Ivor-Lewis食管癌切除术中闭合式空肠营养管置入临床经验

Non-invasive closed placement of nasojejunal feeding tube during Ivor-Lewis esophagectomy for esophageal carcinoma

目的:食管癌患者术后营养支持至关重要,目前肠内营养在食管癌术后应用广泛,经鼻-空肠营养管是主要的肠内营养途径,具有无创、简便、安全、易行的特点。但目前为止,国内外鲜见报道上腹-右胸食管癌切除术中闭合式空肠营养管安置的文献。本研究中通过改进手术操作,探索Ivor-Lewis术中闭合式安置空肠营养管的方法。方法:2010年1月至2013年12月四川大学华西医院共连续实施85例Ivor-Lewis食管癌/贲门癌切除术患者,其中男72例,女13例,平均年龄59.7±7.5岁。每例患者均尝试闭合式安置空肠营养管。主要手术步骤包括:1)经腹游离胃,食管裂孔的扩大和幽门括约肌捏断术;2)经胸管胃制作,食管肿瘤切除和胃食管胸内吻合;3)在巡回护士协助下,术者进行空肠营养管的闭合式安置。结果:全组病例无术后死亡或营养管相关不良事件发生。营养管安置成功52例,总体安置成功率为61.2%(52/85),其中40例安置成功并成功实施术后全肠内营养支持;12例安置成功,但因其它原因无法实施肠内营养;安置失败(33例)的患者均进行肠外营养支持。肠内营养组与肠外营养组在术后住院时间、术后并发症方面差异无统计学意义(P>0.05),肠内营养组在营养制剂费用、营养制剂费用占总住院费用比例两项指标上显著低于肠外营养组(1 469±741元vs.3 223±917元,P<0.001;3.4%vs.7.2%,P<0.001)。结论:Ivor-Lewis食管癌切除术中闭合式空肠营养管安置,是一种无创、安全、简单可行的手术操作方式,可以为患者提供有效、经济的肠内营养支持方案。外科医生通过练习完全可以熟练实施Ivor-Lewis术中营养管闭合式安置。

Objectives： To improve the surgical procedures and investigate the feasibility of the closed placement of nasojejunal tube during Ivor-Lewis esophagectomy. Methods： From January 2010 to December 2013, 85 patients （72 males and 13 females） with esophageal or gastric cardiac carcinoma underwent Ivor-Lewis esophageetomy in our department. Briefly, the general surgical proce- dures were performed as follows： 1） stomach mobilization and enlargement of esophageal hiatus and pyloric sphincter digital fracture via laparotomy; 2） tubular stomach reconstruction, esophageal carcinoma resection, and intra-thoracic esophagogatrostomy via right posterolateral thoracotomy; and 3） forward closed placement of feeding tube through the nostrils and jejunum of patients under the guid- ance of a surgeon, who palpates the pylorus through the hiatus with the use of fingers. Results： No operative death or feeding tube-asso- ciated adverse event was observed. Among the 85 patients who have undergone Ivor-Lewis esophagectomy, feeding tube placement in- to the jejunum during surgery failed in 33 cases. The success rate of nasojejunal feeding tube placement was 61.2% （52/85）. Twelve pa- tients with successful tube placement did not receive enteral feeding for several reasons and were thereby transferred to parenteral group. Significant differences were observed in terms of the nutritional cost and proportion between enteral feeding and parenteral groups （￥1,469± 741 vs. ￥3,223±917, P〈0.001; 3.4% vs. 7.2%, P〈0.001）. No differences in postoperative hospital stay and morbidi- ty were observed between the two groups （P〉0.05）. Conclusion： The novel forward closed placement of nasojejunal feeding tube dur- ing Ivor-Lewis esophagectomy provides a non-invasive, feasible, simple, and economical method for postoperative nutritional support. Surgeons could perform this novel technique successfully in practice.