中下段食管癌Ivor鄄Lewis术管状胃宽度与术后早期胃排空障碍关系的临床研究

Study on the association of gastric conduit width and postoperative early delayed gastric emptying in middle-lower esophageal cancer patients undergoing Ivor-Lewis procedure

目的：探讨中下段食管癌Ivor-Lewis术管状胃宽度与术后早期胃排空障碍（DGE）的关系。方法回顾性分析2013年1月至2015年6月期间，由南京医科大学第一附属医院胸外科单一手术组行Ivor-Lewis术的282例中下段食管癌患者的临床资料，按术中管状胃制作宽度分为宽管状胃组（管状胃宽度＞5．0 cm，93例）、中等管状胃组（管状胃宽度3．0~5．0 cm，70例）和窄管状胃组（管状胃宽度＜3．0 cm，119例），其中窄管状胃组患者的管状胃完全纳入食管床，并行管状胃-心包固定。所有患者都未做幽门成型或切开术。分别于术后1周和4周行上消化道造影造影检查，明确吻合口情况及有无DGE。结果3组患者基线资料的比较，差异均无统计学意义（均P＞0．05）。3组的手术时间、术中出血量以及术后住院时间的差异无统计学意义（均P ＞0．05）。术后宽管状胃组、窄管状胃组患者各出现1例吻合口瘘；3组术后肺部相关并发症以及心律失常发生率相近（均P ＞0．05）。窄管状胃组平均胃液引流量为（98±57） ml／d，明显少于宽管状胃组[（157±62） ml／d， P＝0．000]和中等管状胃组[（123±68） ml／d， P＝0．008]。术后1周DGE总发生率为10．6％（30／282），其中宽管状胃组为17．2％（16／93），中等管状胃组为14．3％（10／70），均高于窄管状胃组3．4％（4／119）的发生率（P＝0．001， P＝0．006）。经保守治疗后，术后4周各组DGE患者无明显差异。全组住院期间及术后1月后复查无死亡病例。结论在Ivor-Lewis术中采用较窄管状胃代食管，并将其行管状胃-心包固定于食管床内，可显著降低食管癌术后早期患者DGE的发生。

Objective To examine the relationship between gastric conduit width and postoperative early delayed gastric emptying （DGE） in patients with middle-lower esophageal carcinoma who underwent Ivor-Lewis operation. Methods Clinical data of 282 consecutive patients with middle-lower esophageal cancer who underwent the Ivor-Lewis operation by same surgical team in our department from January 2013 to June 2015 were retrospectively analyzed. Patients were divided into three groups according to the width of gastric conduit： width〉 5.0 cm as broad group （n=93）; width 3.0-5.0 cm as moderate group （n = 70）; width 0.05）. There were no significant differences in operative time, blood loss, and postoperative hospital stay among groups （all P〉0.05）. No patients died during perioperative peried. Anastomotic leakage occurred in 2 cases, one from broad group and another from narrow group. The incidences of arrhythmia and postoperative pulmonary complications, including infection, atelectasis, pneumothorax, and pleural effusion were similar among groups （all P〉0.05）. The average amount of gastric juice drainage in narrow group was （98 ± 57） ml/day, which was markedly lower than that in broad group [（157 ± 62） ml/day, P=0.000] and in moderate group [（123 ± 68） ml/day, P=0.008]. One week after operation, the overall incidence of DGE was 10.6%（30/282）, the incidence of DGE in broad, moderate, narrow groups was 17.2%（16/93）, 14.3%（10/70）, and 3.4%（4/119） respectively, and broad and moderate groups had higher incidence as compared to narrow group （P=0.001 and P=0.006）. Conclusion During the Ivor-Lewis operation, application of a narrow gastric conduit （width 〈 3.0 cm）, which completely position the esophageal bed with fixation to the pericardium posterior wall, can significantly reduce the incidence of postoperative early DGE.