食管癌术后吻合口瘘的临床特点及危险因素分析

Clinical features and risk factors of anastomotic leakage after radical esophagectomy

目的 探讨食管癌根治术后吻合口瘘的临床特点和诊治体会.方法 回顾性分析天津医科大学肿瘤医院食管肿瘤科2012年1月至2013年12月行根治性手术的547例食管鳞状细胞癌患者的临床资料.男性421例,女性126例;年龄29～82岁,中位年龄65岁.胸上段食管癌155例,胸中段食管癌340例,胸下段食管癌52例.手术方式包括经左胸食管癌根治术41例,颈胸腹三切口食管癌根治术145例,上腹右胸二切口食管癌根治术279例,腔镜辅助食管癌根治术（左颈吻合）82例.其中,术前新辅助放化疗24例.分别利用χ^2检验和Cox比例风险回归模型对食管癌术后吻合口瘘发生的危险因素进行单因素分析和多因素分析.结果 547例患者中,术后发生吻合口瘘27例,发生率为4.9％（27/547）;死亡1例,病死率为3.70％ （1/27）.发现吻合口瘘的时间为术后4 ～45 d,中位时间为10 d;早期瘘0例,中期瘘20例,晚期瘘7例.27例吻合口瘘患者中,气管食管瘘3例,对侧胸腔瘘3例.单因素分析结果显示,不同瘘口位置、不同手术方式、是否新辅助治疗的患者,吻合口瘘的发生率差异有统计学意义（χ^2 =7.41、21.48、9.20,均P=0.000）.多因素分析结果显示,手术方式（HR=5.689,P=0.003）、吻合口位置（HR =2.594,P=0.048）、术前放化疗（HR=3.604,P=0.027）是食管癌术后吻合口瘘的独立危险因素.结论 食管癌术后吻合口瘘以中期瘘为主.颈胸腹三切口食管癌根治术是造成术后吻合口瘘的重要术式,术前新辅助放化疗是吻合口瘘发生的一个重要因素.

Objective To analyze the clinical features and risk factors of anastomotic leakage after radical esophagectomy of esophageal carcinoma.Methods The clinical data of 547 esophageal cancer patients underwent radical esophagectomy in Tianjin Medical University Cancer Hospital from January 2012 to December 2013 was analyzed retrospectively.There were 421 male and 126 female patients,with a median age of 65 years （ranging from 29 to 82 years）.There were 155 cases of upper esophageal carcinoma,340 cases of middle esophageal carcinoma and 52 cases of lower esophageal carcinoma.The surgical procedures included 41 cases completed through Sweet,145 cases completed through McKeown,279 cases completed through Ivor Lewis,82 cases completed through minimally invasive esophagectomy.Moreover,24 of 547 cases underwent preoperative neoadjuvant radiochemotherapy.χ^2 test and Cox＇s proportional hazards regression model were used for univariate analysis and multivariate analysis of the risk factors of postoperative anastomotic leakage.Results Twenty-seven of 547 cases with esophagectomy occurred anastomotic leakage and the incidence rate was 4.94% （27/547）.One of 27 cases died and the mortality rate was 3.70% （1/27）.The time of anastomotic leakage found was 4 to 45 days,with a median time of 10 days.There were 0 case of early leakage,20 cases of mid-term leakage,7 cases of late leakage.Three of 27 cases with anastomotic leakage had tracheoesophageal fistula,while 3 cases had contralateral pleural fistula.As to the incidence rate of anastomotic leakage,there was statistically significant difference between cervical anastomotic leakage （8.14%,18/221） and intrathoracic anastomotic leakage （2.76%,9/326） （χ^2 =7.41,P=0.000）,among Sweet （4.88%,2/41）,McKeown （9.66%,14/145）,Ivor Lewis （2.51%,7/279） and M IE （4.88%,4/82） （χ^2 =21.48,P=0.000）,and between with （16.67%,4/24） and without （4.40%,23/523） neoadjuvant radioehemotherapy （χ^2 =9.20,P =0.000）.The multivariate analysis showed that anastomotic site （HR =2.594,P =0.048）,surgical approach （HR =5.689,P =0.003） and preoperative neoadjuvant radiochemotherapy （HR =3.604,P =0.027） are independent risk factors for anastomotic leakage after esophagectomy.Conclusions The mid-term anastomotic leakage after esophagectomy occurs higher.McKeown is a main surgical procedure and neoadjuvant radiochemotherapy is an important factor for the anastomotic leakage.