梭形管状胃在胸腹腔镜联合食管癌根治术消化道重建中的应用价值

Application value of the fusiform tube stomach in the digestive tract reconstruction after thoracoscopic and laparoscopic radical resection of esophageal carcinoma

目的：探讨梭形管状胃在胸腹腔镜联合食管癌根治术消化道重建中的应用价值。方法：采用回顾性队列研究方法。收集2016年11月至2017年5月郑州大学第一附属医院收治的96例胸段食管癌患者的临床病理资料。96例患者均行胸腹腔镜联合食管癌根治术，其中45例术中采用细管状胃重建消化道，设为细管状胃组；51例采用梭形管状胃重建消化道，设为梭形管状胃组。观察指标：（1）术中及术后情况。（2）术后并发症情况。（3）胃各部位血流检测情况。（4）随访和生存情况。采用电话或门诊方式进行随访。了解患者术后生存情况。随访时间截至2017年11月。正态分布的计量资料采用±s表示，组间比较采用t检验；偏态分布的计量资料采用M（范围）表示，组间比较采用秩和检验。等级资料采用两独立样本的Wilcoxon秩和检验，两分类变量采用x2检验。配对实验数据采用Friedman检验和Wilcoxon秩和检验。结果：（1）术中及术后情况：96例患者均成功施行胸腹腔镜联合食管癌根治术。细管状胃组患者消化道重建使用闭合器数量、术后纵隔管拔除时间、术后CT检查胸胃前后径、术后CT检查胸胃最大处层面数与隆突层面数比值、术后住院时间分别为4个（3～5个）、14 d（11～45 d）、28.35 mm（9.96～75.70 mm）、0.56（0.33～2.13）、16 d（12～62 d），梭形管状胃组患者上述指标分别为4个（2～4个）、12 d（10～16 d）、45.80 mm（17.36～89.77 mm）、1.10（0.47～2.15）、14 d（12～61 d），两组上述指标比较，差异均有统计学意义（Z=4.525，4.240，-3.796，-4.604，2.154，P〈0.05）。（2）术后并发症情况：细管状胃组患者术后瘘（颈部吻合口瘘、胸胃瘘），肺部并发症Clavien-Dindo分级（Ⅰ～Ⅱ级、Ⅲ～Ⅳ级）分别为4、5例（1例同时合并颈部吻合口瘘和胸胃瘘），32、13例，梭形管状胃组患者上述指标分别为0、0，47、4例，两组上述指标比较，差异均有统计学意义（χ^2=9.937，7.266，P〈0.05）。发生并发症患者均经对症治疗后好转。（3）胃各部位血流检测情况：7例患者非接触式激光多普勒线扫描成像仪检测自身对照状态胃窦、胃体、胃底血流灌注量分别为314 PU（294～320 PU）、252 PU（242～259 PU）、206 PU（194～223 PU），梭形管状胃模型分别为295 PU（277～314 PU）、255 PU（244～267 PU）、219 PU（199～233 PU），细管状胃模型分别为277 PU（263～300 PU）、216 PU（201～235 PU）、199 PU（176～207 PU），3者上述指标分别比较，差异均有统计学意义（χ^2=10.286，14.000，10.286，P〈0.05）。其中自身对照状态分别与梭形管状胃模型比较，差异均有统计学意义（Z= -2.028，-2.384，-2.197，P〈0.05）；自身对照状态分别与细管状胃模型比较，差异均有统计学意义（Z= -2.371，-2.371，-2.201，P〈0.05）；梭形管状胃模型分别与细管状胃模型比较，差异均有统计学意义（Z= -2.201，-2.366，-2.366，P〈0.05）。（4）随访情况：96例患者中，90例获得术后随访。随访时间为6～12个月，中位随访时间为8个月。随访期间，细管状胃组1例患者因肿瘤复发死亡，梭形管状胃组患者无肿瘤复发及死亡，两组比较，差异无统计学意义（χ^2=1.264，P〉0.05）。结论：在胸腹腔镜联合食管癌根治术中，梭形管状胃与细管状胃重建消化道比较，可减少术后瘘、肺部并发症的发生率，缩短住院时间；梭形管状胃的血流灌注优于细管状胃。

Objective：To explore the application value of the fusiform tube stomach in the digestive tract reconstruction after thoracoscopic and laparoscopic radical resection of esophageal carcinoma. Methods：The retrospective cohort study was conducted. The clinicopathological data of 96 patients with thoracic esophageal cancer who were admitted to the First Affiliated Hospital of Zhengzhou University between November 2016 and May 2017 were collected. All the patients underwent thoracoscopic and laparoscopic radical resection of esophageal carcinoma, 45 using thin tubular stomach and 51 using fusiform tube stomach for digestive tract reconstruction were respectively allocated into the tubular stomach group and fusiform stomach group. Observation indicators： （1） intra and postoperative situations; （2） postoperative complications; （3） detection of gastric hemodynamics; （4） followup situations. Followup using outpatient examination and telephone interview was performed to detect patients＇ survival up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M （range） and comparison between groups was analyzed using the rank sum test. Ordinal data and categorical variables were respectively done using the independentsample Wilcoxon ranksum test and chisquare test. Paired experimental data were analyzed by the Friedman test and Wilcoxon test. Results：（1） Intra and postoperative situations： 96 patients underwent successful thoracoscopic and laparoscopic radical resection of esophageal carcinoma. The number of closers, time of postoperative mediastinal tube removal, thoracic stomach anteroposterior diameter by postoperative CT examination, number of slices at maximal width of thoracic stomach by postoperative CT examination and duration of hospital stay were respectively 4 （range, 3-5）, 14 days （range, 11-45 days）, 28.35 mm （range, 9.96-75.70 mm）, 0.56 （range, 0.33-2.13）, 16 days （range, 12- 62 days） in the tubular stomach group and 4 （range, 2-4）, 12 days （range, 10-16 days）, 45.80 mm （range, 17.36-89.77 mm）, 1.10 （range, 0.47-2.15）, 14 days （range, 12-61 days） in the fusiform stomach group, with statistically significant differences between groups （Z=4.525, 4.240,-3.796,-4.604, 2.154, P〈0.05）. （2） Postoperative complications： cases with postoperative cervical anastomotic fistula, thoracic gastric fistula, grading Ⅰ-Ⅱ and Ⅲ-Ⅳ of Clavien-Dindo classification were respectively 4, 5, 32, 13 in the tubular stomach group （1 with a combination cervical anastomotic fistula and thoracic gastric fistula） and 0, 0, 47, 4 in the fusiform stomach group, with statistically significant differences between groups （χ^2=9.937, 7.266, P〈0.05）. Patients with complications were improved by symptomatic treatment. （3） Detection of gastric hemodynamics： hemodynamic values of gastric antrum, gastric body and gastric fundus that was detected by noncontact laser Doppler line imaging were respectively 314 PU （range, 294- 320 PU）, 252 PU （range, 242-259 PU）, 206 PU （range, 194-223 PU） in selfcontrol status of 7 patients and 295 PU （range, 277-314 PU）, 255 PU （range, 244-267 PU）, 219 PU （range, 199-233 PU） in tubular stomach model and 277 PU （range, 263-300 PU）, 216 PU （range, 201-235 PU）, 199 PU （range, 176-207 PU） in fusiform stomach model, with statistically significant differences among groups （χ^2=10.286, 14.000, 10.286, P〈0.05）. There were statistically significant differences in the hemodynamic values of gastric antrum, gastric body and gastric fundus between selfcontrol status and fusiform stomach model （Z=-2.028,-2.384,-2.197, P〈0.05）, between selfcontrol status and tubular stomach model （Z=-2.371,-2.371,-2.201, P〈0.05） and between fusiform stomach model and tubular stomach model （Z=-2.201,-2.366,-2.366, P〈0.05）. （4） Followup situations： among 96 patients, 90 were followed up for 6-12 months, with a median time of 8 months. During the followup, 1 patient in the tubular stomach group died of tumor recurrrence, and no patient died in the fusiform stomach group, with no statistically significant difference between groups （χ^2=1.264, P〉0.05）. Conclusion：Compared with the thin tubular stomach, the fusiform tube stomach can reduce the incidences of postoperative fistula and pulmonary complications and shorten duration of hospital stay after the thoracoscopic and laparoscopic radical resection of esophageal carcinoma, and hemodynamics of the fusiform tube stomach is superior to that of thin tubular stomach.