食管胃侧侧吻合术预防胸段食管癌术后吻合口并发症临床价值分析

Application of side-to-side stapled esophagogastric anastomosis after resection of esophageal carcinoma to reduce incidence of the anastomotic complications

目的观察胸段食管癌应用食管胃侧侧吻合方法预防术后吻合口并发症发生的临床效果。方法回顾性分析2011-12-01-2014-07-31山东省肿瘤医院手术治疗的160例食管癌患者的临床资料。选取食管胃侧侧吻合组70例,术中按肿瘤手术切除原则常规游离食管及近端胃,切除肿瘤,采用直线型缝合器纵向缝合食管胃吻合口后壁,使吻合口后壁延长至≥5cm。同期90例食管癌切除食管胃常规吻合作为对照组。分析2组患者术后情况,纤维胃镜和造影评估吻合口面积。结果食管胃侧侧吻合组术后吻合口瘘发生率为1.43%(1/70),低于手工吻合组的14.47%(11/76),χ2=8.220,P=0.004;也低于机械环形吻合组的14.29%(2/14),χ2=5.600,P=0.018。食管胃侧侧吻合组术后的吻合口狭窄发生率为2.86%(2/70),低于手工吻合组的13.16%(10/76),χ2=5.125,P=0.024;也低于机械环形吻合组的14.29%(2/14),χ2=3.360,P=0.067。食管管状胃全侧侧吻合口面积为(2.45±0.12)cm2,端端+侧侧吻合口面积为(2.05±0.10)cm2,大于Gambee’s吻合的(1.25±0.18)cm2,t=39.174,P=0.001;也大于机械环形吻合的(1.45±0.35)cm2,t=17.054,P=0.001。食管胃侧侧吻合组的胸胃综合征发生率为5.71%(4/70),低于常规吻合组的12.22%(11/90),χ2=3.106,P=0.078;颈部手工吻合方法切除食管长度明显长于侧侧吻合组,t=5.283,P=0.011;食管胃侧侧吻合组术后9例轻度返流,1例中度返流,占14.28%(10/70);相比常规吻合,食管胃侧侧吻合组术后反流性食管炎发生率低,但差异无统计学意义,χ2=3.055,P=0.081。结论在食管癌手术中,应用食管管状胃侧侧吻合术可以显著降低术后吻合口并发症的发生。

OBJECTIVE To investigate the advantages and the clinical application of side-to-side stapled esopha- gogastric anastomosis to reduce incidence of the anastomotic complications during resection of esophageal carcinoma. METHODS One hundred and sixty patients with esophageal carcinoma underwent curative esophagectomy at Shandong Cancer Hospital and Institute between Dec. 1,2011 and Jul. 31,2014. Seventy patients （52 men and 18 women;age ran- ging from 38 to 76 years） with esophageal carcinoma underwent curative esophagectomy （tumor resection and lymph node dissection） and side-to-side stapled esophagogastric anastomosis, using linear endoscopic stapler to create a large than 5 cm posterior wall of esophagogastric anastomosis, including lower thoracic esophageal cancer 16 ,middle thoracic esoph- ageal cancer 39,upper thoracic esophageal cancer 13, and multifocal lesion 2 cases. The surgical procedures included total esophagectomy,gastric tube construction and side-to-side esophagogastric anastomosis. The analysis of variance, 2-test and linear correlation were performed. RESULTS All patients had successful operation, no remnants of the surgical margin were found in these cases. One patient（1.43 % ） complicated with anastomotic leak and was cured in 2 weeks by cervical drainage and absolute diet. The incidence of leak occurred in the side-to-side stapled anastomotic group was significantly lower than that in the other two groups（hand-sewn anastomosis： 14.47% ,P=0. 004, circular anastomosis： 14.29% ,P=0. 018）. Sixty-two patients were followed up for 1 to 37 months, and slight anastomotic stricture occurred in 2 patients（2.86%） and was significantly more common in the circular anastomosis group （hand-sewn anastomosis： 13.16%, P= 0. 024; cir- cular anastomosis： 14.29 %, P= 0. 067）. The area of the stoma was similar in the two groups, total side-to-side stapled： （2.45±0.12） cm^2 , end-to-side ＋side-to-side stapled.. （2.05±0.10） cm^2. The area of the stoma in the total side-to-side stapled anastomotie technique was significantly larger than that in the hand-sewn Gambee＇s group（P= 0. 001） and circular anastomosis group（P=0. 001）. The rate of thoracic stomach syndrome occurred in the total side-to-side stapled anasto- motic and traditional group was 5.71% and 12.22% （P= 0. 078）, respectively. The length of esophagus from tumor cut edge in the total side-to-side was more less （P=0. 011）. Reflux esophagitis was found in 10 and the incidence rate was 14.28% （10/70）. It observed no statistically significant correlation between the anastomotic technique and reflux esoph- agitis, by compared with routine operation （P=0. 081）. CONCLUSION The resection of esophageal cancer with side-to- side stapled esophagogastric anastomosis is an effective method, which can reduce incidence of the anastomotic complica- tions such as anastomotic stricture and fistula, and the method can decrease incidence of reflux esophagitis.