改良内镜引导下三腔喂养管置管法的临床应用

Establishment and clinical application of modified endoscopic freka trelumina placement

目的探讨改良内镜引导下三腔喂养管(FT)置管法对需要进行肠内营养和胃肠减压的患者中应用的安全性及可行性。方法采用回顾性队列研究方法,分析2016年1月至2018年1月间在解放军联勤保障部队第九二○医院普通外科应用改良内镜引导下置管法(改良组)和传统内镜旁置管法(传统组)行FT置管术患者的临床资料。纳入标准:下消化道功能正常;不能经口或鼻胃管进食,需进行肠内营养或胃肠减压;预计FT留置时间不超过2个月。排除标准包括胃镜检查禁忌证、疑休克或消化道穿孔、疑精神病或存在消化道炎性病变以及患有胸腹主动脉瘤者。改良组是将FT经一侧鼻腔插入胃内,胃镜进至胃腔,经活检孔用活检钳夹住FT前端细部,胃镜直视下将活检钳和FT插入幽门或吻合口,并向十二指肠或输出袢推送5cm以上,推送过程中胃镜不通过幽门或吻合口;松开并退出活检钳,同步将FT向十二指肠或输出袢推送,经活检孔插入异物钳,在胃内钳夹FT管身推进至幽门或胃肠吻合口;多次同法操作,直至负压吸引腔到达幽门或胃肠吻合口;轻柔退出胃镜,将导丝缓慢退出,固定FT。传统组则采用异物钳钳夹FT前端,在操作中需胃镜、异物钳、FT三者一起同时经过幽门或胃肠吻合口,整体到达十二指肠降部或输出袢进行置管。记录置管时间,置管后1h内行X线透视检查FT位置,并评估比较置管成功率及置管后并发症发生率。结果共纳入141例患者。改良组72例,男45例,女27例,平均年龄55.8(37~76)岁,上消化道解剖正常27例(结肠癌和直肠癌术后胃瘫综合征各分别有17例和10例),上消化道解剖改变45例(胃癌伴幽门梗阻和胃肠吻合术后吻合口梗阻分别有18例和27例)。传统组69例,男41例,女28例,平均年龄55.3(36~79)岁,上消化道解剖正常33例(结肠癌与直肠癌术后胃瘫综合征分别有20例和13例),上消化道解剖改变36例(胃癌伴幽门梗阻和胃肠吻合术后吻合口梗阻分别有15例和21例)。上消化道解剖正常患者改良法置管时间少于传统法[(4.9±1.7)min比(7.6±1.7)min,t=6.683,P<0.001];胃癌伴幽门梗阻患者改良法置管时间也少于传统法[(6.6±1.6)min比(10.5±2.6)min,t=4.724,P<0.001];胃肠吻合术后吻合口梗阻患者改良法置管时间同样少于传统法[(11.3±2.5)min比(15.1±3.5)min,t=4.513,P<0.001]。上消化道解剖正常患者改良法与传统法置管成功率及置管并发症发生率差异无统计学意义(均P>0.05)。上消化道解剖改变患者改良法的置管成功率虽高于传统法[97.8%(44/45)比86.1%(31/36),χ^2=2.880,P=0.089],但差异并无统计学意义;而置管并发症发生率低于传统法[0比8.3%(3/36),χ^2=3.894,P=0.048]。结论无论上消化道解剖正常与否,改良内镜引导下FT置管法比传统内镜旁置管法置管时间少,置管成功率高,且安全;可推广应用于需要进行肠内营养和胃肠减压的患者。

Objective To establish a modified endoscopic Freka Trelumina placement(mEFTP)for modifying or substituting the traditional endoscopic Freka Trelumina placement(EFTP)and to explore the safety and feasibility of mEFTP in patients requiring enteral nutrition and gastrointestinal decompression in general surgery.Methods A retrospective cohort study was conducted to analyze the clinical data of patients undergoing EFTP or mEFTP at General Surgery Department of 920 Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from January 2016 to January 2018.Inclusion criteria: the function of lower digestive tract was normal;patients who could not eat through mouth or nasogastric tube needed to have enteral nutrition and gastrointestinal decompression;the retention time of Freka Trelumina(FT)was not expected to exceed 2 months.Exclusion criteria: contraindication for gastroscopy;suspected shock or digestive tract perforation;suspected mental diseases;infectious diseases of digestive tract;thoracoabdominal aortic aneurysm.mEFIP procedure was as follow.FT was inserted into stomach through one side nasal cavity,gastroscope was inserted into stomach cavity,and the front part of FT was clamped with biopsy forceps through biopsy hole.Biopsy forceps and FT were inserted into the pylorus or anastomosis under gastroscope,and they were pushed into the duodenum or output loop.During pushing,the gastroscope did not pass through the duodenum or output loop.The biopsy forceps was released and pushed out,and FT was pushed with biopsy forceps synchronously into the duodenum or output loop more than 5 cm.The foreign body forceps was inserted through the biopsy hole,and the FT tube was held in the stomach and pushed to the duodenum or output loop.The previous steps repeated until the suction cavity reached the pylorus or anastomosis.The gastroscope was exited gently;the guide wire was pulled out slowly.EFTP procedure: foreign body forceps was used to clamp the front part of FT,and gastroscope,foreign body forceps and FT pass the pylorus or anastomosis simultaneously to reach the descendent duodenum or output loop as a whole.The time of catheterization was recorded and position of FT was examined by X-ray within 1 h after catheterization.The success rate of catheterization and morbidity of complications after catheterization were evaluated and compared between the two groups.Results A total of 141 patients were enrolled,72 in the mEFTP group and 69 in the EFTP group.In mEFTP group,45 cases were males and 27 were females with an average age of 55.8(37-76)years;27 cases had normal upper gastrointestinal anatomy(postoperative gastroplegia syndrome due to colon cancer in 17 cases,due to rectal cancer in 10 cases)and 45 had upper gastrointestinal anatomic changes(gastric cancer with pylorus obstruction in 18 cases and anastomotic block after gastroenterostomy in 27 cases).In the EFTP group,41 were males and 28 were females with an average age of 55.3(36-79)years;33 cases had normal upper gastrointestinal anatomy(postoperative gastroplegia syndrome due to colon cancer in 20 cases,due to rectal cancer in 13 cases)and 36 had upper gastrointestinal anatomic changes(gastric cancer with pylorus obstruction in 15 cases and anastomotic block after gastroenterostomy in 21 cases).In patients with normal upper digestive tract anatomy,the average catheterization time of mEFTP was(4.9±1.7)minutes which was shorter than(7.6±1.7)minutes of EFTP(t=6.683,P<0.001).In patients of gastric cancer with pyloric obstruction,the average catheterization time of mEFTP was(6.6±1.6)minutes which was shorter than(10.5±2.6)minutes of EFTP(t=4.724,P<0.001).In patients with anastomotic block after gastroenterostomy,the average catheterization time of mEFTP was(11.3±2.5)minutes which was shorter than(15.1±3.5)minutes of EFTP(t=4.513,P<0.001).In patients with normal upper gastrointestinal anatomy,there were no significant differences in the success rate of catheterization and the morbidity of catheterization complication between mEFTP and EFTP(all P>0.05).In patients with upper gastrointestinal anatomic changes,the success rate of catheterization in mEFTP was even higher than that in EFTP,but the difference was not significant[97.8%(41/45)vs.86.1%(31/36),χ^2=2.880,P=0.089];while the morbidity of catheterization complication in mEFTP was lower than that in EFTP[0 vs.8.3%(3/36),χ^2=3.894,P=0.048].Conclusions Whether the upper gastrointestinal anatomy is normal or not,mEFTP presents shorter catheterization time,higher success catheterization rate than EFTP,and is safety.mEFTP can be widely applied to clinical practice for patients requiring enteral nutrition and gastrointestinal decompression.