageal carcinoma. METHODS： A total of 41 patients with esophageal carcinoma perforated the right lung （19 cases）, the mediastinum （17 cases） and the trachea （5 cases） were treated with operations： 39 underwent open thoracic operation, and 2 only underwent palliative gastric ostomy. Of the 39 patients, 16 received operation through the right thoracic approach with 3 incisions, and 23 received staging operation; 35 received retrosternal substitution of esophagus with stomach or colon, 4 underwent substitution of the esophagus with stomach via the esophageal bed. RESULTS： The operations were success in 36 cases. The patients could eat and take care of themselves. The patients were followed up for 3-72 months after operation： 2 survived for 3 months, 31 survived for 6-12 months, 2 survived for 24 months, and 1 survived for 72 months; 2 died during operation and 3 dead in 1 month after discharge. Of the latter 3 patients, 2 had underwent palliative gastric ostomy, 1 had stoma tracheal fistula recanalization. CONCLUSIONS： The surgical treatment of perforation in esophageal carcinoma could improve the survival rate and life quality of the patients. We suggest to perform retrosternal replacement of esophagus with stomach or colon through the right thoracic approach with 3 incisions or staging operations for the patients with perforation in carcinoma.