腔镜食管癌切除术后颈部吻合口瘘的处理体会

Treatment Experience of Cervical Anastomotic Fistula After Thoracolaparoscopic Esophageal Cancer Resection

目的总结腔镜食管癌切除术后颈部吻合口瘘的处理经验。方法回顾性分析2013年1月～2018年4月腔镜食管癌切除术528例资料,发生术后颈部吻合口瘘29例(5. 5%),其中7例继发胸内瘘,2例纵隔瘘。无早期瘘(术后1～3天),中期瘘(术后4～14天) 27例,晚期瘘(术后14天以上) 2例。发现吻合口瘘后及时颈部切口敞开,充分引流换药,持续胃肠减压,抗感染和营养支持治疗,合并胸内瘘者予胸腔引流,应用生长抑素减少胃液分泌。结果确诊吻合口瘘后2～4周愈合20例,1～2个月8例,2个月以上1例。6例半年内出现吻合口狭窄行胃镜下扩张术。结论手术中注意尽量切除管状胃上端血供较差部分组织,消除各种对管状胃持续挤压的因素,预防消化液对术野的污染,手术后彻底的颈部引流和及时发现处理继发的胸内瘘有助于降低吻合口瘘的风险。

Objective To investigate the treatment of cervical anastomotic fistula after thoracolaparoscopic esophageal cancer resection. Methods A retrospective analysis of 528 cases of thoracolaparoscopic esophageal cancer resection from January 2013 to April 2018 was made.A total of 29 cases (5.5%) of postoperative neck anastomotic fistula happened,including 7 cases of secondary thoracic fistula and 2 cases of mediastinum.No early fistula (1-3 days after surgery) was seen.There were 27 cases of mid-term sputum (4-14 days after surgery) and 2 cases of advanced fistula (more than 14 days after surgery).Once the anastomotic fistula was found,the neck incision was opened and the drainage was applied.The gastrointestinal decompression,anti-infection and nutritional support treatment were used coinstantaneously.The chest drainage was performed in patients with thoracic fistula,and somatostatin was used to reduce gastric secretion. Results The anastomotic fistula healed within 2-4 weeks after diagnosis in 20 cases,within 1-2 months in 8 cases,and more than 2 months in 1 case.Six cases of anastomotic stenosis underwent endoscopic dilatation in 6 months.Conclusions In the operation,attention should be paid to remove the poor blood supply to the upper part of the tubular stomach,eliminate various factors of continuous extrusion of the tubular stomach,and prevent the contamination of the digestive juice on the surgical field.Thorough neck drainage and timely discovery of secondary intrathoracic fistula help reduce the risk of anastomotic fistula.