胸腔内食管—胃吻合口瘘诊治新模式探讨

发布时间：2018-05-30 03:43

本文选题：食管-胃吻合口瘘 + 数字减影血管造影　；参考：《苏州大学》2016年硕士论文

【摘要】：目的胸腔内食管-胃吻合口瘘是食管癌、贲门癌术后最严重的并发症之一,其诊断和治疗尚无明确有效的方法。近来,我单位开展了一项对于胸腔内食管-胃吻合口瘘的新的诊疗模式并取得了一定的效果,本文旨在探讨早期DSA下瘘口造影、放置瘘口引流管冲洗和胃镜下钛夹夹闭的诊治模式处理胸腔内食管-胃吻合口瘘的可行性。方法回顾性分析2007年1月至2014年12月苏州大学附属第一医院胸外科食管癌、贲门癌根治术后发生胸腔内吻合口瘘55例患者的临床资料,其中男36例,女19例,年龄49~81岁(平均67±6岁)。原发病为食管中段癌42例,食管下段癌11例及贲门癌2例。根据诊治方法的差异分成传统诊疗组和新模式诊疗组。其中传统诊疗组31例,为2007年1月至2011年11月病例,所有患者采取传统诊治法,在怀疑吻合口瘘后行食管造影以明确诊断,充分引流及感染控制后置入食管支架;新模式诊疗组24例,为2011年3月至2014年12月病例,所有患者采取新模式诊治法,在怀疑吻合口瘘时立即在DSA下直接吻合口造影,明确瘘口位置及探查瘘腔形态及大小,根据探查情况行瘘腔内置管引流或冲洗,控制感染后逐步退出瘘腔内引流管,后经胃镜钛夹夹闭瘘口,少数钛夹治疗失败者行食管支架置入。分别采用t检验、卡方检验和精确概率法比较两组资料的术前一般情况、吻合口瘘确诊时间、确诊吻合口瘘后住院时间、严重并发症发生率和死亡率。结果两组资料的术前一般情况无统计学差异(P0.05);相较于传统诊疗组,新模式诊疗组吻合口瘘确诊时间显著缩短(1.2±0.8比3.6±2.2,t=5.212,P0.001),确诊吻合口瘘后住院时间明显缩短(26.4±11.9比55.5±25.4,t=4.992,P0.001)。两组出现严重并发症的例数分别为15例和4例,死亡例数分别为7例和1例,相对于传统诊疗组,新模式诊疗组严重并发症发生率显著下降(16.7%比48.4%,?2=6.019,P=0.014),总体死亡率无统计学差异(4.2%比22.6%,P=0.119)。结论在我们的临床初步研究中,早期介入诊断、早期瘘腔内置管引流或冲洗及后期胃镜下钛夹夹闭的诊治新模式较传统的保守治疗模式具有一定的优势,不仅能够明显缩短胸腔内食管-胃吻合口瘘的诊断和治疗周期,降低严重并发症发生率,而且总体死亡率也明显下降,值得在临床上推广。
[Abstract]:Objective the thoracic esophagogastric anastomotic fistula is one of the most serious complications after the operation of the esophagus and cardia cancer. There is no clear and effective method for diagnosis and treatment. Recently, our unit has developed a new diagnosis and treatment model for the esophagogastric anastomotic fistula in the thoracic cavity and has achieved some effect. This paper aims to explore the early DSA fistula. The feasibility of treating intrapleural esophagogastric anastomotic fistula with fistula drainage tube irrigation and endoscopic titanium clip clipping. Methods the clinical data of 55 patients with esophageal carcinoma in the Department of thoracic surgery of First Hospital Affiliated to Suzhou University from January 2007 to December 2014 after radical resection of cardia cancer were analyzed retrospectively, including 36 male patients. There were 19 cases of female, 19 years old (average 67 + 6 years). The primary disease was 42 cases of middle esophageal carcinoma, 11 cases of lower esophageal carcinoma and 2 cases of cardia cancer. According to the difference of diagnosis and treatment, the traditional diagnosis and treatment group was 31 cases from January 2007 to November 2011. All patients took traditional diagnosis and treatment method and suspected anastomosis. After fistula, esophagography was performed to make a clear diagnosis, full drainage and infection control were placed into the esophageal stent; 24 cases of the new mode diagnosis and treatment group were from March 2011 to December 2014. All the patients were treated with new mode of diagnosis and treatment. The direct anastomosis examination under DSA was taken immediately when the anastomotic fistula was suspected, and the location of the fistula and the shape and size of the fistula were determined. The fistula cavity was drained or washed in the fistula cavity. After controlling the infection, the fistula endovascular drainage tube was gradually withdrawn from the fistula, and the fistula was closed through the titanium clip of the gastroscope. A few titanium clips were used to treat the losers. The t test, the chi square test and the accurate probability method were used to compare the general conditions of the two groups of data, the diagnosis time of anastomotic fistula, and the diagnosis and anastomosis. The time of hospitalization after oral fistula, the incidence of severe complications and mortality. Results there was no statistical difference between the two groups before operation (P0.05). Compared with the traditional diagnosis and treatment group, the time of diagnosis of anastomotic fistula was significantly shortened (1.2 + 0.8, 3.6 + 2.2, t=5.212, P0.001), and the hospitalization time was significantly shorter (26.4 + 11.9) after the diagnosis of anastomotic fistula (26.4 + 11.9). 55.5 + 25.4, t=4.992, P0.001). The number of cases of severe complications in the two groups were 15 and 4, the number of death cases was 7 and 1, compared with the traditional diagnosis and treatment group, the incidence of severe complications in the new model group decreased significantly (16.7% to 48.4%, 2=6.019, P=0.014), and the overall mortality rate was not statistically different (4.2% than 22.6%, P=0.119). The conclusion was in me. In our preliminary clinical study, early interventional diagnosis, early fistula cavity internal tube drainage or rinse and late gastroscopy titanium clip closure have some advantages compared with traditional conservative treatment mode, not only can obviously shorten the diagnosis and treatment cycle of esophagogastric anastomotic fistula in the thoracic cavity, but also reduce the incidence of serious complications. The overall mortality rate is also significantly lower, which is worth promoting in clinical practice.
【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R735

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