食管癌术后吻合口瘘的影像表现与临床处理

The imaging findings and clinical manifestations of the esophagogastric anastomotic leak occurred after the surgery of esophageal cancer

目的探讨食管胃吻合口瘘的不同影像表现在介入治疗中的价值。方法对68例食管癌术后食管-胃吻合口瘘患者,根据吻合口瘘发生的时间、瘘口部位及周围脓腔大小,采用透视下经鼻腔置入胃减压管、空肠营养管和脓腔引流管,再择期置入食管内支架封堵瘘口的治疗方法。结果经鼻腔置入胃减压管、空肠营养管和脓腔引流管位置合适。经复查治愈40例,治愈率58.5%(40/68)。28例支架置人治疗吻合口瘘中6例置入7枚蘑菇状覆膜内支架,22例置入24枚编织型双喇叭覆膜内支架,技术操作全部成功,脓腔愈合后将引流管拔出。随访期间25例支架封堵瘘口完全,治愈率89.3%(25/28)。4例3个月后支架上缘再狭窄,再次置入新支架;1例支架置入2个月后因反流性食管炎而取出支架。2例1个月后发生大出血死亡;1例于术后3个月死于严重肺部感染。结论食管癌术后吻合口瘘的治疗,应根据影像表现的不同,采用脓腔及时、有效的引流,空肠营养管及胃减压管置入,择期食管内支架置入等介入治疗手段,安全、有效、经济。

Objective To discuss the imaging findings of the esophagogastric anastomotic leak and their practical value in performing interventional therapy. Methods A total of 68 patients with esophagogastric anastomotic leak were enrolled in this study. The occurring time, location and size of the peripheral abscess of the leak were determined. Under fluoroscopic guidance, the abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube were inserted through a transnasal route. According to the therapeutic results, esophageal stent implantation was carried out to closure the leak. Results The placement of abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube was successful in all patients. Reexamination showed that cure and favourable change was obtained in 40 patients （58.5%, 40/68）. The other 28 patients with esophagogastric anastomotic leak received stent implantation. Among them, six patients received 7 mushroom shaped covered stents, 22 patients received 24 woven double horns shaped covered stents. Technical success of stent placement was obtained in all patients. The drainage tubes were pulled out when the abscesses were healed. During the follow-up period, the leaks were completely occluded by the stents in 25 cases, the cure rate was 89.3%% （25/28）. Three months after the treatment, restenosis of the upper margin of the stents occurred in 2 patients, and the new stent placement had to be carried out. In one case the stent had to be removed due to reflux esophagitis which occurred two months after the treatment. One month after the stent placement, two patients died of massive hemorrhage. One patient died of severe lung infection one month after the stent placement. Conclusion The therapeutic plan of esophagogastric anastomotic leak should be based on the imaging findings, and the placement of abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube should be properly and promptly adopted. As comprehensive interventional therapy, the use of esophageal stent should also be taken into account.