两种不同消化道重建吻合方式在胸腹腔镜食管癌切除术中的临床疗效对比分析

Comparative analysis of the clinical efficacy of two different methods of digestive tract reconstruction and anastomosis in thoracoscopic and laparoscopic esophagectomy for esophageal cancer

目的 比较胸腹腔镜食管癌切除术中采用锥形管状胃颈部端端分层手工吻合与常规管状胃颈部端端机械侧侧吻合的临床疗效。方法 回顾性分析2018年1月1日—2021年3月25日四川省内江市第一人民医院胸心外科连续收治的经胸腹腔镜联合食管癌切除术患者的临床资料。根据术中采用的吻合重建方式,将患者分为锥形管状胃手工组(锥形管状胃+端端分层手工吻合)和常规管状胃机械组(常规管状胃+端端机械侧侧吻合),比较两组患者的吻合时间、术中出血量、淋巴结清扫数量、吻合口瘘、吻合口狭窄、吻合费用、胸胃扩张、胃食管反流症状、术后并发症等临床指标。结果 共纳入患者161例,其中男112例、女49例,年龄40~82岁。锥形管状胃手工组80例,常规管状胃机械组81例。两组患者的术中出血量、淋巴结清扫数目、声音嘶哑、肺部感染、心律失常、呼吸衰竭、乳糜胸发生率差异无统计学意义(P>0.05)。锥形管状胃手工组吻合时间长于常规管状胃机械组[(28.35±3.20)min vs.(14.30±1.26)min,P<0.001],但锥形管状胃手工组吻合费用和胸胃扩张发生率明显低于常规管状胃机械组[(948.48±70.55)元vs.(4 978.76±650.29)元,P<0.001;3(3.8%)vs. 14(17.3%),P=0.005],锥形管状胃手工组吻合口瘘、吻合口狭窄发生率低于常规管状胃机械组,但差异无统计学意义(P>0.05)。术后1、3、6及12个月锥形管状胃手工组胃食管反流评分均低于常规管状胃机械组(P<0.05)。Logistic回归分析显示,吻合重建方式是影响术后胃扩张的影响因素,锥形管状胃+端端分层手工吻合可降低胸胃扩张发生率。结论 锥形管状胃颈部端端分层手工吻合能明显降低胸腹腔镜食管癌切除术后胸胃扩张发生率,节约住院费用,且胃食管反流症状轻,在降低术后吻合口瘘、吻合口狭窄发生率方面仍有一定优势,值得临床推广。

Objective To compare the clinical efficacy of cone-shaped gastric tube combined with cervical endto-end stratified manual anastomosis and conventional tubular stomach combined with neck end-to-end mechanical sideto-side anastomosis in thoracoscopic and laparoscopic esophagectomy for esophageal cancer.Methods The clinical data of consecutive patients treated by thoracoscopic and laparoscopic esophagectomy for esophageal cancer in the Department of Cardiothoracic Surgery of the First People's Hospital of Neijiang from January 1,2018 to March 25,2021 were analyzed.The patients were divided into a cone-shaped gastric tube manual group(treated with cone-shaped gastric tube combined with cervical end-to-end stratified manual anastomosis)and a conventional tubular stomach mechanical group(treated with conventional tubular stomach+end-to-end mechanical side-to-side anastomosis).The anastomotic time,intraoperative blood loss,number of lymph node dissection,anastomotic fistula,anastomotic stenosis,anastomotic cost,sternogastric dilatation,gastroesophageal reflux symptoms,and postoperative complications were compared and analyzed between the two groups.Results A total of 161 patients were enrolled,including 112 males and 49 females aged 40-82 years.There were 80 patients in the cone-shaped gastric tube manual group,and 81 patients in the conventional tubular stomach mechanical group.There was no statistical difference in the intraoperative blood loss,number of lymph nodes dissected,hoarseness,pulmonary infection,arrhythmia,respiratory failure or chylothorax between the two groups(P>0.05).The anastomosis time of the cone-shaped gastric tube manual group was longer than that of the conventional tubular stomach mechanical group(28.35±3.20 min vs.14.30±1.26 min,P<0.001),but the anastomotic cost and incidence of thoracogastric dilatation in the cone-shaped gastric tube manual group were significantly lower than those of the conventional tubular stomach mechanical group 948.48±70.55 yuan vs.4978.76±650.29 yuan,P<0.001;3(3.8%)vs.14(17.3%),P=0.005.The incidences of anastomotic fistula and anastomotic stenosis in the cone-shaped gastric tube manual group were lower than those in the conventional tubular gastric mechanical group,but the dfferences were not statistically significant(P>0.05).The gastroesophageal reflux scores in the cone-shaped gastric tube manual group were lower than those in the conventional tubular gastric mechanical group at 1 month,3 months,6 months and 1 year after the operation(P<0.05).Logistic regression analysis showed that digestive tract reconstruction method was the influencing factor for postoperative thoracogastric dilation,which was reduced in the cone-shaped gastric tube manual group.Conclusion Cone-shaped gastric tube combined with cervical end-to-end stratified manual anastomosis can significantly reduce the incidence of thoracogastric dilatation after thoracoscopic and laparoscopic esophagectomy for esophageal cancer and save hospitalization costs,with mild gastroesophageal reflux symptoms,and it still has certain advantages in reducing postoperative anastomotic fistula and anastomotic stenosis,which is worthy of clinical promotion.