胸腔内食管-胃吻合口瘘诊治新模式初步研究结果

Diagnosis and treatment for intrathoracic gastroesophageal anastomotic leak： investigation of a new mode

目的探讨胸腔内食管．胃吻合口瘘的诊治新模式的可行性。方法回顾性分析苏州大学附属第一医院心胸外科2007年1月至2014年12月食管癌、贲门癌根治术后55例发生胸腔内吻合口瘘患者的临床资料，其中男性36例，女性19例，年龄49～81岁，平均年龄（67±6）岁。原发病为食管中段癌42例，食管下段癌11例及贲门癌2例。2007年1月至2011年11月31例患者接受传统诊治方法（传统组），在怀疑吻合口瘘后行食管造影以明确诊断，充分引流及感染控制后置入食管支架；2011年3月至2014年12月24例患者采取新模式诊治法（新模式组），在怀疑吻合口瘘时立即行数字减影血管造影下吻合口造影，明确瘘口位置及探查瘘腔形态及大小，根据探查情况行瘘腔内置管引流或冲洗，控制感染后逐步退出瘘腔内引流管，后经胃镜钛夹夹闭瘘口，失败者行食管支架置入。采用t检验、χ^2检验和Fisher确切概率法比较两组的临床资料。结果两组患者术前一般情况差异无统计学意义（P〉0．05）。相比传统组，新模式组吻合口瘘确诊时间缩短[（1．2±0．8）d比（3．6±2．2）d，t=5．212，P=0．000]，确诊吻合口瘘后住院时间缩短[（26±12）d比（56±25）d，t=4．992，P=0．000]，严重并发症发生率下降（16．7％比48．4％，χ^2=6．019，P=0．014），总体病死率差异无统计学意义（4．17％比22．58％，P=0．119）。结论早期介入诊断、早期瘘腔内置管引流或冲洗及后期胃镜下钛夹夹闭的诊治模式能缩短胸腔内食管．胃吻合口瘘的诊断和治疗周期，降低严重并发症发生率。

Objective To investigate the feasibility of a new mode to diagnose and treat intrathoracic gastroesophageal anastomotic leak. Methods From January 2007 to December 2014, fifty-five patients were confirmed intrathoracic gastroesophageal anastomotic leak among those were performed surgical operation due to esophageal or cardiac carcinoma in the First Affiliated Hospital of Soochow University. To retrospectively analyze the clinical data of these patients, thirty-six male and nineteen female were included with the ages from 49 to 81 years （ average age of （67 ± 6） years）. Among them, forty-two were middle esophageal carcinoma, eleven were lower esophageal carcinoma and two were cardiac carcinoma. According to the differences of diagnosis and treatment methods for anastomotic leak, fifty-five patients were divided into two groups. Thirty-one patients distributed from January 2007 to November 2011 were received conventional management （ conventional group） ： to definitively diagnose by contrast swallow when suspected to be developing anastomotic leaks, to place an esophageal stent when the drainage was sufficient and the infection was controlled. Twenty-four patients distributed from March 2011 to December 2014 were received new-mode management （new-mode group） ： to perform a anastomotic radioscopy under digital subtraction angiography -guidance instantly when suspected anastomotic leak and find out the fistula, search the shape and size, place a drainage tube into the fistula to drain or lavage the vomica according to the exploration results, pull back the tube gradually and close the leak by clips under endoscope later. The pathoclinical features, the confirmation time （ time from clinical signs emergence to leak confirmation）, the hospital duration after confirmation, the incidence of severe complications and total mortality were compared between the two groups by t-test and χ^2 test or Fisher＇s exact test. Results There was no significant statistical differences in pathoclinical features between two groups （P 〉 0. 05）. The confirmation time was significantly reduced in new-mode group than that in conventional group （ （1.2 ±0. 8） d vs. （3.6 ±2. 2） d, t =5. 212, P =0. 000）, and so was the hospital duration after confirmation （ （26 ±12） d vs. （55 ±25） d, t =4. 992, P = 0. 000） and the incidence of severe complications （ 16.7% vs. 48.4% , χ^2 = 6. 019, P = 0. 014）, although there was no statistical differences in total mortality （4. 2% vs. 22. 6%, P =0. 119）. Conclusion The new mode of early interventional diagnosis, early fistula drainage through nose and clipping under endoscope later is able to shorten diagnosis and treatment period, reduce incidence of severe complications.