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食管、贲门癌切除器械吻合术519例

目的 总结食管、贲门癌切除后应用器械吻合防止吻合口瘘和狭窄的临床经验。方法 回顾性地分析519例食管、贲门癌患者应用吻合器治疗的结果。结果 发生并发症7例，包括吻合口瘘2例，吻合口出血2例，吻合口狭窄3例，无手术死亡和住院死亡。结论 器械吻合完整快捷，明显地减少了手术操作时间和吻合口并发症的发生，降低了手术死亡率。

Accurate Drainage for Intrathoracic Anastomotic Leakage after Esophagectomy

Objective To explore an effective and minimal invasive drainage procedure for intrathoracic anastomotic leakage after esophagectomy. Method A total of 14 patients (10 males and 4 females, aged 48 to 70 years) with encapsulated effusion due to thoracic anastomotic leakage after esophagectomy were performed accurate thoracic drainage which was guided by ultrasonography in Renji Hospital from January 2012 through December 2014. The J shape flexible catheter was placed into the effusion cavity near the leakage. Gasric drainage and enteral nutrition support were conducted as well. Result All the patients with leakage healed smoothly. The hospital stay was 27 to 94 days. Time of drainage was 17 to 89 days. The drainage volume was 5-260 ml per day. No complication related to drainage occurred. Conclusion Placing the J shape flexible catheter for plural drainage guided by ultrasonography or chest CT scan is a desirable and less injured therapy for intrathoracic leakage after esophagectomy.

带膜食管支架置入治疗食管癌术后胸内食管吻合口瘘

目的　总结覆硅胶膜镍钛合金食管支架置入治疗食管癌术后胸内食管吻合口瘘的临床经验。方法　回顾性分析 2005年 1月至 2009年 12月上海交通大学医学院附属仁济医院 12例食管癌手术后发生胸内食管吻合口瘘经覆硅胶膜镍钛合金食管支架置入治疗的临床资料，其中男 7例，女 5例；平均年龄 65（45～ 70）岁。胸内食管吻合口瘘发生于术后第 5～ 28 d，均为单个漏口，漏口直径约 0.2～ 1.0 cm。确诊食管吻合口瘘后给予支持治疗 7 d，待病情稳定后置入覆硅胶膜镍钛合金食管支架，支架长 5～ 12 cm ，内径 1.8～ 2.0 cm。结果　术后因进食呛咳死于肺部感染 1例。术后出现胸骨疼痛 7例，支架移位 3例，消化道出血 1例，均经相应的治疗后好转或治愈。生存患者于置入食管支架后第 3～ 15 d经口进食。随访 11例，随访时间 1～ 6个月，食管吻合口瘘愈合良好 9例；支架移位 1例，瘘口未愈合，术后 4个月死于肿瘤复发；在回收食管支架过程中黏膜撕裂，致吻合口狭窄 1例。结论　带膜食管支架置入是治疗食管癌术后胸内食管吻合口瘘的一种有效方法。

食管瓣片成形——食管胃套接术的临床应用

目的 探讨消除食管胃吻合术后吻合口瘘、吻合口狭窄及胃反流等手术方法. 方法 食管两侧纵行剪开1.5cm,形成二叶瓣片.胃前壁造口为套接口,将二叶瓣片经胃套接口确保完全置入胃腔内.不缝粘膜层,仅将食管肌层与胃壁浆肌层做双层间断缝合,二层间距为3cm,以食管胃套接术代替食管胃吻合术. 结果 临床应用176例,无手术死亡,无吻合口瘘,无吻合口狭窄及胃反流,效果满意. 结论 (1)缝合粘膜层是食管胃吻合术后发生吻合口瘘的重要原因之一;(2)食管瓣片成形--食管胃套接术,不缝粘膜层,以套接术代替吻合术,能消除吻合口瘘,吻合口狭窄及胃反流三大并发症.

Analysis of risk factors of cervical anastomotic leakage after esophageal cancer operation

ObjectiveTo analyze the risk factors of anastomotic leakage after esophagectomy.MethodsThe clinical data of 1 328 patients with esophageal cancer, who underwent esophagectomy in the First Affiliated Hospital of Henan University of Science and Technology from January 2010 to December 2016, were retrospectively analyzed. There were 726 males and 602 females, at an average age of 67.2±14.1 years. According to whether there was anastomotic leakage after operation, patients were divided into two groups: an anastomotic leakage group (167 patients) and a non-anastomotic leakage group (1 161 patients). Univariate and multivariate logistic regression analysis was used to identify related risk factors of anastomotic leakage after operation.Results The incidence of postoperative anastomotic leakage was 12.6% (167/1 328). Univariate analysis showed that body mass index, arrhythmia, chronic obstructive pulmonary disease (COPD), diabetes, preoperative albumin level, preoperative chemotherapy and chemoradiotherapy, lesion location, anastomosis types and postoperative pulmonary infection were associated with statistically significant increase in risk of cervical anastomotic leakage (P<0.05). Logistic regression analysis showed that preoperative COPD, lesion location and postoperative pulmonary infection were independent risk factors of cervical anastomotic leakage after esophagectomy (P<0.05).ConclusionThe occurrence of cervical anastomotic leakage after esophageal cancer is related to many factors. The preoperative COPD, the lesion location and the postoperative pulmonary infection are independent high risk factors. Paying attention to these factors and doing perioperative management can effectively reduce the occurrence of anastomotic leakage.

The relations between cervical esophageal pressure difference with the formation of cervical anastomotic leakage

Objective To confirm the difference between internal and external pressure of cervical esophageal and to discuss the relations between cervical esophageal pressure difference with the formation of cervical anastomotic leakage. Methods In the present study, 12 New Zealand white rabbits were used. We applied a pressure transducer to describe the variation of pressure of intrathoracic, thoracic esophagus, cervical esophagus and upper esophageal sphincter during resting and cough. Pressure value was recorded and read through MD3000 system. And the difference between each point was analyzed. Results The pressures resulting from the cough induced were significantly higher in intrathoracic than in thoracical esophagous (10.2±0.6 cm H2O vs. 36.7±1.0 cm H2O), exhibited significantly higher in upper esophageal sphincter and thoracic esophagous than in cervical esophageal (7.5±0.2 cm H2O vs. 12.0±0.4 cm H2O, vs. 10.2±0.6 cm H2O). Conclusion Cervical anastomotic leaks are affected by many factors.And the most notabe one is the constant pressure from inside-out around cervical anastomotic.

Influence of Mechanical versus Hand-sewn Anastomosis on Surgical Complications of Patients with Esophageal Carcinoma after Esophagectomy: A Systematic Review and Meta-analysis

ObjectiveTo compare the complication morbidity of mechanical and hand-sewn esophagogastric anastomosis systemically. MethodsMedline (January 1960 to June 2015), EMbase (January 1980 to June 2015), Cochrane Library (January 1996 to June 2015), Web of Science (January 1980 to June 2015) and other databases were searched to identify randomized controlled trials (RCTs) about comparing the complication morbidity of hand-sewn and mechanical anastomosis. Moreover, the references were searched by search engines such as Google Scholar. Papers were screened according to the inclusion and exclusion criteria. And then the data were extracted. The quality of current meta-analysis was assessed by GRADE profiler 3.6 software. The meta-analysis was conducted using Stata 12.0 software. ResultsA total of 1 611 patients in 14 RCTs were reviewed. The results suggested that the anastomatic leakage rate of mechanical method showed no significant difference from that of hand-sewn method[RR=1.07, 95%CI (0.76, 1.51), P=0.699]. While the anastomatic stenosis rate was even higher[RR=1.59, 95%CI (1.21, 2.09), P=0.001]. ConclusionMechanical method can't reduce the anastomotic leakage rate following esophagogastrostomy, while it maybe increase the risk of anastomotic stenosis on the contrary. The patients' physical condition should be considered when surgeons make the choice.

食管癌术后消化道瘘的个体化治疗

目的 总结食管癌术后消化道瘘的治疗经验，探讨其个体化治疗方法。 方法 2004年1月至2009年11月中山市人民医院收治食管癌患者并行食管癌切除、胃食管吻合术338例，术后出现消化道瘘22例(6.51%)，全组患者均为男性，年龄44~77岁，中位年龄62岁。颈部吻合口瘘8例，胸内吻合口瘘11例，胸胃瘘3例。再次手术治疗5例，植入食管支架2例，保守治疗15例。 结果 治疗时间5~181 d，平均47.0 d，主要并发症为肺部感染11例、呼吸衰竭5例、败血症3例；死亡7例，病死率31.8％（7/22）。5例再次手术治疗，其中死亡3例，治愈1例，再发生瘘1例，改保守治疗后治愈；2例经支架治疗均治愈；保守治疗15例，其中10例治愈，治疗时间20~73 d，平均46.3 d。 结论 对食管癌术后消化道瘘的局部处理，应根据患者瘘发生的时间、部位、瘘口大小和局限程度等给予个体化治疗。

Risk factors and prediction model of anastomotic leakage after McKeown esophagectomy

ObjectiveTo investigate the risk factors for anastomotic leakage after McKeown esophagectomy, and to establish a risk prediction model for early clinical intervention.MethodsWe selected 469 patients including 379 males and 90 females, with a median age of 67 (42-91) years, who underwent McKeown esophagectomy in our department from 2018 to 2019. The clinical data of the patients were analyzed.ResultsAmong the 469 patients, 7.0% (33/469) patients had anastomotic leakage after McKeown esophagectomy. Logistic analysis showed that the risk factors for anastomotic leakage were operation time >4.5 h, postoperative low albumin and postoperative hypoxemia (P<0.05). A prognostic nomogram model was established based on these factors with the area under the receiver operator characteristic curve of 0.769 (95%CI 0.677-0.861), indicating a good predictive value.ConclusionOperation time >4.5 h, postoperative low albumin and postoperative hypoxemia are the independent risk factors for anastomotic leakage after McKeown esophagectomy. Through the nomogram prediction model, early detection and intervention can be achieved, and the hospital stay can be shortened.

胸腔镜探查治疗食管癌术后胸内吻合口瘘三例