改良吻合及包埋方式预防食管癌Sweet术式胸内吻合口瘘的经验总结

发布时间：2018-03-23 09:57

本文选题：食管癌　切入点：吻合口瘘　出处：《吉林大学》2017年硕士论文

【摘要】：研究目的:结合文献,综合分析食管癌根治术后影响胸内吻合口瘘发生的主要相关因素。探究“改良式食管-管状胃吻合”与“环式套入包埋”联合应用的手术技巧对于预防胸内吻合口瘘发生是否有积极的作用。研究方法:采用具有前瞻性的随机对照试验方式,纳入我院胸外科自2014年11月至2016年11月行Sweet术式的胸中下段食管癌鳞癌患者共200例。将所有入选患者随机分为对照组和试验组两个组别:对照组于管状胃切割闭合线近侧端下方平行于长轴切开管状胃,置入吻合器行食管-管状胃端侧吻合,对吻合环行浆肌层多点式加强缝合,常规闭合胃壁造口,对造口全层包埋缝合,100例,男92例,女8例;试验组于管状胃顶端垂直于管胃长轴另造口,置入吻合器,反折管状胃胃底与食管残端行端侧吻合,切割闭合器闭合并切除管状胃顶端造口及周围胃壁,全层包埋缝合后,将管状胃轻轻上提套住吻合口,使胃壁折叠约2-3cm,在胃壁折叠的最高点与食管下段行环式浆肌层包埋缝合加固,100例,男94例,女6例。两组患者术中均预置食管床引流管;术后均给予早期肠内营养。两组患者自术后第4天至第7天每日均给予口服亚甲蓝检测,凡有一次出现胸引管或纵隔引流管蓝染的,判定为发生吻合口瘘;对于两组中行4次亚甲蓝试验均阴性的患者,于拔除引流管前再行亚甲蓝试验一次,5次亚甲蓝试验均为阴性者,判定未发生吻合口瘘。主要对发生术后胸内吻合口瘘的患者的组别、人数、性别、病理分期进行记录和对比分析。病理分期参照食管癌TNM国际分期第7版。采用SPSS 21.0统计软件对各项数据进行分析,以α=0.05为检验标准,P0.05表示差异有统计学意义。结果:两组患者一般状况相当(P0.05),无统计学差异,有可比性。同等条件下性别不同对术后胸内吻合口瘘的发生没有统计学差异(P0.05)。试验组对吻合和包埋的改进,能明显降低术后胸内吻合口瘘的发生率,与对照组的差别有统计学意义(P0.05)。同等条件下,病理分期对吻合口瘘的发生率有影响,分期越晚,瘘发生率越高,差异有统计学意义(P0.05)。研究结论:本研究所采用的“改良式食管-管状胃吻合”和对吻合口的“环式套入包埋”,能有效预防Sweet术式食管癌根治术术后胸内吻合口瘘的发生,与术中预置的食管床引流管,共同构成了对于Sweet术后胸内吻合口瘘的三位一体式的预防措施,改善了吻合口血供,降低了吻合口的张力,为吻合口营造了良好的局部愈合环境,措施全面,技巧简单,效果显著,应予推广。
[Abstract]:Objective: to combine the literature, The main factors related to the occurrence of intrathoracic anastomotic fistula after radical resection of esophageal cancer were analyzed. The combined application of "modified esophagojejunostomy" and "ring embedding" was explored to prevent intrathoracic anastomosis. Whether oral fistula has a positive effect. Methods: a prospective randomized controlled trial was used. From November 2014 to November 2016, 200 patients with squamous cell carcinoma of middle and lower thoracic esophageal carcinoma underwent Sweet operation in our hospital. All the patients were randomly divided into two groups: the control group and the experimental group. The proximal end of the closure line is parallel to the long axis incision of the tube stomach. The esophagojejunostomy was performed with stapler. The anastomosed circular serous myometrium was sutured with multiple points, and the gastric wall was routinely closed. 100 cases (92 males and 8 females) were buried and sutured in the whole layer of anastomosis. In the test group, the tip of the tube stomach was perpendicular to the long axis of the tube stomach, and a stapler was inserted. The stomach fundus of the tube was anastomosed with the esophageal stump by end-to-side anastomosis. The cut-closure device closed and removed the orifice of the top of the tube stomach and the surrounding gastric wall. After the whole layer was buried and sutured, The tubular stomach was gently lifted up to cover the anastomotic site, and the gastric wall was folded about 2-3 cm. 100 cases (94 males and 6 females) were strengthened with circular sarcoplasmic muscular layer embedding at the highest point of gastric wall folding and the subesophagus segment. All patients in both groups were preplaced with esophageal bed drainage tube during the operation. The patients in both groups were given oral methylene blue test from the 4th to 7th day after operation. If there was a blue staining of the thoracic drainage tube or the mediastinal drainage tube, the anastomotic leakage was determined. For the two groups of patients who were negative for 4 methylene blue tests, one methylene blue test and five methylene blue tests were all negative before the drainage tube was removed. The group, number and sex of patients with intrathoracic anastomotic fistula after operation were determined. The pathological stages were recorded and compared with each other. The pathological staging was based on the seventh edition of TNM international staging of esophageal carcinoma. The data were analyzed by SPSS 21.0 software. Results: the general condition of the two groups was similar to that of P0.05, and there was no statistical difference between the two groups. There was no significant difference in the incidence of intrathoracic anastomotic leakage between the two groups under the same conditions. The improvement of anastomosis and embedding in the trial group could significantly reduce the incidence of postoperative intrathoracic anastomotic leakage. Under the same conditions, pathological staging had an effect on the incidence of anastomotic leakage, and the later the stage was, the higher the incidence of fistula was. The difference was statistically significant (P 0.05). Conclusion: the modified esophagojejunostomy and the loop embedding of anastomosis can effectively prevent the occurrence of intrathoracic anastomotic leakage after radical resection of esophageal carcinoma by Sweet. Together with the pre-inserted esophageal bed drainage tube during the operation, the three-in-one preventive measures for intrathoracic anastomotic leakage after Sweet were formed, which improved the blood supply of the anastomotic site, reduced the tension of the anastomotic site, and created a good local healing environment for the anastomotic site. The measure is comprehensive, the skill is simple, the effect is remarkable, should be popularized.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.1

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