食管癌及贲门癌术后隐匿胸腔瘘的诊断与治疗

Diagnosis and management of concealed thoracic cavity fistula in postoperative patients with esophageal or cardia carcinoma

目的 探讨食管癌及贲门癌术后隐匿胸腔瘘的诊断、治疗方法.方法 回顾性分析2010年1月至2013年9月40例行胸内胃食管吻合术的食管癌、贲门癌患者资料.40例患者出现高热、白细胞升高等脓毒血症表现,早期均无造影剂渗漏,但CT显示吻合口或胃残端周围出现散在小气泡、少量包裹性积液,存在吻合口或胃残端早期微小瘘口的可能,定义为隐匿胸腔瘘.20例按隐匿胸腔瘘处理,给予禁食、抗感染治疗、保持胃肠减压通畅、鼻肠管肠内营养等治疗;另20例按术后未出现胸腔瘘进行常规治疗,给予降温及抗生素治疗.比较两组胸腔瘘发生情况,总结泛影葡胺食管造影及胸部CT扫描隐匿胸腔瘘的特点.结果 按吻合口瘘处理的20例患者泛影葡胺食管造影及胸部CT扫描显示,有2例（10％）发展为较小的吻合口瘘,未按胸腔瘘处理的20例患者中有17例（85％）发展为胸腔瘘,6例并发多器官衰竭死亡.结论 食管癌、贲门癌术后出现脓毒血症表现,泛影葡胺食管造影及胸部CT扫描显示吻合口或胃残端周围有小气泡、不规则包裹性积液为隐匿胸腔瘘的特异性征象,应按胸腔瘘处理.

Objective To investigate diagnosis and treatment of concealed thoracic cavity fistula in the postoperative patients of esophagus or cardia carcinoma.Methods The clinical data of 40 patients were analyzed who presented with unexplained sepsis （elevated white blood cell count and temperature〉38 ℃） after esophagectomy and intrathoracic anastomosis from January 2010 to September 2013.All patients underwent oral meglumine diatrizoate esophageal imaging and computerized tomography scan of the chest.None of the patients had any sign of contrast leak in the early in these diagnostic examinations,but their chest CT scan all showed peri-anastomotic or the gastric remnant diffuse bubble and bit encapsulated effusion.Twenty patients were treated as concealed intrathoracic anastomotic or the gastric remnant leak including fasting,broad spectrum antibiotic treatment,kept the gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube.The other twenty patients were not treated only received broad spectrum antibiotic treatment.Results Two of the 20 patients in group of who were treated as concealed intrathoracic leak finally developed intrathoracic leak proved by oral meglumine diatrizoate esophageal imaging and CT scan （10 %,2/20）.Among the twenty patients who were not treated as intrathoracic leak,seventeen patients developed intrathoracic leak （85 %,7/20）,six patients died of multiple organ dysfunction syndrome.Conclusions Perianastomotic or the gastric remnant diffuse bubble and irregular encapsulated effusion in oral meglumine diatrizoate esophageal imaging and CT scan of the chest should be considered as specific signs of concealed intrathoracic anastomotic or the gastric remnant leak after esophagectomy and intrathoracic anastomosis.Patients with such signs should be treated as intrathoracic leak.